Surgical Techniques and Procedures Quiz

Surgical Haemostasis

• Surgical haemostasis aims to stop bleeding during surgery.

• Understanding and managing surgical blood loss is essential for successful procedures, patient safety, and preventing complications.

• Proper technique minimizes blood loss, preserves tissue, and facilitates a clear surgical field.

• Recognizing the signs and importance of surgical blood loss is critical.

• Methods for measuring surgical blood loss include weighing surgical swabs, comparing dry and saturated swabs, and recording suctioned blood.

• Limiting intraoperative haemorrhage is key, involving planning, ligation, coagulation of vessels before cutting, and gentle tissue handling.

• Materials promote clotting, though their benefits and drawbacks should be considered.

• Dressings can help control bleeding post-operation.

• Haemostasis is the process of stopping bleeding.

• It allows good visualisation and decreases surgical time.

• Prevents post-operative infections (SSIs).

• Good tissue apposition is vital for post-operative healing.

• Bleeding is a normal part of surgery.

• The extent of haemorrhage is inversely proportional to the surgeon's skill.

• Preventative haemostasis, proper planning, and accurate dissection are vital.

• Significant bleeding can occur unexpectedly, during or after surgery.

• Maintaining IV access and monitoring blood pressure (BP) are crucial for volume resuscitation.

Intra-operative Haemostasis

• Proper surgical technique is crucial
• Meticulous surgical haemostasis is needed, including gentle tissue handling and appropriate instruments.
• Excellent knowledge of relevant anatomy and surgical procedure is needed.
• Normal haemostatic mechanisms must be considered.
• Awareness of diseases impacting haemostasis, such as bleeding disorders, is essential.

Intra-operative Blood Loss

• Blood loss is normal part of surgery.
• The amount of blood loss depends on the surgeon's technical skill.
• Preventative haemostasis, planning, and accurate dissection reduces blood loss.
• Significant haemorrhage could happen unexpectedly.
• Maintaining IV access and monitoring blood pressure (BP) aid volume resuscitation.

Shock

• Reduced tissue perfusion leads to reduced oxygen delivery.
• Clinical signs include sinus tachycardia/bradycardia, hypotension, poor pulse quality, cold extremities, pallor, and biochemistry changes (renal, lactate?).
• Untreated shock can be fatal.

Approach to Intra-operative Haemorrhage

• Recognizing and addressing blood loss is paramount.
• Ruling out the source of bleeding, including examining for suture malfunction, concealed bleeding, and accidental damage, is necessary.
• Restoring haemostasis is essential.
• Reversing hypothermia, shock, and other complications related to the bleeding is also critical.

Quantifying Blood Loss

• Blood loss during surgery should be estimated or measured.
• Swabs are used for assessing blood loss, and their weights are recorded.
• Blood essentially has a density similar to water (1 gram=1 ml).
• Blood losses on the floor or drapes should be estimated.
• Recorded volumes of flush use are calculated to determine blood loss.

Avoiding Surgical Bleeds

• Knowledge of the anatomy is critical prior to procedures.
• Good surgical preparation and planning are important steps.
• Appropriate surgical instruments (such as clamps and a sufficient surgical kit) and lighting are needed.
• Assistance during surgery is helpful.
• Proper tissue dissection and avoiding unnecessary cutting are important.
• Finger and blunt dissection are preferred techniques where applicable.

Prevention of Surgical Bleeds

• Awareness of potential bleeding disorders is vital.
• Pre-treating conditions like greyhounds fibrinolytic syndrome with Tranexamic Acid can be helpful, as well as being aware of breeds (e.g. Doberman Pinscher) predisposed to von Willebrand's disease.
• Other conditions that may contribute to bleeding disorders include: liver disease, platelet disorders, and coagulopathy.

Surgical Bleed (during the operation)

• Remain calm during surgical bleeds.
• Return to basic principles to determine the source of the bleed.
• Increase exposure, adjusting clips or drapes to more efficiently access the bleed.
• Ensure an assistant or additional support is available when needed.
• Use resources such as retractors, swabs, and suction to identify and isolate the source of bleeding and contain it.

