Bloodless Operative Field Research Articles

Effect of hot saline irrigation on the operative field during endoscopic sinus surgery: a randomized controlled trial.

Control of bleeding is very important during endoscopic sinus surgery. Saline heated up to 50°C causes dilatation of vessels and edema without nasal mucosa necrosis. It also promotes the clotting cascade so helps in having a bloodless procedure. This randomized controlled trial was conducted on 60 patients divided into two groups (30 each). Group A was the interventional group in which patients were irrigated with saline of 50°C during surgery. Group B was the control group where room-temperature saline was used. The operative field was assessed using the Boezaart score, duration of surgery, and bleeding in ml. The Boezaart score in group A came out to be 2.23 ± 0.72 whereas it was 3.43 ± 0.72 in group B. Most of the patients who were in the interventional group had their surgery completed within 60min with comparatively less bleeding (mean bleeding = 221.83ml). Patients of the control group had increased duration of surgery mostly and bleeding (mean = 265.67ml). Our study showed a strong correlation amongst the Boezaart score, duration of surgery, and bleeding in ml with a p value of < 0.001 where all three variables significantly improved in the interventional group due to a good operative field provided by warm saline heated up to 50°C. Normal saline heated up to 50°C is a cost-effective way to achieve a bloodless operative field during endoscopic sinus surgery. Reduced bleeding also decreases the duration of surgery.

Tight Application of a Surgical Tourniquet Prior to Inflation Increases Venous Pressure In the Upper Limb; Potentially Resulting in Increased Blood Loss and Poorer Visibility

Tourniquets are commonly used in extremity surgery to help provide a bloodless operative field to improve visibility and reduce length of procedures. With the development of WALANT (wide awake, local anaesthetic, no tourniquet) techniques, many surgeons undertake surgery without tourniquet inflation. The correct technique of pneumatic tourniquet application is poorly understood by healthcare staff. The application of a tight tourniquet when applied for optional use or use for only a portion of a procedure, rather than for inflation throughout can cause venous engorgement of an extremity leading to increased blood loss and reduced operative field visualisation thereby discouraging surgeons from persevering with WALANT strategies. To determine the effect of tourniquet application tension on limb volume prior to skin incision. 30 volunteers had the volume of their non-dominant forearm measured post-inflation of a surgical tourniquet using two different application techniques. Tight application was defined as the tourniquet fastened using a dynamometer to a tension of 100N. Loose application was defined as the tourniquet fastened using a dynamometer to a tension of 50N. The tourniquet was then inflated to 200mmHg after both application techniques. Exsanguination was performed by elevation of the arm for 1min prior to tourniquet inflation. At 5min the forearm volume was measured using a volume displacement technique. 93% of participants (28/30) had a higher volume of water displaced when the tourniquet was applied tightly. The mean difference between the loose and tight applications was 30.06mls. The increase in volume in tightly applied tourniquets is believed to result from increased intravascular volume. This increase in blood volume can lead to increased intra-operative blood loss and poor intra-operative visualisation when operating without tourniquet inflation. Loose application of the tourniquet pre-inflation appears to prevent sequestration of venous blood in the limb, therefore decreasing operative blood loss and improving view for operating. Level 1; Symptom Prevalence Study.

Introducing the A-view endotracheal balloon in cardiac surgery: Guiding the surgeon

Stroke is serious modus for death following cardiac surgery. For twothird it is contributed to unloosend particles from atherosclerotic plaques in the ascending aorta ending up in the brain. Using regular trans esophageal echocardiogram (TEE) does not provide adequate information of the distal ascending aorta due to air in the trachea (‘Blind Spot’). The quality of the distal ascending aorta is of great importance to the cardiac surgeon as the aorta is maltreated by inserting a cannula for connection to the heart-lung machine and clamping to provide a bloodless operation field. The mission ahead is to improve real-time diagnostic information of the distal ascending aorta before opening the chest and providing the surgeon the opportunity to execute safe and reliable care. By replacing air in the trachea for the A-View saline filled endotracheal balloon, crucial information is obtained during TEE-imaging of the fully anesthetized cardiac patient. With this information at hand, the anesthesiologist may guide the surgeon to execute the best and safest operation.

