Journal of Cancer and Clinical Oncology

Vol. 3(3), pp. 036-041, October, 2019. © www.premierpublishers.org. ISSN: 5907-4449

Analysis

Retrospective Analysis of Intra Operative Blood Loss in Pelvic

Oncological Surgeries - A Single Institution Experience in 7 Years
*1Subbiah Shanmugam, 2Arul Murugan, 3Kishore Kumar Reddy
1,2,3 Centre for oncology, Government Royapettah Hospital & Kilpauk Medical College, Chennai, India.

To study intraoperative blood loss and analyse average blood loss and number of transfusions
in patients who underwent pelvic oncological surgeries in this oncology centre in South India
from January 2012 – December 2018. A retrospective analysis of medical records of 257 patients
who had undergone pelvic oncological surgeries in our institute from January 2012 and December
2018 was done and information regarding blood loss and transfusions was analysed with
student’s T test. Out of 257 patients, 72 underwent pelvic exenteration of which 18 were operated
for primary and 54 were operated for recurrences, 105 underwent Wertheim’s hysterectomy, 19
patients underwent APR, 8 underwent LAR, 5 underwent AR, 36 underwent surgical staging 8
underwent Cystectomy and 4 underwent sacrectomy. In our analysis we found that laparoscopic
surgeries had less blood loss (average 354 ml) compared to open surgeries (average 811 ml) and
upfront surgeries (531 ml) had less blood loss compared to surgeries done post
chemoradiotherapy (668 ml) resulting in less number of transfusions, transfusion reactions,
infections and early recovery in laparoscopic and upfront surgeries. Laparoscopic surgery in
pelvic oncological surgeries has become a benefit to surgeons because of less intraoperative
blood loss, reduced hospital stay and better outcomes. Though laparoscopic surgeries require a
learning curve, extensive anatomical knowledge about the procedure during open surgeries made
learning curve less steep. Blood loss in upfront cases is less than that of post chemoradiotherapy
cases leading to less infection rates, better recovery and with increase in duration of surgery,
blood loss is more.

Keywords: pelvic surgeries, blood loss, laparoscopic, chemoradiation

INTRODUCTION
Surgical oncology, perioperative medicine, and Cervix cancer is one of the most common cancers in
anaesthesia for oncological care have been evolving over females in India contributing 21.2% of cancer burden in
the last four decades. Aggressive chemoradiation women. Ovary 6.7%, corpus uterus 2.5% (Uma Devi k et
regimens, newer and radical surgical techniques, effective al, 2009), incidence rates of colon cancer vary from 3.7 to
anaesthesia modalities and impressive intensive care 0.7/100,000 among men and 3 to 0.4/100,000 among
medicine strategies have facilitated tumor resections, women. For rectal cancer the incidence rates range from
which were considered difficult or unadvisable in the past 5.5 to 1.6/100,000 among men and 2.8 to 0/100,000
(Buchler et al., 2003; Balcom et al., 2001; Merion, 2010) among women (Mohandas et al, 1999).bladder cancer
Thus, patients with large hyper vascularised tumors or 2.25% (Naik et al, 2011). Majority of the patients present
cancers encasing major blood vessels are now considered in advanced stages requiring chemoradiation and
acceptable surgical candidates (Saif et al, 2010). One of extensive surgeries.
the consequences of performing surgery in such patients
is the risk of significant intra- and postoperative blood loss. *Corresponding Author: Subbiah Shanmugam; Professor and
Head, Centre for Oncology, Government Royapettah Hospital &
When bleeding occurs unexpectedly and uncontrollably in
Kilpauk Medical College, Chennai, India. Email:
the perioperative period, there is a sharp increase in [email protected], Tel: +919360206030;
mortality (Copeland et al, 1991; Boyd et al, 1987). Co-Authors Email: [email protected];
[email protected]

Retrospective Analysis of Intra Operative Blood Loss in Pelvic Oncological Surgeries - A Single Institution Experience in 7 Years
Shanmugam et al. 037

