Abdominal access in laparoscopic surgery of obese patients: a novel abdominal access technique.

BACKGROUND: An important step in laparoscopic surgery is abdominal access. Several abdominal access techniques have been described to reduce complications. We compare our novel abdominal access technique (MESAD) with other abdominal access techniques, particularly to reduce complications in obese patients. OBJECTIVE: Compare the MESAD method and other methods we use for abdominal access in gynecologic laparoscopic surgery of obese patients DESIGN: Retrospective SETTING: Gynecology department in university hospital PATIENTS AND METHODS: Patients who underwent abdominal access by the MESAD technique, the Veress needle technique, and the Hasson technique were included in our study. In addition to demographic data, minor and major complications, number of unsuccessful attempts, conversion to another technique, and abdominal access times were collected from all patient files. MAIN OUTCOME MEASURES: Clinical data and complications SAMPLE SIZE: 66 patients, 26 by MESAD technique, 24 by the Veress needle technique, and 16 by the Hasson technique. RESULTS: There were two major complications (one in the Veress group and one in the Hasson technique group) and 7 minor complications. No significant difference was found between the groups in terms of complications (P=.477, P=.476, respectively). The fastest technique for abdominal access was in the MESAD technique whereas the slowest was in the Hasson (P<.001). The failure of abdominal access and subsequent conversion to another technique was most common in the Veress group. However, no significant difference was found between the groups (P=.092). CONCLUSIONS: The MESAD technique is an easy method to both learn and teach. We think that the low major-minor complication rates in the MESAD technique will allow surgeons to reduce their anxiety at the first entry and to perform a more comfortable operation. LIMITATIONS: Retrospective CONFLICT OF INTEREST: None.

Cosmetic outcomes of infraumbilical, supraumbilical, and transumbilical entry routes in laparoscopic surgery.

OBJECTIVE: The aim of the present study was to determine which of the umbilical entry routes for intraperitoneal access has a better cosmetic result. MATERIAL AND METHODS: This was a prospective study (Canadian Task Force classification II-1). In total, 105 patients who underwent laparoscopic surgery were included. A vertical or transverse umbilical incision is appropriately made for the trocar to be inserted, and an infraumbilical, supraumbilical, or transumbilical route was preferred for initial intraperitoneal access. Demographic data of patients, body mass indices, entry point of the trocars (infraumbilical-transumbilical-supraumbilical), type of incision (vertical-transverse), duration of the operation, and scar properties at postoperative week 12 were prospectively collected and analyzed. The Vancouver scar scale was used to evaluate the cosmetic results. RESULTS: Cosmetic results did not differ statistically between the transumbilical-infraumbilical-supraumbilical groups. The variables, such as vascularity, height, and total score, of the Vancouver scar scale were significantly higher in patients who had transverse incisions. There was no statistically significant effect of using a Veress needle with the cosmetic results. There was no statistically significant correlation between age, gravida, body mass indices, skin thickness, time of entry, duration of the operation, and cosmetic results in terms of vascularity, height, and total score. CONCLUSION: During laparoscopic surgery, each patient should be assessed individually for the satisfaction of the patient and, thereby, of the surgeon in terms of cosmetic outcomes. Vertical incision offers superior cosmetic effects than transverse incision. Further research is required to define long-term scar-related outcomes of the laparoscopic intraperitoneal access techniques.

Modified abdominal packing method in "near miss" patients with postpartum hemorrhages.

OBJECTIVE: To describe a more effective abdominal packing method in patients with disseminated intravascular coagulation following peripartum hysterectomy due to postpartum hemorrhage (PPH). MATERIALS AND METHODS: The present retrospective and descriptive study was conducted to document six cases with refractory pelvic bleeding who underwent a second surgery for PPH between January 2016 and December 2017 at Istanbul Zeynep Kamil Woman and Children Diseases Training and Research Hospital. RESULTS: Karateke packing was performed to control intra-abdominal massive hemorrhages of five women who were referred to our clinic due to PPH who had undergone peripartum hysterectomy and hypogastric artery ligation but hemostasis could not be provided. In addition, a case of hypovolemic shock due to placenta percreta rupture in a woman who had also undergone an emergency hysterectomy and hypogastric artery ligation, which had failed. Hemostasis was provided in all patients. No method-related complication developed. CONCLUSION: Karateke packing is a very easy method to perform, it is more effective than the classic abdominal packing technique, with a low complication rate, and most importantly, life-saving in patients undergoing a peripartum hysterectomy due to PPH and thereafter experiencing diffuse hemorrhage.

