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2/1/2013

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

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 proven otherwise. 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 ability to ascertain possible retroperitoneal bleeding.

The anesthesia team should be informed, and intravenous fluids 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 (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, or laparoscopy if resources are immediately available. 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. 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 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 with 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:

Clarke-Pearson DL and Geller EJ. Complications of hysterectomy.  Obstet Gynecol. 2013 Mar;121(3):654-73. doi: 10.1097/AOG.0b013e3182841594.

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

Initial Approval: February 2013, Revised September 2018. Reaffirmed March 2020; Reaffirmed November 2021. Reaffirmed July 2023

 

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