Till few years back most of the surgeries used to be done RESULTS
in open method with wound morbidity and prolonged bed
rest. With advances in laparoscopic surgery it became an The patient characteristics and blood loss are tabulated in
effective and economically efficient alternative to open table 1,2,3,4 respectively. The average age group of
surgery. It is known that the laparoscopic approach is patients included in this study were between 25- 80 years
associated with a shorter hospitalization, faster recovery, with mean age of 51.05 years. Out of 257 patients 232
lower risk of thromboembolic complications, and were female patients and 25 were male patients. Out of
postoperative infections. 257 patients 73 belong to performance status 1, 149
belong to status 2, 35 belong to status 3. (Table 1)
In case of oncologic surgeries which need extensive
dissection, laparoscopic surgeries help in minimising the In the 257 patients included in our study 145 had
morbidity compared to open surgeries. Further surgeries carcinoma cervix, 51 had carcinoma rectum and anal
done before giving chemoradiotherapy (upfront surgeries) canal, 24 had carcinoma endometrium, 12 had carcinoma
are associated with less morbidity compared to surgeries ovary, 10 carcinoma bladder, 4 pelvic bone tumors, 6
done after giving chemoradiotherapy as there is distortion carcinoma vagina and 5 uterine sarcoma. (table 1)
of anatomy and fibrosis post chemoradiotherapy.
In this analysis we found that the mean duration of surgery
Intraoperative haemorrhage is the most frequent for Pelvic exenteration surgery, Low anterior resection,
complication of pelvic surgeries during dissection (Stolfi et Abdominoperineal resection and Anterior resection was
al., 1992). Appropriate preoperative planning, a meticulous 240 minutes each, Surgical staging and Hysterectomy 180
and consistent surgical technique and the appropriate minutes each, Cystectomy 210 minutes and sacrectomy
utilization of haemostatic adjuncts are potentially useful (anterior and posterior) 420 minutes.
strategies to minimize the risk of severe blood loss. Pelvic
haemorrhage is problematic due to the particular Of the 257 patients 72 underwent PE; average blood loss
anatomical arrangement of pelvic blood vessels within a was 550 ml in 20 patients who underwent laparoscopic
confined physical space. Injury to the presacral venous surgery and 920 ml in 52 patients who had open surgery
plexus (PSVP) and the sacral basivertebral veins during (p value=0.7).Thirty six patients underwent surgical
dissection in the retro-rectal plane may result in large staging; average blood loss was 250ml in 8 patients who
volume bleeding within a short time period (D’Ambra et al. underwent laparoscopic surgery and 460 ml in 28 patients
2009) who had open surgery (p value=0.6). Eight patients
underwent cystectomy; average blood loss was 450ml in 3
In this retrospective study the incidence of blood loss was patients who underwent laparoscopic surgery and 850 ml
studied in patients who underwent major pelvic oncological in 5 patients who had open surgery (p value=0.7). One
surgeries. hundred and five patients underwent hysterectomy;
average
TABLE 1: PATIENT CHARACTERISTICS
MATERIALS AND METHODS No. of patients: 257

The Intraoperative records of all 257 patients who Sex: Male: 25 (9.7%)
underwent Pelvic exenteration (PE), Surgical staging, Female: 232 (90.3%)
Interval cytoreduction (IC), Cystectomy, Hysterectomy,
Abdomino pelvic resection (APR), Anterior and Low PERFORMANCE STATUS:
Anterior resection (AR & LAR) from January 2012 to I : 73 (28.4%)
December 2018 in the age group of 25-80 years were II : 149 (58%)
collected from the database of our institution and III : 35 (13.6%)
information regarding blood loss and transfusions during
different procedures was analysed with student’s T test. DIAGNOSIS: NO. OF PATIENTS
Out of 257 patients 145 had carcinoma cervix, 51 had Carcinoma cervix 145 (56.4%)
carcinoma rectum and anal canal, 24 had carcinoma Carcinoma rectum and anal canal 51 (19.8%)
endometrium, 12 had carcinoma ovary, 10 had carcinoma Carcinoma endometrium 24 (9.3%)
bladder, 4 had pelvic bone tumors, 6 had carcinoma Carcinoma ovary 12 (4.7%)
vagina and 5 had uterine sarcoma. Details of intra Carcinoma bladder 10 (3.9%)
operative blood loss measured from suction canisters and Pelvic bone tumours 4 (1.5%)
gravimetric method (difference in preoperative and Carcinoma vagina 6 (2.3%)
postoperative weight of gauze used), transfusions Uterine sarcoma 5 (1.9%)
required, type of surgery, mean duration of surgery and PERIOPERATIVE MORTALITY:
details of chemoradiotherapy are collected and analysed. OVERALL: 4(1.5%)
POST APR: 1(4%)
POST PELVIC EXENTERATION: 3(4.1%)