Postpartum urinary retention: Evaluation of risk factors.

OBJECTIVE: Postpartum urinary retention means the absence of spontaneous micturition more than 6 hours after birth or when residual volume after urination is less than 150 cc. If neglected, postpartum urinary retention may result in bladder denervation and detrusor muscle weakness requiring intermittent catheterization or permanent micturition dysfunction. Our goal was to identify the possible risk factors for postpartum urinary retention. MATERIALS AND METHODS: Five hundred sixty female subjects were included in this retrospective study. All data obtained including variables such as age, parity, body mass index, duration of labor, prepartum bladder catheterization were compared between female subjects with and without postpartum urinary retention. RESULTS: Among the 560 patients recruited to our study, 124 (22.1%) had postpartum urinary retention. Third stage duration, time from birth to the first void, and number of peripartum micturitions were found to be potential risk factors for postpartum urinary retention. Different than other studies, our study revealed a correlation between peripartum catheterization and postpartum urinary retention. There were no statistically significant differences between patients with and without postpartum urinary retention in terms of other variables. CONCLUSION: In this study, a correlation between peripartum catheterization and postpartum urinary retention was found. There are studies that reported the possible risk factors related to the occurrence of postpartum urinary retention. More studies should be conducted to investigate long-term results with larger populations.

Vaginal axis on MRI after unilateral and bilateral sacral hysteropexy: a controlled study.

The objective of this study was to evaluate the vaginal position on magnetic resonance imaging (MRI) after bilateral abdominal sacral hysteropexy (BASH) and classical abdominal sacral hysteropexy (ASH) and to investigate which method keeps the vagina the most proximate to its original anatomical position. Ten patients, with 10 having BASH, 10 ASH and 10 being nulliparous, were compared. The angle between the vagina and the pubococcygeal plate, the angle between the upper and lower vaginal segments, the distance between the posterior fornix and the 2nd vertebra and the distances between the lateral fornices and spina ischiadica were measured on MRI. A p value less than .05 was considered statistically significant. The distance between the vaginal axis and the left spina ischiadica was greater in the ASH group compared to the control and the BASH group (p = .011, .047), while it was similar between the BASH group and the control individuals (p = .473). The angle between the upper and lower vaginal segments was greater in the ASH group compared to the control group (p = .004), while no significant difference was found between the BASH and control groups (p = .112). BASH keeps the vaginal axis at a more proximate location to its original anatomical position. IMPACT STATEMENT What is already known on this subject: In pelvic reconstructive surgery; the anatomic correction serves the functional results. What the results of this study add: On MRI examination bilateral abdominal sacral hysteropexy (mimicking uterosacral ligament), keeps the vagina closer to the original anatomic position than classical abdominal sacral hysteropexy. Hence functional outcomes could be better, especially in the long term. What the implications are of these findings for clinical practice and/or further research: This study may be of interest for clinicians in terms of different methods for pelvic floor surgery and may be of interest for researchers to investigate the relationship between anatomic position and functional outcomes especially in younger patients.

Outcome of Cesarean Myomectomy: Is it a Safe Procedure?

OBJECTIVE: Myomectomy performed during cesarean section is still controversial because of the potential for associated complications, especially with large myomas. Many obstetricians avoid performing cesarean myomectomy procedures because of the risk of uncontrollable hemorrhage. However, the prevalence of pregnant women with myomas is increasing, leading to an increase in the likelihood that physicians will encounter this issue. The aim of this study was to compare outcomes and complications of patients who either had or did not have cesarean myomectomy. METHOD: A total of 361 patients were evaluated in this retrospective study. Patients who had cesarean section with myomectomy and patients had cesarean section without myomectomy were compared with regard to demographics, drop in hemoglobin levels, complications, blood transfusion rates and duration of operation. These parameters were also compared when the diameter of the myoma was larger than 5 cm. Values of p < 0.01 and p < 0.05 were considered statistically significant. RESULTS: While maternal age and gravidity were similar in both groups (p > 0.05), the mean myoma diameter was smaller and the duration of operation was longer in the group who underwent cesarean myomectomy (p < 0.05). The reduction in hemoglobin level, rate of complications, and number of transfusions were similar in both groups (p > 0.05). CONCLUSION: This study shows that myomectomy during cesarean section does not increase complications or transfusion rates and appears to be a safe procedure.

A new operation technique for uterine prolapse: Vaginally-assisted laparoscopic sacrohysteropexy.