Use of chalazion clamp for excision of the eyelid margin lesion.

Reconstruction after eyelid lesion excision is very important. It calls for preserving normal eyelid function for the protection of the eye and restoring good cosmesis. It is important to precisely align the tarsal plate. However, the unique anatomy of eyelids often makes haemostasis difficult and surgical field obscured. We report an effective method to solve this problem. This retrospective study included 25 patients who underwent eyelid margin lesion excision using the chalazion clamp between March 2020 and October 2021. The chalazion clamp is placed on the desired location and tightened, providing a bloodless field for eyelid lesion removal. Without bleeding, visibility of the cut edges is improved considerably. It facilitates anatomical anastomosis of the tarsal plate. All 25 patients maintained normal eyelid function and good cosmesis, with no recurrence during the follow-up period. The use of the chalazion clamp during excision of the eyelid margin lesion could stabilize the eyelid, protect the eyeball from accidental injury and, and provide a clear bloodless operative field. It can ensure the neatness of the cut edges and offer better incision alignment for suture. It also avoids wasting too much time on haemostasis, without additional expensive equipment.

The Safety and Effectiveness of an In-Depth Esmarch Tourniquet Technique in Achieving Target Pressures for Pediatric Upper Extremity Surgery

Purpose: This study aimed to determine the appropriate number of turns required for an Esmarch tourniquet, using commonly sized Esmarch bandages, to achieve a pressure target of at least 150 mm Hg during pediatric upper extremity surgery. Methods: Twenty participants who underwent upper extremity surgery were included in the study. Two surgeons used 2- and 3-inch-sized Esmarch bandages to apply an Esmarch tourniquet to each participant’s arm. The pressure and number of turns were recorded from the second to fifth turns. The pressure was measured using a pressure sensor device. Results: At the third turn of both the 2- and 3-inch-sized Esmarch bandages, a 150 mm Hg pressure was achieved in all participants. Intra-observer reliability resulted was “good”; however, inter-observer revealed “poor” reliability. Conclusions: The Esmarch tourniquet is an effective and safe method for creating a bloodless operative field for upper extremity surgery in pediatric patients. The results of this present study suggested the application of three turns of the 2- and 3-inch-sized Esmarch bandages.

Current concepts in tourniquet uses

<h2>Abstract</h2> Tourniquets have been around for many years, providing surgeons with a bloodless operative field and saving lives in the pre-hospital care of major limb trauma. However, their use does come with risk. It is therefore extremely important that we, as surgeons, fully understand the physiological influence they impose on patients, the complications associated with their use and, moreover, how to minimize the incidence of these complications. Most tourniquets are now electronically controlled pneumatic devices with built-in pressure sensors and timers. Classically, inflation to 250 mmHg in the upper limb and 300 mmHg in the lower limb is used, but a move towards patient-specific limb occlusion pressures is suggested, although it is more difficult due to the requirement of more time-consuming set-up. Complications from tourniquets can occur, such as nerve injury, pain, venous thromboembolism or even cardiac overload and reperfusion injury. Limiting use to key parts of an operation or using alternatives such as adrenaline infiltration and tranexamic acid can be of benefit. As such, any use of a tourniquet during an operation must be treated with caution and be deployed taking into account the specific characteristics of that particular patient.