Retrospective Analysis of Intra Operative Blood Loss in Pelvic Oncological Surgeries - A Single Institution Experience in 7 Years
 J. Cancer Clin. Oncol. 038

blood loss was 200ml in 50 patients who underwent chemoradiotherapy when compared to 220 ml in 60
laparoscopic surgery and 450 ml in 55 patients who had upfront cases of hysterectomy (p value=0.6). There was
open surgery (p value=0.6). Since we had less number of 640 ml blood loss in 25 patients who underwent surgery
patients in each group to analyse separately we had post chemoradiotherapy when compared to 310 ml in 7
clubbed APR/LAR/AR together. Thirty two patients upfront cases of APR/LAR/AR (p value=0.6). There was
underwent APR/LAR/AR; average blood loss was 320ml 1500 ml blood loss in 4 upfront cases of sacrectomy
in 20 patients who underwent laparoscopic surgery and laparoscopy was not used in sacrectomy cases.
690 ml in 12 patients who had open surgery (p value=0.6).
Four patients underwent sacrectomy with average blood TABLE 2: MEAN DURATION OF SURGERY
loss of 1500 ml, with more blood loss in posterior approach
than anterior approach. TYPE OF SURGERY MEAN DURATION
OF SURGERY
In our study there was 970 ml average blood loss in 45 (minutes)
patients who underwent surgery post chemo radiotherapy 1. PELVIC EXENTERATION 240
when compared to 480ml in 27 upfront pelvic exenteration 2. LAR/APR/AR 240
cases (p value=0.6). There was 440ml blood loss in 30 3. SURGICAL STAGING/IC 180
patients who underwent surgery post chemoradiotherapy 4. HYSTERECTOMY 180
cases when compared to 260 ml in 6 upfront cases of 5. CYSTECTOMY 210
surgical staging (p value=0.7).. There was 870ml blood 6. SACRECTOMY (ANTERIOR+ 420
loss in 2 patients who underwent surgery post POSTERIOR )
chemoradiotherapy cases when compared to 420 ml in6 2 staged procedure
upfront cases of cystectomy (p value=0.6). There was 420
ml blood loss in 45 patients who underwent surgery post

TABLE 3: COMPARISON OF AVERAGE BLOOD LOSS BETWEEN LAP AND OPEN PELVIC PROCEDURES
TYPE OF SURGERY NO. OF AVERAGE BLOOD LOSS in ml P VALUE* NO. OF
CASES TRANSFUSIONS
LAP(no. of OPEN(no. of LAP OPEN
patients) patients)
PELVIC EXENTERATION 72 550 (20) 920 (52) 0.7 5 29
SURGICAL STAGING/IC 36 250 (8) 460 (28) 0.6 1 6
CYSTECTOMY 8 450 (3) 850 (5) 0.7 0 3
HYSTERECTOMY 105 200 (50) 450 (55) 0.6 0 7
APR/LAR/AR 32 320 (20) 690 (12) 0.6 2 6
SACRECTOMY 4 1500(4) 4
*student’s t – test

TABLE 4: COMPARISON OF AVERAGE BLOOD LOSS BETWEEN UPFRONT AND POSTCHEMORADIOTHERAPY

CASES
TYPE OF SURGERY POST CRT AVERAGE BLOOD UPFRONT AVERAGE BLOOD P VALUE*
CASES LOSS CASES LOSS
POST CRT(ml) UPFRONT(ml)
PELVIC EXENTERATION 45 970 27 480 0.6
SURGICAL STAGING/IC 30 440 6 260 0.7
CYSTECTOMY 2 870 6 420 0.6
HYSTERECTOMY 45 420 60 220 0.6
APR/LAR/AR 25 640 7 310 0.6
SACRECTOMY Nil 4 1500
*student’s t – test
Number of transfusions required in patients who DISCUSSION
underwent laparoscopic surgeries is less compared to
those who underwent open surgeries (8 vs 55). In our The incidence of presacral haemorrhage during pelvic
retrospective analysis we found that surgeries done dissection has been reported to be between 4.6 - 9.4 %.
laparoscopically had less average blood loss when The challenging anatomy is complicated by the
compared to open surgeries and upfront surgeries had vasodilatory properties of anaesthetic drugs and the
less average blood loss compared to surgeries done post lithotomy position frequently utilized in pelvic surgery,
chemoradiotherapy (CRT). resulting in sacral venous pooling and increased
hydrostatic pressure exacerbating blood loss (Hill et al.,

