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Pre-sacral venous plexus bleed during laparoscopic/open APR: a rare case report.

INTRODUCTION: Presacral haemorrhage is bleeding resulting from injury to the presacral venous plexus during the dissection of the pelvic viscera from the sacrum. The incidence and the mortality have been reported as high as 9.4% and 4.3%, respectively. [4] Several haemostatic techniques for controlling this intraoperative emergency proposed.

Here, we report a case of lower rectal adenocarcinoma planned for laparoscopic APR, but converted to open because of pre-sacral bleeding which was successfully managed by bilateral internal iliac artery ligation & pelvic packing.

CASE REPORT: A 58 years old lady already diagnosed case of low rectal adenocarcinoma was planned for lapaoscopic APR (Fig.1) but have to be converted to open surgery due to uncontrolled massive haemorrage (Fig. 3). Perhaps it was due to the lack of meticulous dissection around rectum in a very limited space as in laparoscopic procedures, leading to injury to the pre-sacral venous plexus during the dissection of the rectum from the surrounding structures. The bleeding was controlled by ligating internal iliac arteries (bilateral), even after which there was still continuous oozing of blood from the surrounding area.

In order to secure complete haemostasis, tight packing was done by surgical gauge (Fig. 4). the tail of which was brought out through perineal wound. After 48hrs, when the pack was removed, there was no fresh bleed & thus haemostasis achieved (Fig. 6).Thus, in this case proper haemostasis was achieved by both (b/l) internal internal iliac artery ligation along with tight pelvic packing. The patient was discharged home on post-operative day 5. On follow-up after one month, the patient was doing well, the ileostomy was functioning properly, the perineal wound has healed up completely.

DISCUSSION: Massive presacral bleeding is considered to be an intraoperative emergency during rectal surgery. It rapidly destablises patient. The anatomical basis is important in prevention and management of the bleeding. The pre-sacral venous plexus is formed by the two lateral sacral veins, the middle sacral vein, and the in-between communicating veins. The veins are avalvular and communicate via the basivertebral veins with the internal vertebral venous system. (Fig. 7) The plane of dissection is between the fascia propria and presacrial fascia which is also known as the "holy plane" of Heald (Fig. 8). The incidence is more common during difficult operations in patients with large and fixed tumours, neoadjuvant radiotherapy, and recurrent rectal carcinoma than in index rectal carcinoma (9% vs 0.12%). [5,6]

Several methods for controlling such bleeding described- Pelvic packing described by Wydra et al, effective but risks infection and requires removal. Thumbtack technique described by Wang et al (1985) [2] involves application of sterile autoclaved thumbtacks on the top of the bleeders presuming that it is the sacral foramina from which the basi-vertebral veins perforated through. Michael WK et al [7] described its use successfully in recurrent Ovarian malignancy. Muscle welding technique was first described by Xu and Lin in 1994.

Harrison et al (2003)[8] reported their experience with this technique which involves excising a small piece of rectus muscle & holding it to a forceps, & pressing against the bleeding sites, followed by electrocautery of the forceps to char the muscle piece & weld on to the bleeding sites. Zheng Lou et al. used eppiploic appendix instead of muscle (2013). [6] Zheng Lou et al differentiated bleeding from basivertebral veins from presacral venous plexuses & advocated surrounding suture ligation for the latter. Other techniques so far described includes- use of Bone Wax Civelek A et al. 2002, [9] Cyanoacrylate adhesives, Haemostatic sponges, Endoscopic Stapling (Tackers) (Van der Vurst TJ et al. 2004). [10]

CONCLUSION: Massive presacral bleeding is rare complication of pelvic surgery. It may rapidly destablise the patient. Several methods have been described for its management but understanding the vascular anatomy and maintaining the plan of dissection in the "Holy plane" serves the best preventive measure.

