Abstract
INTRODUCTION: The use of topical hemostatic agents has become common during surgical interventions. There is a wide variety of substances available to augment clotting, ranging from physical agents to topical thrombin combinations. Application of these agents in gynecologic surgery in patients with existing coagulopathies has not been studied. CASE PRESENTATION: A 62-year-old woman with an inferior vena cava filter and a history of multiple deep vein thromboses presented to the clinic with pelvic pain, stress urinary incontinence, and uterovaginal prolapse. She underwent a total vaginal hysterectomy, sacral colpopexy, tension-free vaginal tape sling, and cystourethroscopy. Warfarin was cross titrated to enoxaparin prior to surgery. Patient had a 10-week sized uterus, normal appearing adnexa, and postoperatively bleeding was identified at the vaginal cuff. Preoperative hemoglobin was 9.0, and postoperative hemoglobin was 8.0 with normal coagulation factors. Several hemostatic techniques were used intraoperatively including combined gelatin-thrombin and gelatin-based agents. The procedure was complicated by a cystotomy which was repaired intraoperatively. The patient had postoperative bleeding from the incision site within the first 2 hours of recovery requiring a revision procedure. Exploration laparotomy was performed identifying the source of hemorrhage as a vaginal cuff hematoma. Suture and additional gelatin-thrombin sealant was applied to the pedicles and thrombin-soaked packing was placed in the vagina. Total estimated blood loss was 800 mL. The patient was transfused 2 units of packed red blood cells, 1 unit of platelets, and 1 unit of fresh frozen plasma. The patient made an uneventful recovery, and routine follow-up was conducted with no apparent complications. CONCLUSION: This case illustrates special considerations for intraoperative topical hemostatic agent use for gynecologic patients taking chemoprophylaxis for history of thrombosis and the value of the material composition for timely activity. Fibrin sealants have more rapid hemostasis than an oxidized regenerated dry matrix of cellulose. Because of the proximity of the reproductive organs to the bladder and urinary system, procedures complicated by cystotomy may result in mild leakage of sanguineous urine. This leakage can reduce the efficacy of combined gelatin-thrombin spray by disrupting its chemical components, compared with other hemostatic agents.