Retrospective Analysis of Intra Operative Blood Loss in Pelvic Oncological Surgeries - A Single Institution Experience in 7 Years
Shanmugam et al. 039

1994; Wang et al., 1985). Blood transfusions have been less intra operative blood loss in laparoscopic surgeries
associated with number of complications like transfusion (78 vs 248) ml. Tae Wook Kong et al (2010) also had
reactions, transfusion related lung injury and transfusion similar results when compared with our study.
associated circulatory overload, allergic reactions,
transmitted infections and coagulation abnormalities. The Pedro T Ramirez et al (2018) study of minimally invasive
transfusion rate correlated with the reported frequency of hysterectomy was associated with lower rates of blood
allogenic blood transfusions in colorectal cancer surgery is loss in laparoscopic surgery compared to open surgeries
between 32 and 68 %. Transfusions during sacrectomies (164+/-131 vs 595+/-284) ml. We had similar results when
and exenterations were associated with high risk of compared with our study.
morbidity (Harlaar et al., 2012, Melton et al., 2006; Bansal
et al., 2009). Nosov et al performed a prospective analysis of
laparoscopic vs open radical cystectomy in 42 patients
Pelvic packing was shown to provide a simple and which concluded that intra operative blood loss is lower in
effective tamponading technique. Care needs to be taken laparoscopic cystectomy when compared to open surgery
on removal of the packing, which may disturb any clot (285 vs 77) ml. Julien Guillotreau et al (2009) also had
formed with resultant pooling of blood obscuring the similar results when compared to above study and our
source of the bleed. In addition, packing may cause a rise study. In our study on radical hysterectomy (shanmugam
in intra-abdominal pressure or excessive inferior vena et al., 2018) we found that post chemo radiotherapy
cava (IVC) compression while repeated packing may patients had more blood loss compared to upfront
cause shearing of the delicate veins in the PSVP hysterectomy cases (350 vs 200) ml due to distorted
(Timmons et al., 1991). anatomical planes and fibrosis.

One case of recurrent uterine sarcoma died Andrea Petruzziello et al (2014) study on surgical results
intraoperatively due to severe blood loss, one case of APR of pelvic exenteration in the treatment of gynaecologic
had secondary haemorrhage and collapsed before shifting cancer had a perioperative mortality rate of 4 out of 28
to operation theatre. One case of vault recurrence that patients compared to 3 out of 72 patients in our study.
underwent open total pelvic exenteration with 800ml blood Rutegard M et al (2010-11) study on rectal cancers had a
loss and 1 intraoperative blood transfusion went into acute mortality rate of 1.5% for APR surgeries compared to 4%
renal failure. One case of carcinoma cervix post RT in our study.
recurrence that underwent total pelvic exenteration with
wet colostomy with 1000 ml intraoperative blood loss and Blood loss during surgery leads to decreased immunity,
2 transfusions died in 1st post-operative day. hypotension leading to decreased perfusion of vital
organs, increased anastomotic leak rates, acute kidney
The emergence of laparoscopic surgery in pelvic injury, increased infection rate, transfusion reactions,
oncological surgeries is an important milestone of the transfusion related infections all of which can be minimised
modern surgery. This revolution means the arrival of the by meticulous surgery with proper anatomic knowledge
minimal invasive surgery. Compared with open procedure, and adequate control of intraoperative bleeding.
less intraoperative blood loss, less postoperative pain and
shorter hospital stay are the outstanding advantages of the In our patients bleeding was controlled intraoperatively by
laparoscopic procedure. ligation of the bleeding vessel, cauterisation of the bleeder,
and by pelvic packing. In our hospital as a routine measure
Even though there is no statistical significance in blood we will do pelvic packing for all exenteration cases and
loss between laparoscopic and open, upfront and post some cases of APR before closing abdomen which will be
chemoradiotherapy cases in our study there is clinically removed after 48 hours through perineal wound.
significant difference in less blood loss, less no. of Intraoperative bleeding in pelvic oncological surgeries can
transfusions and early recovery in laparoscopic surgeries. be controlled by preoperative optimisation by prophylactic
Kunlin Yang et al (2015) performed a study in 11 cases tranexamic acid, preoperative optimisation of the patient,
that underwent laparoscopic total pelvic exenteration vs preoperative embolization of the suspected vessel if
open total pelvic exenteration which concluded that there significant bleeding is anticipated.
was less blood loss, early recovery time and shortened
duration of hospital stay. Comparing our results with above
study we found laparoscopic PE had lesser blood loss CONCLUSION
hence early recovery. Atsushi Ogura et al (2016) also
concluded that blood loss was less and lesser number of Laparoscopic surgery in pelvic oncological surgeries has
transfusions in laparoscopic pelvic exenteration surgeries become a benefit to surgeons because of less
when compared to open surgeries. intraoperative blood loss, reduced hospital stays and
better outcomes. Though laparoscopic surgeries require a
Ling Hui Chu et al (2016) performed a study of learning curve, extensive anatomical knowledge about the
laparoscopic vs open surgical staging in 151 patients had procedure during open surgeries have made the learning