Pro: Modified Ultrafiltration Is Beneficial for Adults Undergoing Cardiac Surgery

CARDIAC SURGERY often necessitates the use of cardiopulmonary bypass (CPB). The benefits of CPB include a completely or partially bloodless operative field, ease of thermoregulation, and the ability to arrest and decompress the heart while maintaining oxygen delivery to vital organs. As with any form of extracorporeal circulation, CPB is nonphysiologic and, therefore, can lead to a significant number of deleterious effects that are known to be associated with increased morbidity and mortality. 1 Naveed D Khan RA Malik A et al. Role of modified ultrfiltration in adult cardiac surgery: A prospective randomized control trial. J Ayub Med Coll Abbottabad. 2016; 28: 22-25 Google Scholar These include significant hemodilution, physical damage to essential components of coagulation, vascular injury, and the production of inflammatory mediators. 2 Grunenfelder J Zund G Schoeberlein A et al. Modified ultrafiltration lowers adhesion molecule and cytokine levels after cardiopulmonary bypass without clinical relevance in adults. Eur J Cardiothorac Surg. 2000; 17: 77-83 Crossref PubMed Scopus (85) Google Scholar A number of interventions have been used in an effort to help reduce the negative effects of CPB.

Reducing Tourniquet Pressures in Hand Surgery: Are Lower Pressures as Effective?

Background Pneumatic tourniquets are widely used in hand surgery. Elevated pressures can be associated with complications, and thus, guidelines based on patient-specific tourniquet pressures have been recommended. The primary aim of this study was to determine whether lower tourniquet values based on systolic blood pressure (SBP) could be effectively applied in upper extremity surgery. Methods A prospective case series of 107 consecutive patients undergoing upper extremity surgery with use of a pneumatic tourniquet was performed. Tourniquet pressure used was based on the patient's SBP. The tourniquet was inflated based on our predetermined guidelines: 60 mm Hg was added for SBP < 130 mm Hg, 80 mm Hg for SBP between 131 and 190 mm Hg, and 100 mm Hg for SBP > 191 mm Hg. The outcome measures included intraoperative tourniquet adjustment, surgeon-rated quality of bloodless operative field and complications. Results The mean tourniquet pressure was 183 ± 26 mm Hg with a mean tourniquet time of 34 minutes (range: 2-120 minutes). There were no instances of intraoperative tourniquet adjustment. The surgeon-rated quality of bloodless operative field was excellent in all patients. No complications were associated with the use of a tourniquet. Conclusion Tourniquet inflation pressure based on SBP is an effective method to provide a bloodless surgical field in upper extremity surgery at significantly lower inflation pressures than are the current standards.

Duration of deep hypothermic circulatory arrest for aortic arch surgery: is it a myth, fiction, or scientific leap?

The use of deep hypothermic circulatory arrest (DHCA) to provide aortic surgeons with a bloodless operative field while simultaneously protecting the brain and peripheries from ischemic damage revolutionized cardiac and aortic surgery, and is currently used in specialist centers across the globe. However, it is associated with manifold adverse outcomes, including neurocognitive dysfunction and mortality. This review seeks to analyze the relationship between DHCA duration and clinical outcome, and evaluate the controversies and limitations surrounding its use. We performed a review of available literature with statistical analysis to evaluate the relationship between DHCA duration (<40 min and >40 min) and key clinical outcomes, including mortality, permanent and temporary neurological deficit, renal damage, admission length, and reintervention rate. The controversies surrounding DHCA use and future directions for care are also explored. Statistical analysis revealed no significant association (P>0.05) between DHCA duration and clinical outcomes (early and late mortality rates, neurological deficit, admission length, and reintervention rate), both with and without adjunctive perfusion techniques. Available literature suggests that the relationships between DHCA duration (with and without adjunctive perfusion) and clinical outcomes are unclear, and at present not statistically significant. Alternative surgical and endovascular techniques have been identified as promising novel approaches not requiring DHCA, as have the use of biomarkers to enable early diagnosis and intervention for aortic pathologies.

Cuffed endotracheal tube as a cardiopulmonary bypass venous return cannula.

Cuffed endotracheal tube as a cardiopulmonary bypass venous return cannula.

Intra-operative Use of Resuscitative Endovascular Balloon Occlusion of the Aorta for Maintaining Bloodless Operative Field and Facilitating Hemostasis: A Case Report

Intra-operative Use of Resuscitative Endovascular Balloon Occlusion of the Aorta for Maintaining Bloodless Operative Field and Facilitating Hemostasis: A Case Report

Effect of tourniquet application on postoperative outcomes in sinus tarsi approach for intra-articular calcaneus fractures.

