Hemostatic Step-by-Step Procedure to Control Presacral Bleeding During Laparoscopic Total Mesorectal Excision

A new procedure of hemostasis during laparoscopic total mesorectal excision is described.

In our surgical department, from January 2004 to December 2007, 128 patients underwent laparoscopic total mesorectal excision. Among them, 47 patients underwent laparoscopic anterior resection after preoperative radiotherapy, 68 patients underwent laparoscopic anterior resection without preoperative radiotherapy, and 13 patients underwent laparoscopic abdominal perineal amputation.

In seven laparoscopic rectal surgery cases, we encountered unstoppable presacral bleeding, not amenable by conventional hemostatic solutions. In these cases we applied a simple staging hemostatic procedure. We first performed local compression: tamponing with a small gauze or absorbable fabric hemostat. If bleeding did not stop, we localized an epiploic or omental scrap and excised it by using bipolar forceps and use it as a plug on the tip of a grasping forceps. This plug is then put on the bleeding source and monopolar coagulation is applied by electrified dissecting forceps through the interposed grasping forceps. If bleeding did not stop, we used a little scrap of bovine pericardium graft and tacked it to the bleeding site using endoscopic helicoidal protack.

Our experience suggests that this hemostatic step-by-step procedure is a valid option to control persistent presacral hemorrhages.