Retrospective Analysis of Intra Operative Blood Loss in Pelvic Oncological Surgeries - A Single Institution Experience in 7 Years
 J. Cancer Clin. Oncol. 040

curve less steep leading to lesser morbidity. Blood loss in hospitalization,” Archives of Surgery, vol. 136, no. 4,
upfront cases is less than that of post chemoradiotherapy pp. 391–398, 2001.
cases leading to less infection rates, better recovery and Kong TW, Lee KM, Cheong JY, Kim WY, Chang SJ, Yoo
with increase in duration of surgery, blood loss is more. SC, Yoon JH, Chang KH, Ryu HS. Comparison of
laparoscopic versus conventional open surgical
staging procedure for endometrial cancer. Journal of
FUNDING SOURCES gynecologic oncology. 2010 Jun 1;21(2):106-11.
M. W. Buchler, M. Wagner, B. M. Schmied et al., “Changes
No funding required in morbidity after pancreatic resection: toward the end
of completion pancreatectomy,” Archives of Surgery,
vol. 138, no. 12, pp. 1310–1315, 2003.
DISCLOSURE SECTION M. W. Saif, N. Makrilia, A. Zalonis, M. Merikas, and
None K.Syrigos, “Gastric cancer in the elderly: an overview,”
European Journal of Surgical Oncology, vol. 36, pp.
709–717, 2010.
CONFLICTS OF INTEREST Melton GB, Paty PB, Boland PJ et al (2006) Sacral
resection for recurrent rectal cancer: analysis of
None morbidity and treatment results. Dis Colon Rectum
49:1099–1107
Mohandas KM, Desai DC. Epidemiology of digestive tract
REFERENCES cancers in India. V. Large and small bowel. Indian
journal of gastroenterology: official journal of the
Bansal N, Roberts WS, Apte SM, Lancaster JM, Wenham Indian Society of Gastroenterology. 1999;18(3):118-
RM (2009) Electrothermal bipolar coagulation 21.
decreases the rate of red blood cell transfusions for Naik DS, Sharma S, Ray A, Hedau S. Epidermal growth
pelvic exenterations. J SurgOncol100:511–514 factor receptor expression in urinary bladder cancer.
C. R. Boyd, M. A. Tolson, and W. S. Copes, “Evaluating Indian journal of urology: IJU: journal of the Urological
trauma care: the TRISS method. Trauma Score and Society of India. 2011 Apr;27(2):208
the Injury Severity Score,” The Journal of Trauma, vol. Nosov A, Reva S, Djalilov I, Petrov S. Comparison of Open
27, pp. 370–378, 1987. and Laparoscopic Radical Cystectomy for Bladder
Chu LH, Chang WC, Sheu BC. Comparison of the Cancer: Safety and Early Oncological Results.
laparoscopic versus conventional open method for Ogura A, Akiyoshi T, Konishi T, Fujimoto Y, Nagayama S,
surgical staging of endometrial carcinoma. Taiwanese Fukunaga Y, Ueno M. Safety of laparoscopic pelvic
Journal of Obstetrics and Gynecology. 2016 Apr 1;55 exenteration with urinary diversion for colorectal
(2):188-92. malignancies. World journal of surgery. 2016 May 1;40
D’Ambra L, Berti S, Bonfante P, Bianchi C, Gianquinto D, (5):1236-43.
FalcoE (2009) Hemostatic step-by-step procedure to Petruzziello A, Kondo W, Hatschback SB, Guerreiro JA,
control presacral bleeding during laparoscopic total Panegalli Filho F, Vendrame C, Luz M, Ribeiro R.
mesorectal excision. World J Surg 33:812–815. Surgical results of pelvic exenteration in the treatment
G. P. Copeland, D. Jones, and M. Walters, “POSSUM: a of gynecologic cancer. World journal of surgical
scoring system for surgical audit,” British Journal of oncology. 2014 Dec;12(1):279.
Surgery, vol. 78, no. 3, pp. 355–360, 1991. R. M. Merion, “Current status and future of liver
Guillotreau J, Gamé X, Mouzin M, Doumerc N, Mallet R, transplantation,” Seminars in Liver Disease, vol. 30,
Sallusto F, Malavaud B, Rischmann P. Radical no. 4, pp. 411–421,2010.
cystectomy for bladder cancer: morbidity of Ramirez PT, Frumovitz M, Pareja R, Lopez A, Vieira M,
laparoscopic versus open surgery. The Journal of Ribeiro R, Buda A, Yan X, Shuzhong Y, Chetty N, Isla
urology. 2009 Feb;181(2):554-9. D. Minimally invasive versus abdominal radical
Harlaar JJ, Gosselink MP, Hop WC, Lange JF, Busch OR, hysterectomy for cervical cancer. New England
JeekelH (2012) Blood transfusions and prognosis in Journal of Medicine. 2018 Nov 15;379(20):1895-904.
colorectal cancer: long-term results of a randomized Rutegård M, Haapamäki M, Matthiessen P, Rutegård J.
controlled trial. Ann Surg256:681–686 (discussion Early postoperative mortality after surgery for rectal
686–687) cancer in S weden, 2000–2011. Colorectal Disease.
Hill AD, Menzies-Gow N, Darzi A (1994) Methods of 2014 Jun;16(6):426-32.
controlling presacral bleeding. J Am Coll Surg Shanmugam S, Govindasamy G, Hussain SA,
178:183–184. Narayanasamy G. LEARNING CURVE IN
J. H. Balcom, D. W. Rattner, A. L. Warshaw, Y. Chang, LAPAROSCOPIC RADICAL HYSTERECTOMY – IS
and C. Fernandez-Del Castillo, “Ten-year experience IT REALLY STEEP? A SINGLE INSTITUTION
with 733pancreatic resections: changing indications, EXPERIENCE. International journal of scientific
older patients, and decreasing length of

