Immediate action proposed for the gynecologist following a m
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Major vascular injury at laparoscopy can be life-threatening and challenging and requires a multidisciplinary approach to obtain an optimum outcome for the woman. Successful management of major hemorrhage is facilitated by early recognition, remaining calm, replacing circulating blood volume, and ensuring cessation of further blood loss. The immediate management of major vascular injury will be the same regardless of the type of hospital and the gynecologist’s expertise. Immediate management steps are outlined below.

1. Declare a major vascular emergency
All team members must realize this is a potentially life-threatening emergency and be available to help with an organized team approach. If the situation allows, the leader, usually the surgeon, should aim to stop for a brief moment and step back to organize their thoughts.

2. Arrest the bleeding with direct pressure
Major vascular injury usually requires a midline laparotomy, however, in certain circumstances it may be possible to deal with it laparoscopically, depending on the operator’s level of skill and experience. Leaving the trocar that caused the injury in place rather than removing it will limit blood loss while preparations can be made for resuscitation and repair. If vascular injury below the bifurcation of the aorta is suspected but not visible clearly and laparotomy is considered, direct pressure on the vessel using laparoscopic instruments should be employed. In addition, external pressure on the aorta just underneath the xiphisternum may decrease further blood loss until the abdomen is opened and direct pressure or vascular clamps are applied.

3. Communicate effectively with the team
This approach is associated with higher team efficiency in the performance of critical tasks and administration of essential drugs.31 Anaesthetist colleagues may delegate a member of the team to communicate with the switchboard and blood bank to announce the major haemorrhage protocol to obtain high-priority blood products. The surgeon and the anaesthetist should clearly request any additional equipment and personnel required to assist with managing the vascular injury.

4. Resuscitate and continue fluid resuscitation
The anaesthetic team need to site sufficient peripheral access to give fluids/emergency medication. An indwelling catheter, if not already present, should be inserted to assist with fluid balance management.

5. Monitoring and investigation
More invasive monitoring may be required in the form of arterial/central lines. While intravenous access is obtained, blood can be taken for urgent full blood count, urea and electrolytes, liver function tests, coagulation screen and cross-match samples.