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Management of a Lost Pedicle At the Time of a Vaginal Hysterectomy

2/1/2013 - Eugene C. Toy, MD

Editor:  Rebecca P. McAlister, MD

Clinically significant bleeding occurs in 1-2% of vaginal hysterectomies; subclinical hematomas, identified by sonography, may be seen in up to 15% of cases. Risk factors include an enlarged uterus, lack of descent, distorted anatomy, and a narrow subpubic arch. The most common site of bleeding is the vaginal vault. However, an unsecured or inadequately ligated pedicle can also lead to hemorrhage.

When a pedicle is lost at the time of vaginal hysterectomy, the pedicle should be assumed to be vascular until otherwise proven. A systematic approach is based on: 1) the magnitude or potential magnitude of hemorrhage, 2) the ability to secure the lost pedicle, and 3) the degree of being able to ascertain possible retroperitoneal bleeding. The anesthesia team should be informed, and volume or blood should be administered as needed. The lost pedicle can be approached vaginally, abdominally or laparoscopically.

If the lost pedicle contains a major artery such as the uterine or ovarian artery (during oophorectomy), then gross and profuse hemorrhage may be noted. Unless the bleeding vessel is immediately adjacent to the surgical field and easily clamped, the best management of profuse hemorrhage is to proceed to laparotomy. The tissue and vessels often retract into the retroperitoneal space and the patient may lose significant blood during transvaginal evaluation. During laparotomy, pressure may be applied to the area of bleeding prior to retroperitoneal space exploration. Identification of the ureters may be required.

When there is no overt bleeding and the patient is hemodynamically stable, the surgeon may try to locate the pedicle vaginally but this may be difficult at times. If the pedicle is lost during the initial operative steps such as near the uterosacral ligament, it is usually easily clamped. Indiscriminate clamping, especially when tissue has retracted away and is not easily visualized, can lead to bowel or urinary tract injury. The anatomical location of the lost pedicle may be approximated by comparing to the contralateral side. Even if the pedicle is unsecured, the remainder of the hysterectomy can be performed if the patient is stable, facilitating vaginal exploration.

When the pedicle remains “lost,” laparoscopy is generally performed to assure hemostasis and assess for possible retroperitoneal bleeding. Lack of apparent bleeding is not evidence of hemostasis. During laparoscopy, a systematic search for bleeding should be undertaken bilaterally. Retroperitoneal hematomas should be surgically repaired. A non-expanding hematoma should not be assumed to be “hemostatic.”

In rare circumstances when bleeding cannot be controlled surgically, arterial embolization or pelvic packing are options. Postoperatively, the patient should be monitored closely for signs of volume depletion, dropping hemoglobin level, and possible intra-abdominal or vaginal bleeding.

Further Reading:

Wood C, Maher P, Hill D. Bleeding associated with vaginal hysterectomy. Aust N Z J Obstet Gynecol 1997;37(4):457-61

Initial Approval:  February 2013; Revised March 2017

 

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