Tourniquets are commonly used during foot and ankle surgery to provide a bloodless operative field and increase surgical comfort, despite the potential risks associated with it. This study compared postoperative outcomes of tourniquet-assisted and non-tourniquet-assisted operative fixation of calcaneal fractures via the sinus tarsi approach. A retrospective study from March 2015 to December 2018 revealed 131 patients with closed calcaneal fractures who underwent minimally invasive surgery at our hospital. Visualization, operating time, blood loss, and postoperative pain were collected. Patients in the tourniquet group (n = 62) were compared with patients in the non-tourniquet group (n = 69). The visibility of the surgical field was fair/poor in 2 cases in the tourniquet group and fair/poor in 19 cases in the non-tourniquet group (P < 0.05). The mean operative time was 64.7 ± 3.5min in the tourniquet group and 76.0 ± 6.1min in the non-tourniquet group (P < 0.05). The estimated intraoperative and postoperative blood loss was 56.6 ± 33.3 and 100.0 ± 25.3mL, respectively, in the tourniquet group and 205.0 ± 31.6 and 38.3 ± 19.8mL, respectively, in the non-tourniquet group (P < 0.05). The VAS pain scores 24h, 48h, and 72h postoperatively were 4.3 ± 1.8, 3.1 ± 1.2, and 2.0 ± 0.5 points, respectively, in the tourniquet group and 2.1 ± 1.1, 1.6 ± 1.0, and 1.0 ± 0.3 points, respectively, in the non-tourniquet group (P < 0.05). Tourniquet application during the sinus tarsi approach for calcaneal fractures can significantly improve surgical visualization and reduce intraoperative blood loss. However, adverse events associated with the use of tourniquets include increased postoperative pain and bleeding. Due to increased postoperative bleeding and pain, more attention should be given to the postoperative phase in patients treated with tourniquets.

Venous drainage for minithoracotomy approach in an adult with interrupted inferior vena cava.

For atrial septal defect closure via right minithoracotomy in an adult patient with infra-hepatic interruption of the inferior vena cava with azygos connection, an alternative venous cannulation strategy was applied. In addition to bicaval cannulations to the femoral vein and the internal jugular vein, a 20 Fr straight cannula draining the hepatic vein was added to the proximal IVC through the right atrium wall via a working port. A bloodless operative field in the right atrium was afforded with bicaval encircling. Preoperative imaging test of the continuity of the IVC was important planning cardiac surgery with peripheral cannulations.

Remifentanil versus labetalol for deliberate hypotensive anesthesia in children undergoing cochlear implantation: A randomized clinical trial

ABSTRACT Background: Deliberate hypotensive anesthesia (DHA) is performed to achieve a bloodless operative field, allowing better visualization and decreasing the intraoperative blood loss amount. The present trial evaluated the efficacy of intravenous infusion (IVI) of remifentanil versus labetalol in inducing DHA in children undergoing cochlear implantation surgery. Methods: Fifty children aged from 2 to 4 years undergoing cochlear implantation surgery under general anesthesia at Al Manaa General Hospital were included in this double-blind, randomized study. Patients were randomly assigned into two equal groups. Group R: received 0.0125–0.05 µg/kg/h remifentanil IVI after anesthesia induction. Group L: received 0.1–0.25 mg/kg/h labetalol IVI after anesthesia induction. Assessment of the quality of operative field and surgeon satisfaction were recorded. Heart rate (HR) and mean arterial blood pressure (MABP) were recorded at baseline, after intubation, then 5 minutes after the start of infusion of study drugs then every 15 minutes until the end of procedure, and for 30 minutes after recovery). Results: Quality of surgical field and surgeon satisfaction were significantly better in group R compared to group L. Good visual field was significantly better in group R compared to group L (96% vs. 72%, P = 0.049). MABP was insignificantly different between both groups at all times of measurement. HR was significantly decreased in group R compared to group L intraoperatively from 15 min till the end. Conclusion: Both remifentanil and labetalol were effective for DHA. However, remifentanil was superior to labetalol by allowing better surgical field quality and surgeon satisfaction with significant intraoperative HR reduction.

