Management of Presacral Hemorrhage During Robotic-Assisted Laparoscopic Sacrocolpopexy

The objective of this video is to highlight a stepwise approach to laparoscopic management of acute presacral hemorrhage. A 64-year-old G3P2012 with International Continence Society (ICS) stage III uterine prolapse and stage III cystocele presented for robotic-assisted supracervical hysterectomy and sacrocolpopexy. During the case, acute bleeding was encountered during dissection of the presacral space originating from the sacral venous plexus. The bleeding progressed to a brisk hemorrhage rapidly accumulating in the pelvis. Initial attempts at management utilized direct pressure and an increase in pneumoperitoneum without adequate hemostasis. Suture ligation of the vascular plexus was then attempted with minimal effect. Hemostasis was finally achieved using seven sheets of Surgicel as a chemical hemostatic and packing agent. The overlying peritoneum was tightly reapproximated. Blood loss for the procedure was estimated to be 1500ml, and the patient received an intraoperative blood transfusion. Ultimately, the planned sacrocolpopexy was converted to a uterosacral cervicopexy. The patient was admitted to the ICU and subsequently discharged home on postoperative day five in stable condition. Sacrocolpopexy requires critical dissection in the presacral space. Hemorrhage is a life threatening complication occurring in up to 4.4% of cases. This video shows an acute presacral hemorrhage during laparoscopic surgery. We demonstrate a stepwise approach to achieving excellent hemostasis while maintaining a minimally invasive approach.