Retrospective Analysis of Intra Operative Blood Loss in Pelvic Oncological Surgeries - A Single Institution Experience in 7 Years
Shanmugam et al. 041

research. 2018;Volume-7 | | July-2018 | ISSN No 2277 Accepted 20 May 2019

- 8179 | IF : 4.758 | IC Value : 93.98(Issue-7):21-23.
Stolfi VM, Milsom JW, Lavery IC, Oakley JR, Church JM, Citation: Shanmugam S, Murugan A, Reddy KK (2019).
Fazio VW (1992) Newly designed occluder pin for Retrospective Analysis of Intra Operative Blood Loss in
presacral haemorrhage. Dis Colon Rectum 35:166– Pelvic Oncological Surgeries - A Single Institution
169 Experience in 7 Years. Journal of Cancer and Clinical
Timmons MC, Kohler MF, Addison WA (1991) Thumbtack Oncology 3(3): 036-041.
use for control of presacral bleeding, with description
of an instrument for thumbtack application.
ObstetGynecol78:313–315.
Uma Devi K. Current status of gynecological cancer care
in India. Journal of Gynecologic Oncology. 2009 Jun Copyright: © 2019: Shanmugam et al. This is an open-
1;20(2):77-80. access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted
Wang QY, Shi WJ, Zhao YR, Zhou WQ, He ZR (1985) New
use, distribution, and reproduction in any medium,
concepts in severe presacral haemorrhage during
provided the original author and source are cited.
proctectomy Arch Surg 120:1013–1020.
Yang K, Cai L, Yao L, Zhang Z, Zhang C, Wang X, Tang
J, Li X, He Z, Zhou L. Laparoscopic total pelvic
exenteration for pelvic malignancies: the technique
and short-time outcome of 11 cases. World journal of
surgical oncology. 2015 Dec; 13 (1):301.

Retrospective Analysis of Intra Operative Blood Loss in Pelvic Oncological Surgeries - A Single Institution Experience in 7 Years