*2.1.3 Location and source of bleeding*

Hemorrhage is responsible for about half of the postoperative complications following gynecological surgery, ranging from persistent venous oozing to massive blood loss from injury to retroperitoneal vessels [5–7, 12, 13].

Main bleeding sites comprise the anterior abdominal wall (both the suprapubic and the umbilical incision), the vaginal cuff (after laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy), and intraabdominal bleeding. Abdominal wall vessel injury occurs with increasing frequency, as the practice of laparoscopic surgery becomes wider and trocars become sharper [2–4, 7, 9].

The source of bleeding in secondary hemorrhage can be the uterine vessels or descending cervical/vaginal vessels; occasionally, uterine artery pseudoaneurysm can cause delayed heavy vaginal bleeding after laparoscopic hysterectomy [2–4, 7, 9]; additionally, the technique of vaginal vault closure may also contribute to the occurrence of secondary hemorrhage [5, 9].


*Postoperative pelvic hematoma* emerging after gynecological surgery may generate serious morbidity and impaired quality of life if large, infected, or incompletely

*AH, abdominal hysterectomy; LH, laparoscopic hysterectomy; VH, vaginal hysterectomy; L-AVH, laparoscopicassisted vaginal hysterectomy.*

#### **Table 1.**

*Incidence of postoperative hemorrhage in gynecological surgery.\**

#### *Bleeding after Hysterectomy: Recommendations and What to Expect DOI: http://dx.doi.org/10.5772/intechopen.101384*

resolved hematoma or hematoma with residual fibrosis and persistent pain [2–4, 9]. It usually develops above the vaginal vault, along the pelvic side-wall, retroperitoneal, in the paravesical space, in the abdominal wall as well as in the ischiorectal fossa and vulva [9]. According to its location, postsurgical hematoma may be recognized at routine abdominal and/or pelvic examinations in women with outstanding postoperative discomfort and unexpected anemia, but a definitive diagnosis can only be made by ultrasound or CT scan [5]. A simple or CT/ultrasound-guided or through abdominal incision drainage is commonly required to address the pelvic hematoma issue [2–4, 9].

Postoperative hemorrhage can result from failure to control vascular injury during surgery. Accurate clamp placement, gentle handling of tissues, and the accuracy of dissection are all important and contribute to maximum efficiency with minimum blood loss and minimum tissue damage when abdominal hysterectomy is performed [9].

The electrosurgical instrument can be used for a precise incision of the abdominal wall with minimal tissue injury. By holding the electrode close to the tissue or touching the metal clamp and pressing the coagulation button, superficial coagulation can be achieved [2–4, 9].