Robotic Radical Trachelectomy Using the Double Bipolar Method- Aiming for a Bloodless Operative Field

Study ObjectiveTo report the application of the double bipolar technique in a patient with 1b1 cervical cancer who wished to preserve her fertility potential.DesignAfter experiencing 105 cases of laparoscopic and robotic radical trachelectomy with a 5 year survival rate of 98% and the birth of 29 babies from 51 of these patients who attempted pregnancy, we introduced the double bipolar method to overcome technical difficulties of the procedure due to the necessity for precise dissection and reconstruction in the deep pelvis. We will show our operative techniques, such as nerve sparing radical trachelectomy and retroperitoneal lymphadenectomy for early invasive cervical cancer in a bloodless operative field.SettingUrban general hospital.Patients or ParticipantsRobotic radical trachelectomy using the double bipolar method was performed in three patients with 1b1 cervical cancer.InterventionsAfter Robotic radical trachelectomy using monopolar scissors in 30 cases of stage Ib1 cervical cancer, we considered techniques for a more bloodless operative field. The double bipolar method (DBM) was originated by a robotic gastrointestinal surgeon, Prof Ichiro Uyama. Using robotic Maryland forceps as a cutting device allows for pinpoint accuracy that cannot be found in other instruments. It is important for bladder and ureteral dissection and exposure of vessels. Cuts are made at a very limited point by a lightning strike mechanism, meaning there is minimal thermal spread to adjacent organs.Measurements and Main ResultsBlood loss was 250ml in the cases presented. In surgeries not using the DBM(n=34), the blood loss ranged from 350ml(100-1200ml). While there is no supporting data, the dissection of the ureter was very smooth.ConclusionA bloodless operative field allows for accurate dissection and can prevent intraoperative injuries. The double bipolar method is able to provide precision cutting and limit thermal spread to adjacent tissue, reducing injury and allowing for a clear operative field.

Magnesium sulfate versus nitroglycerin in controlled hypotensive anesthesia in middle ear surgeries

Background: Controlled hypotension is required for middle ear surgeries to achieve a bloodless operative field and improve its quality, both magnesium sulfate and nitroglycerine used to produce deliberate hypotension. Aim of the work: This study aimed to compare the efficacy of magnesium sulfate and nitroglycerin in inducing controlled hypotensive anesthesia as a primary outcome and using propranolol if tachycardia occurred as a secondary outcome, in middle ear surgeries. Patients and Methods:The study was carried out on 40 adults’ patients were randomly classified into two equal groups, twenty patients each: Group [M]: Received an intravenous [IV] bolus of magnesium sulfate 30 mg/ kg in 100 ml saline over 10 min followed by infusion of 10 mg/kg/h. Group [N]: Received nitroglycerin IV infusion 0.5-10 mcg/kg/min. Propranolol 1- 2.5 mg IV had been given to both groups if there was tachycardia. Results: Both drugs induced hypotension with statistically significant difference in systolic and mean blood pressure [BP] and there was highly significant increase in heart rate [HR] in nitroglycerin more than magnesium sulfate and high doses of propranolol were administrated in nitroglycerine group. Postoperative pain was significantly increased in nitroglycerin than magnesium sulfate groups which had more analgesic effect. Conclusion: Both drugs induced hypotension. However, magnesium sulfate was better as it provided optimum surgical field, less tachycardia, need less dose of propranolol with less post-operative pain in comparison to nitroglycerin

Local Infiltration Anaesthesia with a Bloodless Operative Field (WALANT). Presentation of the Technique and its Use in Hand Surgery.