Surgical Methods of Haemostasis

• Pressure (tamponade) is useful for smaller vessels and as an initial control of larger bleeds.
• Haemostatic forceps temporarily contain haemorrhage.
• Ligation techniques control bleeding with sutures.
• Vascular clips and sealing devices provide effective and rapid hemostasis in many cases; they are more precise and prevent complications.
• Electrocautery, radiosurgery and Vessel sealing devices stop bleeding via heat-based techniques.
• Topical haemostatic agents and antifibrinolytics aid in clotting and prevent breakdown of the clot.
• Tourniquets temporarily reduce blood flow in certain procedures; their use needs to be managed cautiously.

Direct Pressure (Tamponade)

• Useful for minor bleeds, initially controlling larger bleeds.
• Not suitable for major bleeds.
• Not suitable for patients who have coagulopathies.
• Compression should utilize swabs for pressure, and avoiding excessive pressure to prevent platelet migration is important.

Haemostatic Forceps

• Used to crush tissues and temporarily stop bleeding.
• Ratchets allow for proper positioning during clamping..
• Damage to surrounding vessels (vascular damage) can aid in clotting.
• Used for smaller blood vessels requiring time for normal clotting.

Using Haemostatic Forceps

• Use smallest forceps suitable for vessel size.
• Avoid unnecessary tissue grasp during use of forceps.
• Use curved forceps to maintain a clear view of the surgical site.
• Use a wide-based grip to immobilize tissues and identify bleed sources.
• Palming multiple forceps aids in management of numerous areas.
• Smaller vessels are managed using forceps tips.
• For larger vessels, forceps jaws are used.

Ligation

• Traditional and secure method of haemostasis.
• Not dependent on clot not dislodging.
• Reduces post-operative bruising.
• Maintains clear surgical field.
• Techniques include two-hand tie, one-hand tie, and instrument tie, surgeon knot, square knot, simple knot, and transfixing knot methods.

Ligating and Temporarily Occluding Vessels

• Pringle maneuver, utilizing clamps for temporary vessel occlusion is a surgical technique for preventing blood flow in the vessels, often utilized for easier surgical access or to reduce bleeding from a region.
• Clamps, bulldog clamps, and tourniquets can be used, optionally using red tubing or Penrose drains.

Different Techniques and Knots

• Two-hand: Produces good square knots, but is time-consuming and challenging for deep ligatures.
• One-hand: Creates square knots quickly but is less tactile, often used for deep ligatures.
• Knots are susceptible to loosening, which requires meticulous technique.
• Instrument tie: Easier, better-maintained knot quality, but with less tactile feel.
• Utilizes less suture material suitable for deep ligature placement.

Knots

• Square knot utilizes two opposing, similar knots.
• Reverses direction during knot tying for each knot throw.
• Maintain even tension throughout.
• Surgeon's knot loops first throw to improve security.
• Often useful in elastic or under-tension tissues.
• Bulky vascular pedicles have a reduced risk of unwrapping.

Knots (continued)

• Miller's knot loops over first layer twice with second overlap, using free end to loop and over first loop before pulling opposite directions and finish with square knots.
• Modified Miller's loops without overlaps.
• Pass free end to ensure both sides overlap before pulling in opposite directions.

Ligature Techniques

• Simple encircling creates a circular knot around the vessel.
• Modified transfixing uses a double-looping knot.
• Halsted transfixing is effective for deep-seated vessels.
• Figure-of-eight secures and holds the vessel to prevent future bleeding.
• Clamp technique often combines tightening multiple vessels, and releasing clamping for further action.
• Divide and Conquer involves dividing tissues, then tying these sutures.
• Stick ties provide an effective method for securing tissues.

Vascular Clips

• Metal clips, like Hemoclips, are used for hemostasis.
• Tissues are dissected, and vessels are clipped after determining diameter.

Electrosurgery

• Electrocautery (non-electrosurgery) is a technique for heating tissue and disrupting blood vessel walls.
• Electrosurgery/electrocoagulation uses electrical currents from the metal tip to the blood vessel.
• Heat is generated in the tissue to seal the vessel, allowing better hemostasis.
• May be better for smaller vessels, less than 2 millimeters in diameter.

