Management of Presacral Bleeding During Sacrocolpopexy

INTRODUCTION: Presacral bleeding during sacrocolpopexy is a rare but potentially life-threatening complication due to the complex and variable vascular anatomy in the presacral space. Injury to the presacral venous plexus or adjacent arterial branches may result in brisk hemorrhage that is difficult to control. Given the increasing adoption of minimally invasive sacrocolpopexy, understanding effective strategies for hemostasis in this confined anatomical space is essential. OBJECTIVE: The objective of this video is to demonstrate the recognition and stepwise management of presacral bleeding during sacrocolpopexy. METHODS: During a robotic-assisted laparoscopic sacrocolpopexy, dissection was performed to identify the anterior longitudinal ligament in the presacral space. Brisk presacral bleeding was encountered while coagulating a perforating vessel. Initial management included direct pressure with laparoscopic sponges and attempted electrocautery. As bleeding persisted, progressive application of topical hemostatic agents was undertaken, including oxidized regenerated cellulose and a gelatin-thrombin matrix. Hemostatic materials were layered to optimize clot formation and tamponade. After achieving hemostasis, the remainder of the sacrocolpopexy was safely completed. RESULTS: Direct pressure with laparoscopic sponges provided temporary hemostasis but failed to achieve durable bleeding control. Electrocautery was ineffective due to vessel retraction and diffuse bleeding. Sequential application of oxidized regenerated cellulose followed by gelatin-thrombin matrix achieved durable hemostasis, allowing for safe completion of the procedure. The patient tolerated the procedure well, had no further intraoperative or postoperative complications, and recovered uneventfully. CONCLUSIONS: Presacral bleeding during sacrocolpopexy, though rare, requires rapid recognition and a stepwise approach to hemostasis. Direct pressure remains the cornerstone of initial management, but adjunctive hemostatic agents play a critical role when bleeding persists. The combination of oxidized regenerated cellulose and gelatin-thrombin matrix provided effective control in this case and may represent a reproducible strategy for minimally invasive procedures. Familiarity with multiple techniques—including packing, cautery, topical agents, and adjunctive methods—is essential for pelvic surgeons to ensure patient safety and procedural success.