Management and Outcomes of Major Pelvic Hemorrhage in Complex Abdomino-Pelvic Surgery

Introduction: Hemorrhage is a challenging complication of pelvic surgery. This study aimed to analyze the causes, management and factors associated with morbidity in patients experiencing major pelvic hemorrhage during complex abdomino-pelvic surgery.Methods: Patients who had major intraoperative pelvic hemorrhage during complex abdomino-pelvic surgery at 11 tertiary referral centers between 1997-2017 were included. Patient characteristics, management strategies to control bleeding, short and long term postoperative outcomes were evaluated retrospectively.Results: There were 120 patients with a mean age of 56.6 +/- 2.4 years and a mean BMI of 28.3 +/- 1 kg/m(2). While 104 (95%) of the patients were operated for malignancy, 16(5%) of the patients had surgery for a benign disease. The most common bleeding site was the presacral venous plexus 90(75%). Major pelvic hemorrhage was managed simultaneously in 114(95 %) patients. Electrocauterization 27(23%), pelvic packing 26(22%), suturing 7(6%), thumbtacks application 7(6%), muscle welding 4(4%), use of energy devices 2(2%) and topical hemostatic agents 2(2%) were the management tools. Combined techniques were used in 43(36%) patients. Short-term morbidity and mortality rates were 48(40%) and 2(2%), respectively. High preoperative CRP levels(p=0.04), history of preoperative radiotherapy (p=0.04), longer bleeding time (p=0.006) and increased blood transfusion (p=0.005) were the factors associated with postoperative morbidity.Discussion/Conclusion: Postoperative morbidity related to major pelvic hemorrhage can be reduced by optimizing the risk factors. Prehabilitation prior to surgery to moderate inflammatory status and prompt action with proper technique to control major pelvic hemorrhage can prevent excessive blood loss in complex abdomino-pelvic surgery.