DOI: 10.14260/jemds/2015/1271


[1.] Li YY, Chen Y, Xu HC, Wang D, Liang ZQ. A new strategy for managing presacral venous hemorrhage: bipolar coagulation hemostasis. Zhonghua Yixve Zazhi 2010; 123: 3486-3488. [PMID: 22166536].

[2.] Wang LT, Feng CC, Wu CC, Hsiao CW, Weng PW, Jao SW. The use of table fixation staples to control massive presacral hemorrhage: a successful alternative treatment. Report of a case. Dis Colon Rectum 2009; 52: 159-161 [PMID: 19273972. DOI: 10.1007/DCR.0b013e3181972242.

[3.] Suh M, Shaikh JR, Dixon AM, Smialek JE. Failure of thumb-tacks used in control of presacral hemorrhage. Am J Forensic Med Pathol 1992; 13: 324-325 [PMID: 1288263].

[4.] Pollard CW, Nivatvongs S, Rojanasakul A, Ilstrup DM. Carcinoma of the rectum. Profiles of intraoperative and early postoperative complications. Dis Colon Rectum 1994; 37: 866-874 [PMID: 8076485].

[5.] Bhangu A, Brown G, Akmal M, Tekkis P. Outcome of abdominosacral resection for locally advanced primary and recurrent rectal cancer. Br J Surg 2012; 99: 1453-61.

[6.] Lou Z, Zhang W, Meng RG, Fu CG. Massive presacral bleeding during rectal surgery: From anatomy to clinical practice. World J Gastroenterol 2013; 19(25): 4039-44.

[7.] Michael WK, Ikhwan SM, Hasmah H, Siti RH, Merican, Andee D Z, Mohd N H, Wan ZZ. The Control of Haemostasis of Presacral Venous Haemorrhage with Sterile Thumbtacks and Roller Gauze Experience in Managing a Case of Recurrent Ovarian Cancer. Int J of Case Reports in Medicine 2013; 1-6.

[8.] Harrison JL, Hooks VH, Pearl RK, Cheape JD, Lawrence MA, Orsay CP, Abcarian H. Muscle fragment welding for control of massive presacral bleeding during rectal mobilization: a review of eight cases. Dis Colon Rectum 2003; 46:1115-7.

[9.] Civelek A, Yegen C, Aktan AO. The use of bonewax to control massive presacral bleeding. Surg Today 2002; 32: 944-5.

[10.] Van der Vurst TJ, Bodegom ME, Rakic S. Tamponade of presacral hemorrhage with hemostatic sponges fixed to the sacrum with endoscopic helical tackers: report of two cases. Dis Colon Rectum 2004; 47: 1550-3.


Aniruddha Basak (1), Suiyibangbe (2), Lokendra (3), Ch. Arun Kumar (4), G. S. Moirangthem (5)

(1.) Aniruddha Basak

(2.) Suiyibangbe

(3.) Lokendra

(4.) Ch. Arun Kumar

(5.) G. S. Moirangthem


(1.) Post Graduate Trainee, Department of Surgery, Regional Institute of Medical Sciences, Imphal, Manipur.

(2.) Post Graduate Trainee, Department of Surgery, Regional Institute of Medical Sciences, Imphal, Manipur.

(3.) Senior Resident, Department of Surgery, Regional Institute of Medical Sciences, Imphal, Manipur.

(4.) Professor, Department of Surgery, Regional Institute of Medical Sciences, Imphal, Manipur.

(5.) Professor and HOD, Department of Surgery, GI & MAS, Regional Institute of Medical Sciences, Imphal, Manipur.



Dr. Aniruddha Basak, Under Graduate Gents Hostel, No. 3, Room No. 68, RIMS, Imphal-795004, Manipur.


Date of Submission: 30/05/2015. Date of Peer Review: 01/06/2015. Date of Acceptance: 13/06/2015. Date of Publishing: 22/06/2015.
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Title Annotation:CASE REPORT
Author:Basak, Aniruddha; Suiyibangbe; Lokendra; Kumar, Ch. Arun; Moirangthem, G.S.
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Jun 22, 2015
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