The Church of Jehovah´s witnesses has almost 8 millions of followers around the the world. Their number in the Czech Republic is estimated at approximately 13000 people. The most famous and debatable principle of their faith is refusal of blood transfusions. Similar to other women female Jehovah´s witnesses experience gynecological problems that often cannot effectively be treated conservatively resulting in the need for a surgical solution. This presents a serious challenge for the gynecologist who has to decide either to operate under these conditions or to not operate because of risk of potential bleeding complications which may have fatal consequences.

The adherence to the rules of minimally invasive procedures usually also means minimal blood loss. Nevertheless, it is not possible to exclude unexpected complications during surgery that may result in significant blood loss and a critical need to restore blood circulation. Though the principles of bloodless surgery are generally accepted and can usually prevent heavy bleeding, it is not completely possible to rule out situations in which the decisions treted to transfusion may result in a question of life or death.

Our study group includes 34 women who belonged to the Church of Jehovah´s Witnesses and were admitted for surgery to the Department of Obstetrics and Gynecology of the University Hospital in Olomouc, from 2007 to 2014. In agreement with their faith all women signed the Informed Consent form which included an unambiguous rejection of receiving blood or blood derivatives. All patients underwent medical examination and anesthesiology consultation before the surgery. The surgical treatment was always the only option or the most optimal alternative of treatment. All operations were provided by standard surgical procedures and techniques routinely used at the department with an emphasis on blood sparing techniques. All operations were performed by one of three experienced surgeons. The patient´s ages ranged from 42 to 72 years with a mean age of 54 years. The indication for the surgery was gynecological cancer in nine cases and the remaining 25 patients suffered from benign gynecologic diseases including uterine fibroids, uterine or vaginal prolapse, chronic metrorrhagia, urinary incontinence or endometrial polyps. Three operations for malignant gynecologic tumors were performed by robotic surgery. The patient´s consent to publish appropriate data was given orally.

No significant complications were observed during the surgery. Postoperative recovery was favorable in all cases. The hospital stay of the study patients did not differ from that of other patients. There was no need for blood transfusion.

Table 1 shows the diagnoses, surgical procedures and estimated blood loss during the operations.

Table 1: The diagnoses, surgical procedures and estimated blood loss during the operations. LAVH: Laparoscopic assisted vaginal hysterectomy, HSC: Hysteroscopy, BSO: Bilateral salpingo oophorectomy, TOT: Tension free transobturator vaginal tape, VH: vaginal hysterectomy, AH :abdominal hysterectomy, OE: Omentectomy, APE: Appendectomy, LSC: Laparoscopy, RTLH: Robot assisted total laparoscopic, LYP: Pelvic lymphadenectomy, LYPA: Paraaortic lymphadenectomy, SUI: Stress Urinary Inkontinence, POP: Pelvic organ prolapse.

During a professional career almost every gynecologist responsible for surgery has encountered a patient belonging to the Church of Jehovah´s witnesses who requested an operation without blood transfusion. This situation always results in many questions to be answered. The real need for blood transfusion during the planned surgical procedure is in most cases rather small, but every surgeon remembers situations where an apparently simple operation suddenly became complicated by unexpected heavy bleeding. The surgeon then has to decide how to proceed in such a situation. Legal regulations in different countries usually dictate how to proceed but there are still several questions that remain unanswered. The decision of how to address such patients depends on the personal opinion, responsibility and individual approach of the surgeon.

The Professional and Ethical Codex of the Czech Medical Chamber (Article 2, paragraph 5, No. 10) allows the surgeon to decline a request to operate on a patient refusing blood transfusion when the surgery is a planned not urgent procedure [1]. On the other hand it is an ethical and moral problem to refuse to operate on a patient, especially when the surgical treatment is the only or by far the most optimal course of treatment and the alternative non-surgical conservative treatment will not have a guaranteed acceptable result. However, it is very unethical if a surgeon refuses to operate on such patients particulary if sarcastic comments are made that offend the patient´s faith. We have been operating on Jehovah´s witnesses in our department for several years such that these patients frequently seek out our department for help. However this does not mean that we admit all patients who request that we perform an operation without blood transfusion. A thorough and responsible consideration of the most suitable treatment is an elementary requirement. An alternative conservative therapy that will bring similar results, must be always preferred. However, in many cases the surgical approach is the only possible therapeutic solution or at least the one that bringst far better benefit than other treatment modalities. In all cases we have to consider all risks of the planned surgical procedure and then carry out the operation only if the potential risk is acceptable.

A difficult situation may arise if a gynecologist meets a young patient with chronic menometrorrhagia resulting in severe sideropenic anemia. All efforts to control the excessive bleeding using conservative treatment failed and surgery is the only reasonable solution [2]. On the other hand, is it possible to risk general anesthesia and surgery on a patient suffering from severe or even critical anemia? The contemporary sophisticated surgical and anesthesiological techniques used by a skilled and experienced surgeon guarantee the performance of most routine operations with acceptable risk. There are only a few very complicated and high risk cases where surgery is not justified [3- 6].

The current operative techniques are primarily aimed not only at stopping and controlling bleeding but at preventing it. Almost all surgical procedures now can be performed without heavy bleeding and the need of transfusion [7-9]. The only exceptions are some extremely challenging operations such as organ transplantations or extensive operations for advanced malignant tumors.

The opposite extreme is the excessively self-confident uncritical surgeon who feels able to manage all possible dangerous complications. It is also irresponsible to indicate surgery in cases that are clearly or even marginally inoperable. The failure of such surgery with possibly fatal consequences would mean a tragedy not only for the patient but also for the conscience of the surgeon. In case of an unsuccessful tretment a well-formulated and signed negative informed consent may give the surgeon some protection against possible legal suits but it does not solve all of the potential problems. Nevertheless, it is always an essential and necessary part of the medical documentation [1,10]. The determination of which surgical procedure and technique are best for surgery on Jehovah´s Witnesses is relatively easy. They should be operated in the same way and with the same care as for any other patients. Unnecessary blood loss is always harmful for any patient not only for Jehovah´s witnesses. Blood transfusion is then only a final resort in case of life threatening bleeding. Bleeding and unnecessary blood loss are in many cases avoidable and often are caused by inexperience or carelessness of the surgeon. Blood transfusion itself always presents a certain health risk and inappropriate use has negative financial consequencies as well [11]. Appart from the replacement of acute blood loss no other positive therapeutic effects have been proven so far for transfusion in surgical patients. Our group of 34 Jehovah´s witnesses who were operated on in our department is not large enough to give statistically significant results. The sample consists of patients with various diagnosis who underwent various surgical procedures ranging from simple hysteroscopy to radical operations for gynecological malignancies. The most suitable operation for gynecological malignancies seems to be a robotic surgery. Compared with classical surgery the robotic procedure results in lower blood loss [12].

The results of the treatments of our group of 34 female Jehovah´s witnesses show that these patients can be safely operated without the need for blood transfusion. Prerequisit for successful treatment with acceptable minimal risk are the responsible indication for operation and the operation being performed by a skilled surgeon. The minimally invasive blood sparing operational techniques should be preferred. In severe complicated cases such as gynecological malignant tumors the robotic surgery should be preferred because it results in minimal blood loss. It is also important to fullfil all legal formalities including the patient´s preopartively signed Negative Informed Consent refusing blood transfusion.

The study was supported by the grant from the Ministry of Health of the Czech Republic No. NT 13566-4/2012.