OBJECTIVE: To describe the new surgical technique and report the safety and feasibility of vaginally-assisted laparoscopic sacrohysteropexy (VALSH). MATERIALS AND METHODS: Thirty-three women with stage 3 or more uterine prolapse underwent VALSH operation. Patients were followed up for 12 months for mesh-related complications and improvements of symptoms. The operation had three sections; 1st laparoscopic, 2nd vaginal, 3rd laparoscopic. RESULTS: The mean age, gravidity, and parity of the study population were 46.5 years (range, 25-68 years), 4.3 (1-9), and 2.9 (1-6), respectively. The mean duration of operation was 59.5 min (range, 20-120 min). There were significant differences between the pre- and post-operative values of pelvic organ prolapse quantification parameters, which were favorable in the latter evaluation (p<0.001); total vaginal length was preserved after surgery (p>0.05). CONCLUSION: VALSH is a safe and minimally-invasive procedure in uterovaginal prolapse, with favorable anatomic and functional outcomes at 12 months post-operatively.

Misinterpretation of Frozen Section in Endometrial Cancer Cases: Does It Have Any Effect on Disease-free and Overall Survival?

The aim of this study was to assess whether misinterpretation of frozen sections in endometrial cancer cases is associated with survival and determine the factors leading to mismatch. One hundred fifty endometrial cancer cases treated in Zeynep Kamil Maternity and Children's Health Training and Research Hospital between January 2010 and December 2014 were included in the study. Frozen sections and final histopathologic reports were screened from a prospectively collected database and analyzed on whether mismatch between the initial and the final reports has any impact on disease-free survival. There were 31 patients with mismatched frozen sections with the final report, whereas in 119 patients, frozen sections and final reports were consistent. The recurrence-free survival time was similar between groups (51 vs. 49, P=0.813). Overall survivals were also similar between groups (55 vs. 52, P=0.880). Frozen section misinterpretation does not affect disease-free and overall survival in endometrial cancer cases.

Comparison of Two Step LEEP and Cold Conisation For Cervical Intraepithelial Lesions to Decrease Positive Surgical Margins.

PURPOSE: To assess the success rates of two step loop electrosurgical excision procedure (LEEP) compared with conventional cold conization procedures for decreasing positive surgical margins. MATERIALS AND METHODS: This study was conducted on 70 patients who underwent colposcopic evaluation in Zeynep Kamil Women and Children's Health Training and Research Hospital between 20132015 with indications of CIN 2/3 or persistent CIN 1 for more than 2 years. The study included age matched groups of patients with similar histopathololical lesions who underwent cold conization (n=40) or LEEP (N=30). RESULTS: Comparison of tissue characteristics between the two groups revealed significantly higher deepest depth and lower volume of tissue removed by the two step LEEP. Ectocervical positivity rate was similar between groups (1/39 versus 0/29, P>0.05), while endocervical surgical margin positivity rate was significantly higher in the cold conization group (9/39 versus 0/29, P<0.05). Surgical margin positive cases were significantly older than the cases with negative margins (P<0.05). CONCLUSIONS: Two step LEEP made it easier to reach the squamocolumnar junction in the endocervical region with lower blood loss and applicability in office settings. Our study suggests to use two step approach in cases with high grade and glandular CIN.

Changing trends in emergency peripartum hysterectomy in a tertiary obstetric center in Turkey during 2000-2013.

OBJECTIVE: To evaluate emergency peripartum hysterectomy (EPH) cases over a 14-year period in a tertiary center in Istanbul, Turkey. MATERIAL AND METHODS: In this retrospective descriptive study, the records of all cases of EPH performed at the Zeynep Kamil Women and Children's Training and Research Hospital between January 2000 and January 2014 were analyzed. Results for 2000-2006 and 2007-2013 were compared to identify changing trends. Demographic and clinical factors associated with EPH were assessed. RESULTS: During the 14-year study period, a total of 161,836 births occurred, out of which 104,783 (64.8%) were vaginal deliveries and 57,053 (35.2%) were cesarean section (CS). EPH was performed in 81 patients with an overall incidence of 0.5 in 1000 deliveries. The EPH rate in 2007-2013 (0.07%) was significantly higher than in 2000-2006 (0.03%). The major difference in the EPH populations between the two periods was the higher number of previous CS in 2007-2013 compared with 2000-2006 (p=0.01). Indications for EPH did not differ between the two periods. There were 7 (8.6%) maternal deaths in 2000-2013, with significantly fewer maternal deaths in 2007-2013 than in 2000-2006 (19.2% vs. 3.6%). CONCLUSION: Rate of EPH increased considerably from 2000 to 2013. This increase was mostly related to the increasing rate of CS. Indications for EPH did not change over the study period, and the number of maternal deaths markedly decreased.

