Haemostasis

Preventing bleeding

Ligature

• Suture choice
  • 2-0 vicryl is sufficient for most cases, for example when tying off the mesentery in a bowel resection
  • 2-0 prolene or silk may be a good choice for large named vessels e.g. IMA or splenic artery
• Technique
  • Large vessels
    • Tie in continuity
      • Free 1.5cm of vessel using blunt dissection (Mixter)
      • Tie it proximally - use a suture passer to give the tie to the Mixter jaws
      • Now tie distally
      • Leave 1cm stump on the end that's staying, 0.5cm on the specimen end
    • Tie with artery forceps
      • If unable to free sufficient length to give a 1cm stump, need to transfix about 3mm distal to the other ligature

Clips

• Useful only when the entire circumference is visible

Stapler

• Use the 2.5mm (white) vascular stapler to take big vessels
• Be careful there aren't any clips or other obstructing material in the tissue

Cautery

• Not to be used for vessels >2mm in diameter

Stopping bleeding - graded approach

• Physicochemical methods
  • Gauze pack
  • Topical:
    • Passive
      • Surgicel - $ - oxidised regenerated cellulose - can cause foreign body reaction, infection, adhesions. Works well if just minimal bleeding. Expect to absorb in 14 days.
      • Gelfoam - gelatine sponge
      • Bone wax - $ - physically occludes bleeding vessels - use a minimal amount.
    • Active
      • Tisseel - fibrin sealant - $$$$ - human fibrinogen and thrombin - liquid. Needs to be mixed just prior to use.
      • Floseal - $$ - gelatine and bovine thrombin complex - for active bleeding
      • Surgiflo - $$ - gelatine and porcine thrombin
      • Tranexamic acid - inhibits activation of plasminogen to plasmin
      • TachoSil - equine collagen sponge coated with fibrinogen and thrombin
    • Tissue adhesives
  • For minor ooze, surgicel is sufficient. For ongoing but mild bleeding, floseal should do the job. For ongoing bleeding, or in the coagulopathic patient, Tisseel may be necessary, but it is expensive.

Stopping major bleeding

• Need a graded response. Try and think in terms of your top 3 or 4 options for this bleeding, and deploy them in turn.
• Start with the simplest

1. Obtain temporary control (work your way through options until you have control)
   1. Compression - use finger/hand first
   2. Don’t panic
   3. Does the organ have a vascular pedicle to access?
   4. Elevate structure
   5. Compress with hand/gauze pad
   6. Vascular clamp such as Satinsky
   7. Proximal and distal control
2. Don't panic
   1. Is this a small problem or BIG TROUBLE?
      1. Bleeding rate vs accessibility defines this
      2. Attack small problems head-on
      3. Deploy multi-pronged, team-based approach for BIG TROUBLE
3. BIG TROUBLE
   1. Temporary control
   2. STOP
   3. Tell anaesthetist - they will need more blood from blood bank
   4. Autotransfusion device?
   5. Get equipment from nurses - vascular trays, thoracic trays, etc
   6. Figure out what equipment you will need
   7. Do we need more help?
   8. Improve exposure
   9. Don't fiddle with your temporary control

Packing

• Pack early
• Packing from without - you need pressure on both sides, you need to sandwich the organ
• Packing from within

Blind haemostatic suture

• Beware of major vessels close by - the bleeding could be coming from that vessel, so you need to expose it
• Monofilament suture (Prolene) on as big a needle as possible - a tapered needle with a half-curve is ideal
• Place first bite right on the site of bleeding, then lift up so you can see which side the bleeding is coming from
• Pull on the suture before tying to see if it works - you may want to turn the figure of 8 into a figure of 16
• Try something else if a single haemostatic suture doesn't work

Aortic clamping