Electrosurgery (diathermy)

• Monopolar operates with a ground plate under the patient.
• A current flows through the electrode and to the ground plate.
• If not properly grounded, current may cause burns.
• Requires a dry surgical field for optimal performance.
• Bipolar provides more precision for hemostasis

Radiosurgery

• Similar to electrosurgery, but uses high-frequency radio waves.
• Patient is not part of the circuit.
• No ground plate is necessary, so it does not require contact with skin.

Bipolar Diathermic Sealing Devices

• Sealing vessels up to 7mm using heat energy.
• Seals, signals with a beep, then cuts.
• Reduces risk of suture/ligature slippage.
• No foreign material left in tissues.
• Quicker surgical times than other methods, but tends to be more costly.

Hotblade

• Plugs into standard diathermy units but lacks automatic adjustment and cutting.
• Surgeon determines adequacy of coagulation visually.
• Knife uses ethylene oxide for sterilization.
• Is a cheaper option.

Other

• Harmonic scalpel uses ultrasonic energy for precise tissue cutting and coagulation.
• Lasers for surgery, provide better health and safety protocols, but are sometimes impractical.

Adrenaline

• Used to constrict small superficial wounds, or where diffusion of local bleeding is needed.
• Reduces blood flow to help clots form.
• Dilute solutions between 1:1,000 to 1:10,000. solutions are often used.

Topical Haemostatic agents

• Mechanical devices to provide pressure or tamponade to create a scaffold for clot formation are used.
• Can cause granuloma formation if used incorrectly.
• Thoroughly removed before closing the site is essential.

Topical Haemostatic Agents (continued)

• Biocompatible materials such as Gelfoam-Spongostan and Lyostypt are absorbed by the body in 3 weeks.
• Used in numerous surgical procedures like haemorrhoidectomy, and are absorbed in approximately 3 weeks.
• Bone wax temporarily blocks vascular channels

Active Topical Haemostatic Agents

• Autogenous muscle tissues are useful where tamponade, scaffold, and coagulation are required.
• Thrombin-gelatin aids blood clotting.
• Topical fibrin sealants (Evicel, Tisseel) immediately initiate clotting.
• Polyethylene glycol helps speed up coagulation

Antifibrinolytic

• Tranexamic acid (TXA) is a synthetic analogue of lysine.
• It inhibits plasminogen and prevents fibrin degradation, thus extending the duration of blood clots.
• Used primarily in greyhounds for surgery.

Coagulation Pathway Reminder

• The intrinsic and extrinsic pathways lead to the common pathway in the coagulation cascade.
• The main factors involved include Tissue factor, X, Xa, APPT, Plasminogen, Plasmin, etc.

Other

• Desmopressin increases the expression of von Willebrand's factor and Factor VIII.
• Decreases bleeding time in some breeds (e.g., some Dobermanns with vWD) and should be administered about 30 minutes before surgery.

Tourniquet

• Reduce arterial blood flow to the distal limb.
• Excessive use can cause ischemic damage (reduced blood flow leading to anaerobic respiration).
• In dogs, tourniquet time should not exceed 5 hours to avoid cardiac abnormalities or harmful potassium buildup.
• Should only be used for procedures lasting ~ 1 hour or less.

Esmarch Bandage

• Useful in lower limb surgery and digital amputation in various species, as well as in surgery of the horse.
• Exsanguination of the limb before surgery aids in efficient use.
• Bandage tightly wraps around the limb to prevent reperfusion.

Postoperative Haemorrhage (Delayed Haemorrhage)

• Ineffective haemostasis during surgery or post-surgery can lead to bleeding.
• Slipped ligatures, necrosis of the vessel and infections increase the possibility of delayed bleeding complications.
• Hypotension can mask injury in early post-operative stages, leading to delayed haemorrhage recognition.
• Inadequate secondary clot formations are common when there are blood clotting deficiencies.

Pressure

• Abdominal wraps/pressure bandages are used temporarily to control abdominal bleeding.
• They are used in haemoabdomen during surgery.
• Care must be taken to avoid impeding ventilation.
• They can reduce perfusion to abdominal organs and prevent movement; so they should have a clear purpose.