hemorrhage is a rare , albeit serious , complication of gynecological surgery . despite meticulous surgical technique , and attention to detail , postoperative
postoperative bleeding is more sinister than intraoperative bleeding , because in the latter , the surgeon would not normally leave the operating theater ( ot ) until hemostasis has been accomplished , whereas in postoperative bleeding the gynecological surgeon may have already left the ot , or indeed , may not be physically present in hospital when the postoperative bleeding is diagnosed .
bleeding begets bleeding , and the patient could eventually develop disseminated intravascular coagulopathy , and even death .
gynecological surgeons and , in fact all surgeons , must have a drill ( fast action plan ) to promptly treat patients with postoperative bleeding .
resuscitation and blood transfusion have to urgently start and continue during the surgical management of the patient to stop the bleeding .
reactionary postoperative gynecological hemorrhage seems to be an area of paucity in the international medical literature .
the aim of this manuscript is to assess the incidence of reactionary postoperative hemorrhage in contemporary gynecological surgery .
the authors chose 2 commonly performed operations , vaginal hysterectomy and laparoscopic hysterectomy , to assess the incidence of reactionary postoperative hemorrhage .
all these operations were performed at the royal brisbane and women 's hospital , brisbane , australia .
the hospital database was used to do a retrospective analysis of patients who underwent vaginal laparoscopy or laparoscopic hysterectomy and suffered reactionary postoperative hemorrhage .
all patients attending the royal brisbane and women 's hospital for a surgical procedure have their full details entered into the hospital database .
patients who underwent vaginal hysterectomy or laparoscopic hysterectomy were noted . there were 719 patients operated on by the authors between november 1990 and march 2007 ( inclusive ) .
patients that were readmitted to the ot within the first 24 hours following the initial surgery were flagged and their details analyzed .
patients ' age , parity , body mass index ( bmi ) , history of previous pelvic surgery and in particular caesarean deliveries were noted as well as the uterine size and pathology .
all these patients exhibited manifestations of hemorrhagic ( surgical ) shock with profound tachycardia , hypotension , cold clammy sweating , pallor , and clinical evidence of free blood in the peritoneal cavity .
immediate resuscitation , including grouped and crossmatched blood transfusion , was started prior to , and during , the return of the patient to the ot for exploratory operative laparoscopy / laparotomy .
the principles of exploratory operations were exposing the former operation field of the hysterectomy by copious irrigation / suction using ringer 's solution ( usually 2 liters to 3 liters was used ) , arresting hemorrhage either by suturing / coagulating a bleeding vessel , or suturing any raw areas , and local application of oxygenated cellulose ( surgicel ) to encourage aggregation of blood platelets and affect hemostasis .
one to two 6-mm drain(s ) were left in the former pouch of douglas as a safeguard to observe any recurrences of bleeding .
the incidence of reactionary postoperative hemorrhage was 0.6% in the vaginal hysterectomy and 1.2% in the laparoscopic hysterectomy groups .
the distribution of the 6 patients who experienced reactionary postoperative bleeding was even throughout the above - mentioned period , and occurred despite the gynecological surgeon in charge using adequate transfixion to all vascular pedicles , affecting satisfactory intraoperative hemostasis , using ringer 's solution to ascertain the absence of active bleeding , and routinely inserting at least one 6-mm drain in the pelvis at the conclusion of the vaginal / laparoscopic hysterectomy procedure . because the current series included only 6 patients who suffered reactionary postoperative bleeding ,
nevertheless , it was noted that the average bmi was 33 kg / m ( range , 24 to 48 ) ; uterus weight averaged 195 g ( range , 120 to 394 ) ; the patient 's median age was 36 years ( range , 27 to 51 ) ; patient 's parity , on average , was 2 children ( range , 0 to 4 ) .
one patient each in the vaginal hysterectomy and laparoscopic hysterectomy groups had a history of one previous caesarean delivery scar .
four of the 6 patients ( 2 each in the vaginal hysterectomy and laparoscopic hysterectomy groups ) had extensive pelvic adhesions attached to the uterus .
none of the treated patients suffered any long - term complications , and there were no mortalities .
the incidence of uterine pathology , eg , leiomyomata and adenomyosis , were similar in both groups .
regarding the mode of emergency treatment , operative laparoscopy was performed in one patient in each of the vaginal and laparoscopic hysterectomy groups .
there were no specific bleeding points in any patient ; nevertheless , excessive blood clots were in the pelvis and nearly  bathing  the intestines .
following laparoscopic irrigation / suction using ringer 's solution to clear the operative field , a combination of laparoscopic suturing using absorbable suture material , eg , monocryl ( 0 ) ( ethicon , australia ) and laparoscopic bipolar coagulation were used .
irrigation / suction was performed , and absorbable vicryl number 1(polyglactin 910 suture ) ( ethicon , australia ) was used to re - do the whole operation field ( including the vascular pedicles ) .
once the gynecological surgeon was happy about hemostasis , 2 negative suction drains ( 6 mm each ) were left in the pelvis , in the laparoscopy or laparotomy groups , to ascertain maintenance of complete hemostasis , and the wounds were closed .
the drains were removed once drainage had nearly stopped ( usually in 24 hours ) .
following emergency operations to stop reactionary hemorrhage , all patients were transferred to the high dependency unit until they were deemed clinically stable , before they were transferred back to the gynecology inpatient ward . on average ,
the duration of operative laparoscopy was 75 minutes ( range , 55 to 95 ) , and 39 minutes ( range , 28 to 50 ) for laparotomy . in our institution , patients are hospitalized for 2 days and 1 day following an uneventful vaginal hysterectomy and laparoscopic hysterectomy , respectively . however , in the current series , emergency operative laparoscopy to manage the reactionary postoperative hemorrhage prolonged the hospitalization by 1.5 more days ; in the cases of emergency laparotomy the hospital stay was extended by 3 more days . estimated blood loss was 2 liters ( range , 1.5 to 2.5 ) as per the combined assessment of the gynecological and anesthetic teams .
