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Management of vascular injuries in gynecologic oncology surgery
  1. Reitan Ribeiro1

    Senior Gynecologic Oncologist, Research Coordinator and Robotic Training Program Director of the Gynecologic Oncology Division, Surgical Oncology Department, Erasto Gaertner Hospital, Curitiba, PR, Brazil.

  2. William Kondo2 and
  3. Fabiano L Erzinger3
  1. 1 Department of Gynecology Oncology, Erasto Gaertner Hospital, Curitiba, Brazil
  2. 2 Department of Gynecology, Vital Batel Hospital, Curitiba, Brazil
  3. 3 Department of Vascular Surgery, Erasto Gaertner Hospital, Curitiba, Brazil
  1. Correspondence to Dr Reitan Ribeiro, Department of Surgical Oncology, Erasto Gaertner Hospital, Curitiba, Brazil; taca2003{at}

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Vascular injuries are not rare in gynecologic oncologic surgery,1 and proper bleeding management is critical to ensure successful outcomes and minimize the risk of complications (Video 1).

Video 1 Management of vascular injuries in gynecologic oncology surgery‌

The management of bleeding during gynecologic oncologic surgery begins with a thorough pre-operative evaluation. Surgical anatomy is crucial, and knowing that some major vessels can be ligated—including the left renal vein2—is important in catastrophic situations. It is important to understand all bleeding control options, including that ligation may be a better option than repair in some situations.3 Patients who are at increased risk of bleeding, such as those with bleeding disorders or those taking anti-coagulant medications, should be identified and appropriate measures taken to minimize the risk of bleeding. This may involve discontinuing certain medications prior to surgery or administering blood products such as platelets or fresh frozen plasma to correct coagulation abnormalities.

During surgery, meticulous hemostasis is essential. This may involve the use of a variety of techniques including bipolar energy, suturing, clips, and hemostatic agents. In some cases, bleeding may be severe and require vascular clamps or ligatures may be required to control bleeding.2 Transoperative blood transfusions may also be necessary if significant blood loss occurs during surgery.

During minimally invasive surgery, the decision to convert to open surgery depends on factors such as the extent and severity of the bleeding, the underlying cause, and the surgeon’s experience. If the surgeon cannot achieve hemostasis or visualize the surgical field adequately, or if there is a major blood vessel injury, conversion to open surgery may be required. In addition, if the patient’s vital signs become unstable, open surgery may be necessary to control bleeding quickly.

In summary, a thorough understanding of the surgical anatomy is fundamental to identifying the source of bleeding and selecting the best control approach. Compression should be a reflex when there is bleeding (Figure 1), followed by considering calling the vascular surgeon and conversion for control, if necessary. Suturing is the best strategy for preparing external and common iliac vessels, cava and aorta, but clips may be used in highly selected situations. Sutures should only be used with control. Hemostatic agents are adjuvant strategies for controlled bleeding.

Figure 1

Vena cava injury caused by fellow vein avulsion.

Ethics approval

The Erasto Gaertner IRB exempted this study from specific IRB approval and all patients consented to the recording of the procedures and use of the images for educational and scientific purposes.

Senior Gynecologic Oncologist, Research Coordinator and Robotic Training Program Director of the Gynecologic Oncology Division, Surgical Oncology Department, Erasto Gaertner Hospital, Curitiba, PR, Brazil.

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  • Contributors RR, WK and JCL contributed to planning, conceptualization, literature review, data analysis, writing the original draft of manuscript, and reviewing and editing the manuscript. RR also recorded and edited the lecture and videos. All authors had access to the educational video lecture and had final responsibility for the decision to submit the video for publication.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.