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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


Packing for Hemorrhage Control

Packing has made a popular return to trauma and pelvic surgery, based on objective data. Every operative team should have its basic rules concerning packing. Basically, when a hemorrhage has occurred and cannot be controlled with the techniques mentioned in this section of the Atlas and more than 10 units of blood have been administered, the patient will start developing the signs and symptoms of hypovolemic shock. They will be hypothermia and/or acidosis. The patient will also develop dilutional coagulopathy with bleeding from other sites.

At this point, further attempts at vascular control are usually fruitless, and it is efficacious to pack this area of the body with any large sterile pack available. Extensive use of large packs is required; there is no role for 4 X 4 sponges. Laparotomy packs may include tools, sheets, and other aids to pack off this area in a proper manner.

In closing the patient's abdomen the rectus fascia should not be closed. The skin should be closed with towel clips. The patient should be taken to the surgical intensive care unit. She should remain intubated and on a mechanical respirator. Central venous access must be made, and corrections must be started for all the signs and symptoms of hypovolemic shock.

The fascia should not be closed to prevent compartmental syndrome. The large amount of packing necessary to control large vessels in the pelvis can make ventilation extremely difficult, resulting in compartmental syndrome.

Forty-eight hours later, when all vital signs, electrolytes, hemoglobin, prothrombin time (PT), and partial thromboplastin time (PTT) levels have been corrected, the patient can be brought to the operating room, the skin clamps and the packing can be carefully removed, and the surgeon may frequently find little if any hemorrhage. If there is hemorrhage, it can be properly controlled at this time with adequate operative personnel and instruments.


Uncontrolled bleeding can occur from laceration of pelvic veins and the external iliac arteries. IVC, inferior vena cava.

The pelvis is packed tightly with any sterile material available. The open veins are seen ghosted under the packs.

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