Methods of Securing Hemostasis in Laparoscopic Surgery
Endoscopic surgery is controlled almost entirely by vision. Any loss of view will result in loss of control and a reduction in safety. Hemorrhage, even to a minor extent, tends to obscure the operative field and consequently to be avoided. This means that vessels of a size that in open surgery could be divided without particular attention need to be secured prior to division when working endoscopically. Dissection must be more meticulous to proceed smoothly and you must develop a disciplined approach.
Magnification of tissues by the endoscope may initially confuse an inexperienced endoscopic surgeon as to the severity of the bleeding. A moderate bleed can appear torrential but an inexperienced endoscopic surgeon is well advised to convert should he have any doubt about his ability to control the situation quickly.
• Pressure on the area applied by grasping adjacent tissue, and using this to overly and apply gentle pressure on to the area.
• Compression with pledget swab if the bleeding is not heavy until hemostasis is achieved by clipping or electrocoagulation and the sucker.
• Suction/irrigation to identify the bleeding point prior to securing it.
• Under-running by suture if the bleeding point cannot be identified.
• Argon spray coagulation for raw bleeding areas.
• Occluding the vessel with graspers before clipping it.
• Application of fibrin and other glues or hemostatic agents.
Avoid Blind Coagulation
Control the initial bleeding and then take your time to identify the bleeding point. In anatomically crowded areas containing important structures, it may be advisable to allow time for the bleeding to stop by compression for one or two minutes. If bleeding cannot be controlled inside within 5 minutes, serious consideration should be given for conversion to open surgery. This period should be shorter if bleeding is massive or arterial.
Suction and Irrigation
The availability of suction and irrigation is as important for hemostasis in endoscopic surgery as gauze swabs are in open surgery. When bleeding does occur irrigation can assist in visualization of the bleeding point and suction removes pooled blood and clears clots from the operative site. In addition, the irrigation activates the Hageman factor and thus initiates spontaneous hemostasis.
Heparinized Hartmann’s solution (1000 units per 500 ml bag) is ideal if clots are present. This solution is preferred to normal saline because of its lesser conductivity, an important consideration when using monopolar HF electrocautery.
The heparin also reduces the stickiness of the instruments and thus improves handling especially of suture and ligature materials. It also aids the removal of pooled blood. The bag of fluid is placed in a Fenwell pressure bag raised to 200 mm Hg and hung from a drip stand. As the contents of the bag are used the pressure needs to be maintained. There are several pressurized irrigation systems available, some heat the irrigating fluid to body temperature, others provide pulse irrigation which is helpful from breaking up blood clots and cleaning the peritoneal gutters. Suction and irrigation are also essential to deal with leakage from ultra-abdominal organs, e.g. bile leakage, bowel content, perforated ulcer, appendicitis. In these acute emergency situations, laparoscopic abdominal lavage of the peritoneal quadrants is aided by shaking the patient from side to side and changing the position of the operating table (head up, head down, and sideways).
Endoscopic surgery is controlled almost entirely by vision. Any loss of view will result in loss of control and a reduction in safety. Hemorrhage, even to a minor extent, tends to obscure the operative field and consequently to be avoided. This means that vessels of a size that in open surgery could be divided without particular attention need to be secured prior to division when working endoscopically. Dissection must be more meticulous to proceed smoothly and you must develop a disciplined approach.
Magnification of tissues by the endoscope may initially confuse an inexperienced endoscopic surgeon as to the severity of the bleeding. A moderate bleed can appear torrential but an inexperienced endoscopic surgeon is well advised to convert should he have any doubt about his ability to control the situation quickly.
• Pressure on the area applied by grasping adjacent tissue, and using this to overly and apply gentle pressure on to the area.
• Compression with pledget swab if the bleeding is not heavy until hemostasis is achieved by clipping or electrocoagulation and the sucker.
• Suction/irrigation to identify the bleeding point prior to securing it.
• Under-running by suture if the bleeding point cannot be identified.
• Argon spray coagulation for raw bleeding areas.
• Occluding the vessel with graspers before clipping it.
• Application of fibrin and other glues or hemostatic agents.
Avoid Blind Coagulation
Control the initial bleeding and then take your time to identify the bleeding point. In anatomically crowded areas containing important structures, it may be advisable to allow time for the bleeding to stop by compression for one or two minutes. If bleeding cannot be controlled inside within 5 minutes, serious consideration should be given for conversion to open surgery. This period should be shorter if bleeding is massive or arterial.
Suction and Irrigation
The availability of suction and irrigation is as important for hemostasis in endoscopic surgery as gauze swabs are in open surgery. When bleeding does occur irrigation can assist in visualization of the bleeding point and suction removes pooled blood and clears clots from the operative site. In addition, the irrigation activates the Hageman factor and thus initiates spontaneous hemostasis.
Heparinized Hartmann’s solution (1000 units per 500 ml bag) is ideal if clots are present. This solution is preferred to normal saline because of its lesser conductivity, an important consideration when using monopolar HF electrocautery.
The heparin also reduces the stickiness of the instruments and thus improves handling especially of suture and ligature materials. It also aids the removal of pooled blood. The bag of fluid is placed in a Fenwell pressure bag raised to 200 mm Hg and hung from a drip stand. As the contents of the bag are used the pressure needs to be maintained. There are several pressurized irrigation systems available, some heat the irrigating fluid to body temperature, others provide pulse irrigation which is helpful from breaking up blood clots and cleaning the peritoneal gutters. Suction and irrigation are also essential to deal with leakage from ultra-abdominal organs, e.g. bile leakage, bowel content, perforated ulcer, appendicitis. In these acute emergency situations, laparoscopic abdominal lavage of the peritoneal quadrants is aided by shaking the patient from side to side and changing the position of the operating table (head up, head down, and sideways).
