Pre-emptive triple tributary internal iliac vein ligation reduces catastrophic haemorrhage from sacrectomy during pelvic exenterative surgery

Abstract

The risk of significant haemorrhage in pelvic exenterative surgery requiring sacrectomy has been well described. Patients requiring a sacrectomy above S3 are placed in the prone position, posing an increased challenge to gaining control of haemorrhage when it occurs. We describe a technique of pre-emptive control of the internal iliac vein and its three named tributaries to tame the pelvis prior to sacrectomy. A retrospective, descriptive analysis was performed on a cohort of 25 consecutive patients operated on by one of the authors (AA E) between January 2005 and December 2010; all of whom underwent pre-emptive internal iliac vein triple tributary venous ligation, either unilaterally or bilaterally prior to sacrectomy above the level of S3. The cohort of patients was a heterogenous group ranging in age from 20 to 80 (mean 46.2) years, with primary tumours in 19 (76%), and secondary tumours in 6 (24%). Median operating time was 8.5h (range 2.32-19.67h). Median blood loss was 5500mL (range 1600-18000mL), with associated median transfusion of packed red blood cells of 9units (range 0-34units). Average stay in the intensive care unit was 1day (range 0-10days), with a median length of hospital stay of 18days (range 5-148days). There was no intraoperative mortality, with one death at 30 days secondary to gram-negative septicaemia. Postoperative morbidity occurred in 17 (68%) patients. Our results show that pre-emptive triple tributary internal iliac vein ligation is feasible for taming the pelvis prior to sacrectomy in the prone position where control of significant haemorrhage can prove challenging. The technique has broader relevance for visceral resections in the pelvis involving the pelvic side walls.