Video-based characterization of intraoperative bleeding patterns and hemostasis behaviors in laparoscopic pancreaticoduodenectomy: a retrospective cohort study.

OBJECTIVE

To systematically characterize intraoperative bleeding patterns during laparoscopic pancreaticoduodenectomy (LPD) and conduct an in-depth analysis of hemostatic behavior and its association with hemostasis quality.

METHOD: We retrospectively collected 210 LPD surgical videos from 15 centers across China (2018-2022), of which 190 were enrolled. Two surgeons manually annotated bleeding events, causes, surgical phases, anatomical locations, bleeding types (arterial, venous, lymph node-related), and hemostasis behavior assessments [good hemostasis (GH), poor hemostasis (PH)). A surgical instrument detection model deployed on the SurgSmart platform extracted per-frame instrument usage and duration data. Hemostatic behaviors-including phase duration, hemostatic instrument utilization patterns, hemostatic instrument switching frequency, and the hemostatic complexity index (HCI) based on Simpson's diversity index-were compared by bleeding type and hemostasis behavior assessment category.

RESULTS

A total of 675 bleeding events were identified, occurring in 87.9% (167/190) of the surgical videos. The pancreatic uncinate process was recognized as the "high-risk bleeding zone," with the highest bleeding incidence observed in the superior mesenteric vein-portal vein axis (34.3%) and superior mesenteric artery-celiac trunk axis (17.4%). Venous bleeding was the most frequent type (n = 334, 49.5%), followed by arterial bleeding (n = 313, 46.4%) and lymph node-related bleeding (n = 28, 4.1%). Excessive tissue tension (41.6%) and incorrect anatomical plane dissection (28.1%) were the leading causes of bleeding. Regarding hemostatic behaviors stratified by bleeding type: venous bleeding exhibited the longest hemostasis duration (68.0 (30.0-148.0) s), and significant differences were observed in hemostatic instrument utilization patterns, instrument switching frequency, and the HCI across bleeding types (all P < 0.05). Comparisons between PH and GH groups revealed that PH groups had a significantly prolonged hemostasis duration (76.0 (29.0-171.5) s vs. 50.0 (24.0-118.0) s, P = 0.001), more frequent instrument switching (median 2.0 (0.5-6.0) vs. 1.0 (0.0-3.0), P < 0.001), and significantly distinct instrument utilization patterns (P = 0.004). Additionally, the HCI was significantly higher in PH groups than in GH groups (0.338 ± 0.233 vs. 0.286 ± 0.222, P = 0.008).

CONCLUSIONS

Our study systematically characterized bleeding sites, causes, and surgical phases during LPD, identifying procedure-specific high-risk anatomical regions and distinct bleeding mechanisms. We demonstrated that hemostatic instrument utilization patterns vary by bleeding type and correlate with hemostasis quality, and proposed the instrument HCI as an objective instrument-based metric for summarizing hemostatic behavior.

TRIAL REGISTRATION: Clinicaltrials.gov, number NCT06128603.