Does performing cesarean section after onset of labor has positive effect on neonatal respiratory disorders?

OBJECTIVE: The aim of this study is to evaluate whether neonatal respiratory disorders relate to the onset of labor or labor pain in patients with history of previous cesarean section. METHODS: This prospective controlled study comprised 164 patients, grouped according to the presence of labor and related labor pain. All patients in both groups were applied cesarean section at 38 weeks gestational age or beyond due to previous cesarean section. The cord blood pH, Apgar scores and the need for the neonatal intensive care unit were compared. RESULTS: There was a greater need for the neonatal intensive care unit in the control group and the cord blood pH values were higher in the study group (p < 0.05). No significant difference was determined between the groups in respect of Apgar scores (p > 0.05). CONCLUSION: The onset of labor and related labor pain provide a positive contribution to a reduction in neonatal respiratory disorders. Therefore, it can be considered reasonable to perform a cesarean section after the onset of labor or related pain.

Shorter the cervix, more difficult the placenta percreta operations.

BACKGROUND: To determine the impact of cervical length (CL) on the clinical outcome of patients undergoing peripartum hysterectomy due to placenta previa/percreta. OBJECTIVE: To assess the association of CL with clinical outcomes in such patients. METHODS: We analyzed the data of patients who were diagnosed with anterior placenta previa/percreta prenatally and subsequently underwent peripartum hysterectomy at our tertiary care institution between 2004 and 2014. The sonographic images and measurements of CL were obtained from prospectively collected database. The duration of operation, units of blood products transfused, and length of stay in the hospital were recorded. Patients were stratified according to CL, and receiver-operating characteristics curves were used to determine the cut-off length for identification of patients at high risk of intra-operative difficulty. RESULTS: Sixty-one patients were included in this study. Number of packages of ES were correlated with the the duration of operation (r = 0.666, p < 0.001) and the CL (-0.793, p < 0.001). Number of packages of fresh frozen plasma was significantly correlated with the CL (-0.642, p < 0.001) and the duration of operation (r = 0.606, p < 0.001). Gestational age (AUC = 0.683, p = 0.014) and the CL (AUC = 0.980, p < 0.014) were significant predictors for the number of ES transfused > 4 packages. The cut-off value of four packages was determined according to the median level of packages transfused. Optimal cut-off value for the CL to predict transfusion ≤ 4 packages was 20.5 with 93% sensitivity and the 99% specificity. CONCLUSIONS: Short cervix appears to be a cause of difficulty in placenta previa/percreta operations. CL may also help in determining the timing of delivery in placenta percreta patients.

Association between maternal serum 25-hydroxyvitamin D level and pre-eclampsia.

OBJECTIVES: The objective of the study was to evaluate the association of maternal plasma levels of 25-hydroxyvitamin D (25(OH)D) at late second and third trimester and the risk of pre-eclampsia. METHODS: In this prospective cohort study, maternal plasma 25(OH)D levels were measured at late second and third trimester in 77 women who later developed pre-eclampsia (31 non-severe and 46 severe cases) and 180 women without pre-eclampsia. RESULTS: The mean gestational age of the timing of the blood sampling was 31.1 ± 4.4 at control group, 32.6 ± 5.7 at non-severe pre-eclamptic group and 32.3 ± 5.4 at severe pre-eclamptic group. The mean 25(OH)D concentration was significantly low in severe pre-eclampsia group (5.8 ± 4.5 ng/ml) than non-severe pre-eclampsia (11.8 ± 7.3 ng/ml, p = 0.039) and control groups (14.9 ± 12.0 ng/ml, p < 0.0001). There was no statistically significant difference in 25(OH)D concentration between non-severe pre-eclamptic and control groups (p = 0.404). In women with 25(OH)D concentration <20 ng/ml, a 12.45-fold increase in the odds of severe pre-eclampsia were detected. CONCLUSION: Women with severe pre-eclampsia had low serum 25(OH)D levels. The correlation between maternal 25(OH)D levels and aspartate aminotransferase, alanine transaminase, serum creatinine levels, platelet count were not determined. 25(OH)D levels may be used as an independent predictive marker of severe pre-eclampsia.

Comparison of the Effect of Laparoscopic and Abdominal Hysterectomy on Lower Urinary Tract Function, Vaginal Length, and Dyspareunia: A Randomized Clinical Trial.

OBJECTIVES: The effect of hysterectomy on vesicourethral and sexual functions remains controversial. The primary objective of this study was to compare the effects of a laparoscopic hysterectomy and a total abdominal hysterectomy on lower urinary tract function. The secondary aims were to compare the two surgeries in terms of postoperative vaginal length and dyspareunia. MATERIALS AND METHODS: This was a prospective randomized clinical study in which 292 women were assigned to either the laparoscopic hysterectomy (n = 146) or total abdominal hysterectomy (n = 146) groups. The vaginal length and urodynamic measurements were taken, and the patients were asked to grade the presence and severity of dyspareunia using a visual analog scale 3 weeks before and 12 weeks after the surgery. The relationship between the postoperative vaginal length and the incidence of dyspareunia was evaluated. The urodynamic procedures used included uroflowmetry and voiding cystometry to record the maximum flow rate (Q-max) and to assess the bladder capacity. RESULTS: The preoperative vaginal length was similar between the groups, whereas the postoperative vaginal length was significantly longer in the laparoscopic hysterectomy group. When the 15 patients who developed postoperative dyspareunia were evaluated, no differences in the postoperative vaginal length were seen, but a significant difference in the change in the length of the vagina was found when compared with the other patients. No significant difference was found with regard to pre- and postoperative Q-max, bladder capacity, and change in bladder capacity between the study groups. CONCLUSIONS: The change in the length of the vagina was much more remarkable after total abdominal hysterectomy, compared with laparoscopic hysterectomy. It seems that the Q-max and the bladder capacity increase after hysterectomies, regardless of the surgical type. Further prospective randomized comparative studies are warranted to ascertain whether laparoscopic hysterectomies cause less damage to the pelvic floor, compared with abdominal hysterectomies.

Effectiveness of local anesthetic on postoperative pain in different levels of laparoscopic gynecological surgery.

PURPOSE: The aim of this study was to assess the effects of preemptive and preclosure analgesia on postoperative pain intensity in patients undergoing different levels of laparoscopic surgery. METHODS: Two hundred and twenty-six patients who underwent laparoscopic gynecological surgery were enrolled in this quasi-randomized, prospective, placebo controlled study. The operations were classified as level 1 or level 2 according to the extent of the surgery. Lidocaine 1 % was administered at the port sites before making the incision in the preincisional study group. In preincisional control group, same amount of saline was infiltrated in same manner. Lidocaine 1 % was infiltrated at the port site immediately after removing the trocars in preclosure study group. In preclosure control group, the same amount of saline was infiltrated in the same manner. Postoperative pain intensity was evaluated by linear visual analogue scale. RESULTS: It was found that preclosure lidocaine infiltration was more effective on postoperative pain intensity than its placebo group in level 1 and level 2 surgery groups at 1 and 2 h postoperatively. The administration of preincisional lidocaine improved postoperative pain scores significantly more than its placebo group in level 1 laparoscopic surgery group at 1 and 2 h postoperatively and in level 2 laparoscopic surgery group at 1 h postoperatively. CONCLUSION: Lidocaine infiltration at port sites had beneficial effects on pain intensity in the early postoperative period after laparoscopic gynecological surgery. However, the results of present study showed that the analgesic effect mechanism of local anesthetic was unrelated to the preemptive analgesia hypothesis.

The Effect of Intrauterine Lidocaine and Rectal Indomethacin on Pain during Office Vaginoscopic Hysteroscopy: Randomized Double-Blind Controlled Study.

BACKGROUNDS/AIMS: The aim of this study was to investigate the effect of rectal and intrauterine anesthesia during vaginoscopic hysteroscopy. METHODS: This was a randomized, double-blind, placebo-controlled study. Patients were randomized to rectal indomethacin, intrauterine lidocaine and placebo groups. Patients with conditions that could cause or contribute to pelvic pain were excluded. Pain was evaluated with Visual Analog Scale, when the cervical canal was passed, while within the cavity and at 10 min after procedure. The Analog Pain Scale scores of the 3 groups were compared with the Kruskal-Wallis 1-way analysis of variance test. A value of p < 0.05 was accepted as statistically significant. RESULTS: The study included a total of 206 patients. No difference was seen between the groups in respect of indication, age, gravid and duration of procedure. While the anesthesia was determined as superior to the placebo in reducing pain at all 3 stages (p < 0.05), intrauterine lidocaine was determined to be more effective than rectal indomethacin in reducing pain within the cavity and 10 min after the procedure (p < 0.05). CONCLUSION: Rectal or intrauterine anesthesia applied with the vaginoscopic technique is useful in hysteroscopy. However, intrauterine anesthesia is more effective in reducing pain.

Tumor Diameter for Prediction of Recurrence, Disease Free and Overall Survival in Endometrial Cancer Cases.

AIMS: To analyse the predictors of recurrence, disease free survival and overall survival in cases with endometrial cancer. MATERIALS AND METHODS: A total of 152 women diagnosed with endometrial cancer were screened using a prospectively collected database including age, smoking history, menopausal status, body mass index, CA125, systemic disorders, tumor histology, tumor grade, lymphovascular space invasion, tumor diameter, cervical involvement, myometrial invasion, adnexal metastases, positive cytology, serosal involvement, other pelvic metastases, type of surgery, fertility sparing approach to assess their ability to predict recurrence, disease free survival and overall survival. RESULTS: In ROC analyses tumor diameter was a significant predictor of recurrence (AUC:0.771, P<0.001). The optimal cut off value was 3.75 with 82% sensitivity and 63% specificity. In correlation analyses tumor grade (r=0.267, p=0.001), tumor diameter (r=0.297, p<0.001) and the serosal involvement (r=0.464, p<0.001) were found to significantly correlate with the recurrence. In Cox regression analyses when some different combinations of variables included in the model which are found to be significantly associated with the presence of recurrence, tumor diameter was found to be a significant confounder for disease free survival (OR=1.2(95 CI,1.016-1.394, P=0.031). On Cox regression for overall survival only serosal involvement was found to be a significant predictor (OR=20.8 (95 % CI 2.4-179.2, P=0.006). In univariate analysis of tumor diameter > 3.75 cm and the recurrence, there was 14 (21.9 %) cases with recurrence in group with high tumor diameter where as only 3 (3.4 %) cases group with smaller tumor size (Odds ratio:7.9 (95 %CI 2.2-28.9, p<0.001). CONCLUSIONS: Although most of the significantly correlated variables are part of the FIGO staging, tumor diameter was also found to be predictor for recurrence with higher values than generally accepted.

Laparoscopic staging of endometrial cancer: Does it have any impact on survival?

OBJECTIVE: To assess whether laporoscopic approach to endometrial cancer is associated with survival. MATERIALS AND METHODS: In total, 158 patients with endometrial cancer underwent staging surgery at a tertiary referral center, 30 of whom underwent laparoscopy, whereas the remainder received treatment with a conventional approach. Survival between groups was analyzed. RESULTS: The comparison of the groups revealed similar disease-free survival (p=0.791). Histology, cervical, adnexal and serosal involvement were found to be significantly correlated with recurrence in the laparoscopically staged group, whereas CA 125, histology, tumor grade, tumor diameter, cervical involvement, degree of myometrial invasion, adnexal and serosal involvement, and pelvic metastasis were significanly correlated with recurrence in the conventionally managed group. CONCLUSION: Laparoscopic approach to endometrial cancer, along with its widely accepted postoperative advantages, has similar disease-free survival but different variables affect recurrence rates.

Balloon tamponade for the management of postpartum uterine hemorrhage.

OBJECTIVE: To evaluate the use of the Bakri balloon in postpartum hemorrhage (PPH) resistant to medical treatment. METHODS: The Bakri balloon was applied to 45 women with PPH after failure of initial management. Bilateral internal iliac artery ligation (BIIAL) and hysterectomy were performed if necessary. RESULTS: The Bakri balloon was applied in 45 women; an additional BIIAL was required in nine women. The mean inflation volume of the Bakri balloon was 571±264 mL (range: 240-1300 mL). Hemostasis was achieved in 34 (75.5%) women with the Bakri balloon alone, and in six women with an additional BIIAL. The Bakri balloon was effective with additional procedures overall in 40 of 45 (88.8%) women. In 34 women with uterine atony, the Bakri balloon was successful alone in 27 (79.4%) and with an additional BIIAL in 30 (88.2%) women. An inflation volume of >500 mL was necessary in 18 women with uterine atony. CONCLUSION: The Bakri balloon may be performed as a first line of treatment for PPH resistant to uterotonic agents, and can be used not only in tertiary centers but also in limited-resource centers. The inflation volume of the Bakri balloon should be adjusted according to the type of PPH; a volume exceeding 500 mL may be necessary in uterine atony.