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Malignant Disease:
Special Procedures

Staging of Gynecologic
Oncology Patients With
Exploratory Laparotomy

Subclavian Port-A-Cath 

Peritoneal Port-A-Cath

Application of Vaginal
Cylinders for Intracavitary
Radiation Therapy

Application of Uterine Afterloading Applicators
for Intracavitary Radiation Therapy  

Pelvic High-Dose Afterloader

Abdominal Injection of Chromic Phosphate

Supracolic Total Omentectomy

Omental Pedicle "J" Flap

Tube Gastrostomy

Total Vaginectomy

Radical Vulvectomy
With Bilateral Inguinal
Lymph Node Dissection

Reconstruction of the
Vulva With Gracilis Myocutaneous Flaps

Transverse Rectus
Abdominis Myocutaneous
Flap and Vertical Rectus
Abdominis Myocutaneous

Radical Wertheim
Hysterectomy With
Bilateral Pelvic Lymph
Node Dissection and With Extension of the Vagina

Anterior Exenteration

Posterior Exenteration

Total Pelvic Exenteration

Colonic "J" Pouch Rectal

Kock Pouch Continent Urostomy

Omental "J" Flap Neovagina

Ileocolic Continent Urostomy (Miami Pouch)

Construction of Neoanus
Gracilis Dynamic Anal

Skin-Stretching System Versus Skin Grafting

Gastric Pelvic Flap for
Augmentation of Continent Urostomy or Neovagina

Control of Hemorrhage in Gynecologic Surgery

Repair of the Punctured
Vena Cava

Ligation of a Lacerated
Internal Iliac Vein and
Suturing of a Lacerated Common Iliac Artery

Hemorrhage Control in
Sacrospinous Ligament
Suspension of the Vagina

Presacral Space
Hemorrhage Control

What Not to Do in Case of Pelvic Hemorrhage

Packing for Hemorrhage

Control of Hemorrhage
Associated With Abdominal Pregnancy

Ligation of a Lacerated Internal
Iliac Vein and
Suturing of a
Lacerated Common Iliac Artery

Laceration of a common iliac vein or artery can occur during insertion of the trocar and sleeve with laparoscopy or can occur with lymph node dissection for cancer.



The most common site for laceration of the common iliac artery is generally on the right side, as shown here, because most surgeons are right-handed and insert the laparoscopic trocar with the right hand. At the bottom, the internal iliac (hypogastric) vein is shown lacerated, with copious bleeding coming from both sites.

The first step any surgeon should utilize is placing the finger over the laceration of the artery or vein. Note the proximity of the right ureter to both the right common iliac artery and the right common iliac vein.


Every laparotomy kit contains sponge sticks. Sponge sticks can be used for proximal and distal pressure against the lacerated vessel, whether it be the internal iliac vein, as shown here, or the common iliac artery, as shown in Figure 2.

Blood flow through the open vessels must be controlled. Do not attempt to suture a large blood vessel while copious volumes of blood are flowing.

Ligation of a lacerated vein can be more difficult than suturing of a lacerated artery. The internal iliac vein can be tied off without sequela. Here, DeBakey vascular clamps are placed proximal and distal on the vein laceration. The vein is tied off at the proximal and distal ends with synthetic absorbable suture. Collateral venous drainage will develop between the lower extremity and the ligated internal iliac vein.


Sponge sticks can also be used to control hemorrhage from a lacerated right common iliac artery. The artery must be repaired with suture. Blood flow must be controlled. Suturing an open artery is inaccurate and poor technique.

Sponge sticks are always available in laparotomy kits. Often, proper vascular instruments are not. It is a serious mistake to use Kelly, Ochsner, or Kocher clamps on large arteries or veins that need to be sutured.

Figure 6 illustrates the proper way to repair a common iliac artery. DeBakey vascular clamps are placed proximal and distal to the site. When the bleeding ceases, a proper closure is made in the transverse plane of the vessel with 5-0 synthetic monofilament permanent suture on a cardiovascular needle. The 5-0 Prolene with a cardiovascular needle frequently comes in double-tipped needle at both ends of the suture. This allows a running suture that everts rather than inverts the suture line in the artery. Inversion may produce eddy currents that may cause blood clots.


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