following the required blood transfusion ( intra- and postoperative ) , all patients were started on twice daily oral iron and vitamin c to enhance iron absorption .
daily laboratory full blood count was performed for the inpatients , and patients were discharged when asymptomatic and the hemoglobin level was more than 80
however , reactionary postoperative bleeding that occurs within the first 24 hours following surgery , commonly within the first 4 hours to 6 hours postoperative , is particularly troublesome , because the gynecological surgeon is often not within the immediate vicinity of the operating theatre .
consequently , urgent surgical intervention may not be within reach . nevertheless , it is crucial that assessment , and blood transfusion start once the postoperative hemorrhage has been diagnosed .
the blood transfusion may continue during and after the emergency operative procedure to manage the reactionary postoperative hemorrhage . minimizing patient morbidity and avoiding mortality
the nursing staff at the recovery bay , operating theatre , and inpatient wards have to be diligent in early recognition and prompt notification of postoperative hemorrhage , and systematic intervention would help avoid poor outcomes . regardless of the method used to affect hemostasis in hysterectomy operations , postoperative reactionary hemorrhage may rarely occur , despite the fact that the gynecological surgeon who performed the procedure is very experienced .
however , our reactionary postoperative rate was 0.6% and 1.2% following vaginal and laparoscopic hemorrhage , respectively .
our presented figures compare favorably with those of other centers . in a large series that included 10 110 hysterectomy procedures ,
mkinen et al reported postoperative bleeding rates of 3.1% and 2.7% in vaginal and laparoscopic hysterectomy , respectively .
similarly , mcpherson et al in a large - scale study that included 37 512 patients in the united kingdom showed that laparoscopic hysterectomy has an operative complication rate of 6.1% , double that of abdominal hysterectomy , and the intra- and postoperative bleeding occurred in younger women , women with a more vascular pelvis who underwent hysterectomy , especially laparoscopic hysterectomy in the presence of fibroids .
however , abdominal hysterectomy is associated with a longer hospitalization , slower recovery and return to the workforce compared with laparoscopic or vaginal hysterectomy .
intra- and postoperative bleeding is not significantly different in vaginal compared with abdominal hysterectomy for enlarged uteri .
however , it must be remembered that operative laparoscopy , especially in compromised patients , is an organized team effort .
the experienced gynecological endoscopist has to use an assistant , and a scrub theatre nursing staff with special interest in advanced gynecological laparoscopic surgery .
if such a competent team can not be assembled , especially after hours , then laparotomy should be affected without delay .
this is multi - system disorder , and the valuable assistance of a clinical hematologist has to be sought in this multi - discipline care situation .
the therapy must be highly individualized according to the patient 's age , site and severity of the hemorrhage , and hemodynamic status of the patient . despite accurate screening for human immunodeficiency virus contamination , many patients and their families are reluctant to authorize a blood transfusion except in life - threatening situations .
clinicians have to fully understand this sensitive issue and reasonably respond . in our series , none of the patients suffered disseminated intravascular coagulopathy . nevertheless , in our institution , all patients were admitted to the high dependency unit for close monitoring following the second operation to treat the reactionary postoperative hemorrhage .
despite meticulous surgical technique to affect a complete intraoperative hemostasis , one would expect a very small percentage of patients to suffer from reactionary postoperative hemorrhage in contemporary gynecological surgery .
the principles of management are timely intervention to recognize the complication , resuscitation , and emergency return to the operating theater to stop the hemorrhage , followed by closely monitoring the patient in a high - dependency unit to exclude recurrence of bleeding .
 background : bleeding is a major complication in contemporary gynecological surgery . we discusses this rare , albeit potentially serious , unexpected complication . the authors mean by  reactionary ,  hemorrhage that occurs within the first 24 hours after surgery . 
 more or less , all gynecological surgeons have had to deal with this situation at some stage of their career . 
 the seriousness of this complication stems from the fact that often the surgeon is not in the immediate vicinity to promptly step in and treat the patient . 
 nevertheless , the key to successful management is prompt diagnosis , immediate resuscitation , and operative intervention.methods:by using the collective hospital database , we reviewed 719 patient records . 
 the authors operated on these patients between november 1990 and march 2007 ( inclusive ) in one hospital , royal brisbane and women 's hospital , the main teaching hospital in brisbane , queensland , australia . 
 the procedures performed in the 719 patients comprised 476 vaginal hysterectomies and 243 laparoscopic hysterectomies . 
 both public and private patients were included . 
 the objective of the review was to establish the incidence of postoperative reactionary hemorrhage following the initial operation , as defined by the number of patients returning to the operating theatre ( ot ) because of postoperative hemorrhage within 24 hours of the initial hysterectomy.results:of the 719 patients , 6 experienced reactionary postoperative hemorrhage , 3 each in the vaginal hysterectomy and laparoscopic hysterectomy groups . 
 that would make the incidence of postoperative reactionary hemorrhage 0.6% in the vaginal hysterectomy and 1.2% in the laparoscopic hysterectomy group . 
 none of these 6 patients had any preoperative hemorrhagica diatheses . 
 there was neither ureteric , bladder , intestinal , nor any other injuries in the whole series . 
 no long - term complications or mortalities occurred.conclusion:reactionary postoperative hemorrhage is a rare , albeit serious , complication of contemporary gynecological surgery ; this complication may occur despite meticulous surgical technique . 
 the key to successful management is prompt diagnosis , urgent resuscitation , and return to the ot to arrest the bleeding . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSION