As quoted in the article, in 1912, Halstead stated "The only weapon with which the unconscious patient can immediately retaliate upon the incompetent surgeon is hemorrhage". How much post-operative bleeding is "enough" to pull the trigger that warrants a trip back to the OR for another look to find and fix the source of the problem? This is a question that continues to plague surgeons even still as we move forward into the era of minimally invasive surgery. Here, Rosevear and colleagues retrospectively examine their experience with the management of post-operative hemorrhage following laparoscopic retroperitoneal surgery.

The authors report on 911 cases performed over an 8 year period. Of these, 598 were radical nephrectomies, 121 partial nephrectomies, 74 cyst resections, 61 reconstructive procedures (pyeloplasty, etc.), 37 adrenalectomies, and 20 "other". Transfusions were required after 53 of the cases (5.8%), of which 34 (3.7%) were for post-operative bleeding. Post-operative hemorrhage only occurred after nephrectomy (3.3%), partial nephrectomy (9.9%), and adrenalectomy (5.4%). The mean number of blood units was 3.3 (range 2-12), although 56% of patients only required 2 units. Only 4 out of 34 patients (12%) required surgical management for their bleeding, with the remainder being treated conservatively. In their multivariate analysis, factors that were associated with post-operative hemorrhage included age (p=0.039), ASA score (p=0.030), OR time (p=0.046), splenic injury during surgery (p=0.002), gastrointestinal complications (p=0.016), and increase length of stay (p=0.014). Post-operative hemorrhage significantly increased the length of stay for patients from 2.5 to 6.4 days. Interestingly, there was no difference in the mean number of transfusions or length of stay for those patients that were treated surgically versus those treated conservatively, although there was a higher incidence of renal complications post-operatively in patients taken back to surgery (50% vs. 7%).

This study demonstrates that not all post-operative hemorrhage requires surgical intervention and that the vast majority can be managed conservatively with observation and blood transfusions, as long as the patient remains hemodynamically stable. Running back to surgery at the first sign of trouble doesn't seem to decrease the number of units transfused, the length of hospital stay, and may in fact be associated with a higher post-operative complication rate.

Rosevear HM, Montgomery JS, Roberts WW, Wolf Jr. JS

J Urology: 176(3): 1458-1462, September 2006

UroToday.com Laproscopic and Robotic Section

UroToday.com Urologic Trauma & Reconstruction Section

Written by Christopher G. Wood, MD, a Contributing Editor with UroToday.

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