HemorrhageAlthough surgical bleeding can be problematic during prostatectomy, the pressure effect associated with laparoscopy results in relatively low levels of blood loss, and significant hemorrhage during laparoscopic robot-assisted prostatectomy is relatively uncommon.20. and 21. The hemorrhagic advantage of laparoscopic prostatectomy over the open counterpart is underscored by the differential blood loss between the two approaches: blood loss of <200 mL is common following laparoscopic robot-assisted prostatectomy and translates to a reduced incidence of postoperative transfusion (1%-2%) and a higher average postoperative hematocrit for most patients.22. and 23. Nonetheless, in some cases, bleeding may be problematic either during the operation or in the postoperative period when areas of inadequate hemostasis were not identified during the surgical procedure. Sources of bleeding are the same as those described for the open procedure: the dorsal venous complex and Santorini's complex overlying the anterior and lateral surfaces of the prostate and bladder, the inferior vesicle and proximal prostatic vascular pedicles, the neurovascular bundles coursing posterolateral to the prostate, the apical prostatic vessels, and the bladder neck. Venous bleeding, such as that encountered with division of the dorsal venous complex, is less troublesome during laparoscopic robotic prostatectomy compared with the open approach secondary to the pneumatic pressure of the working space. Nevertheless, venous bleeding may still be a potential source of hemorrhage, particularly in the delayed setting when the hemostatic effect of laparoscopic insufflation is no longer operational. Hemostatic techniques available to control venous and arterial bleeding range from standard suturing and electrocautery to more device-based methods, such as vascular staples and laparoscopic hemostatic clips. Bleeding of large veins and venous complexes may be controlled effectively using suture ligatures or vascular staples. The dorsal venous complex, for example, has been controlled in several ways, including predivision placement of a hemostatic figure-of-eight suture ligature, control with suture oversewing after division, and use of a laparoscopic vascular stapler. If problematic dorsal venous complex bleeding is encountered, temporary increase of the insufflation pressure may improve visualization to allow accurate hemostatic control. Unnecessary bleeding from small arteries may be encountered during sharp dissection and when hemostatic control is not complete. During seminal vesicle dissection, for example, vasal and seminal arteries may retract posteriorly following division, with resulting bleeding that is subsequently difficult to expose and control. Control of the proximal pedicles generally relies on hemostatic staples, hemoclips, or electrocautery; however, in cases characterized by misapplication or dislodgment, pedicle bleeding may be significant. Additionally, in nerve-sparing procedures, antegrade dissection of the periprostatic fascia may result in bleeding in exchange for avoidance of thermal or mechanical injury to the neurovascular bundles. In general, this bleeding does not cause significant hemorrhage postoperatively, and it can be controlled with either discrete bipolar electrocautery or application of hemostatic agents. Minimizing bleeding in laparoscopy is important because blood loss generally correlates with efficiency, not only in the time saved not spent searching for sources of bleeding and subsequent control but also in maintaining optimal visualization of the surgical field. When the operative field becomes contaminated with blood, the visual benefits of laparoscopy diminish slightly. |
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