Problem: after hysterectomy, massive pelvic floor hemorrhage sometimes occurs especially in those who have undergone complicated procedures

The bleeding usually originates from lateral pelvic floor or presacral venous plexuses that frequently are difficult to control by conventional methods. If satisfactory hemostasis were not achieved in a timely manner, secondary coagulopathy potentially would occur and result in life-threatening hemorrhage.

Our solution

The author used the Bakri Postpartum Balloon (Cook Medical, Winston-Salem, NC) as a pelvic pack to control posthysterectomy intractable pelvic floor hemorrhage with successful results in 3 consecutive cases that included peripartum hysterectomy for an atonic uterus, staging surgery for endometrial cancer, and removal of a large myomatous uterus, all complicated by coagulopathy. Figures 1-4 and the Video Clip demonstrate important steps of the packing technique as previously described. The bleeding was controlled promptly when the balloons were filled up to 400-550 mL. The balloons were removed at bedside 24-30 hours after the operation. Before the balloons were deflated, it was important to be certain that coagulation status was normal, that there was no continuing hemorrhage, and that the patients were hemodynamically stable. On follow-up examination, all patients recovered well without complication.

Application of the balloon

In dorsal lithotomy position, a small posterior culdotomy is made, facilitated by an upward pushing sponge holder placed in the posterior fornix. The size of the culdotomy incision is just enough to accommodate the deflated balloon for easy removal. Then, the Bakri balloon, with the stopcock at the distal part of its inflation port detached, is brought in through the laparotomy incision. The port is passed through the posterior culdotomy to the vagina with the help of the holding forceps. The shaft of the balloon is then pulled through the vaginal canal.

Charoenkwan. Posthysterectomy pelvic packing balloon. Am J Obstet Gynecol 2014 .

Positioning the balloon

When proper tamponade position is achieved, the balloon is inflated gradually with sterile normal saline solution through the reattached stopcock. The balloon is filled up to the minimal volume that effectively compresses against the pelvic floor and successfully controls the hemorrhage.

Charoenkwan. Posthysterectomy pelvic packing balloon. Am J Obstet Gynecol 2014 .

Maintaining the pressure to the pelvic floor

Continuous traction is used by connecting the balloon shaft to a 1-L intravenous fluid bag that hangs from the end of the bed. The drainage port is connected to the fluid collection bag.

Charoenkwan. Posthysterectomy pelvic packing balloon. Am J Obstet Gynecol 2014 .

The balloon in place

Charoenkwan. Posthysterectomy pelvic packing balloon. Am J Obstet Gynecol 2014 .

In the author’s experience, the pelvic pressure packing with the Bakri balloon can be an immediate lifesaver. It would provide a period of temporary hemostasis during which volume replacement and coagulation defect correction can be obtained. An apparent advantage of this method over conventional methods of abdominopelvic packing is that the balloon pack can be removed vaginally without the need for reexploration. The umbrella pack would be considered a valid option in these situations, given that it would provide effective control of bleeding and that the pack also can be removed vaginally. However, the difference in physical structure of the Bakri balloon pack and the umbrella pack is important, one has an inflated balloon as a pack with its shaft passing through the vaginal canal and the other has a sterile plastic bag filled with gauze rolls tied end-to-end forming a pack with the opening of the bag delivered transvaginally. This difference leads to 3 advantages that are associated with the use of the Bakri balloon.

First, the balloon pack is easier and faster to assemble and apply. The operator simply inflates the balloon with sterile normal saline solution through its inflation port instead of having to form a long folded chain of tied gauze rolls of adequate size to fill up the plastic bag and to fit the pelvic dimension. On application, a smaller posterior culdotomy incision is needed to accommodate the balloon when deflated and its shaft compared with that needed for the vaginal part of the umbrella pack. The posterior culdotomies were created with electrocautery with minimal blood loss in this report. This convenience is invaluable during the attempt to control life-threatening pelvic hemorrhage. Unlike the removal of the umbrella pack, which usually requires some forms of anesthesia in the operating room, the deflated balloon pack can be removed comfortably at bedside without the need for anesthesia.

Second, the size of the balloon pack is adjustable easily to match the size of hemorrhagic areas by inflation or deflation of the balloon. With the umbrella pack after its application, reduction of the size of the pack may be accomplished by pulling out more of the tied gauze rolls; however, enlarging the pack would likely need a reassembly. Before being removed, the balloon is partially or totally deflated, followed by a period of observation. If satisfactory hemostasis has not been achieved, the balloon can be reinflated easily to the required volume.

Third, the continuing intraabdominal blood loss can be monitored conveniently through the balloon’s drainage port without the need for additional drain.