Local infiltration anaesthesia with a bloodless operation field (WALANT) allows for performing hand surgery without a tourniquet. This effect is obtained through an injection of greater than standard volume of the anaesthetic solution composed of lignocaine and adrenaline. The addition of adrenaline induces spasm of small arteries within the infiltration area, which inhibits bleeding and allows visualization of most of the subtle but important structures in the hand and fingers. This article presents a method of preparation of the anaesthetic solution and the technique of anaesthesia for several common procedures in hand surgery. In 2019, our centre performed 340 operations under WALANT anaesthesia, with no serious complications observed. Data from the literature are presented showing that this technique is attracting increasing popularity worldwide. Our centre was the first in Poland to introduce the WALANT method to hand surgery.

Brain tissue oxygenation during transnasal endoscopic skull base procedures

PurposeWe aimed to study brain tissue oxygenation during the period of controlled reduction of arterial blood pressure – a maneuver often used in extended endoscopic skull base surgery for bloodless operative field. MethodsIntracranial pressure, arterial blood pressure and the resultant cerebral perfusion pressure were measured during extended endoscopic skull base surgery in 5 patients with diagnosed tumors of the skull base and arterial hypertension. Simultaneously, in those patients, we measured partial pressure of oxygen in the brain parenchyma (PbtO2). ResultsValues of PbtO2 lower than 15 mm Hg (risk of brain ischemia) were observed in 3 patients for periods of 40 min, 110 min and 123 min, respectively. In 2 of these patients, no hypotension (mean arterial pressure <65 mm Hg) was necessary for bloodless operative field. Another 2 patients had PbtO2 above 30 mm Hg at the time when their mean arterial pressure was below 65 mm Hg. The time course of PbtO2 followed that of cerebral perfusion pressure with a time lag of 40–60 s in all patients. ConclusionModerate reduction of arterial pressure, often used to obtain bloodless operative field during extended endoscopic skull base surgery, may in patients with the medical history of arterial hypertension be associated with critically low values of partial oxygen pressure in brain tissue.

Extirpation of a Ruptured Anterior Spinal Artery Aneurysm Accompanied by Dural Arteriovenous Fistula at the Craniovertebral Junction via a Posterolateral Approach: The Management of Extradural Venous Congestion.

Objective This study was aimed to discuss how to control extradural venous congestion with an increased pressure in cases of arteriovenous shunt disease of the craniovertebral junction. Design The study is presented through an operative video. Results A 77-year-old patient with subarachnoid hemorrhage had a dural arteriovenous fistula located at the C1–C2 level. Left vertebral angiography showed a fistula between the left C2 radiculomeningeal muscular artery and perivertebral plexus. Furthermore, right vertebral angiography showed a ruptured aneurysm at the aberrant branch of the anterior spinal artery originating from the contralateral vertebral artery (VA), possibly formed because of the concurrently increased pressure of the perimedullary veins. Aneurysm extirpation was planned through a posterolateral approach. To reduce venous bleeding during the approach, preoperative embolization of the radiculomeningeal muscular artery was performed. During surgery, the suboccipital triangle was exposed following layer-by-layer dissection of the suboccipital muscles ( Figs. 1 and 2 ). Subperiosteal dissection of the paravertebral plexus surrounding the VA around the C1 lamina was effective to avoid venous bleeding. A bloodless operative field was achieved, and key anatomical structures, such as the C2 nerve root, feeder, and V3 portion of the left VA, were clearly identified. With a sufficient amount of lateral exposure, the ruptured anterior spinal artery aneurysm was successfully extirpated with bipolar coagulation. The patient was discharged with no neurologic deficit. Fig. 1 ( A ) The initial CT scan showing the subarachnoid hemorrhage. ( B ) Left vertebral angiogram demonstrating a dural arteriovenous fistula at the craniovertebral junction. ( C ) Right vertebral angiogram showing an aneurysm (arrow) arising at the aberrant branch of the anterior spinal artery. ( D ) The postoperative angiogram demonstrating the extirpation of the aneurysm (arrowhead). Fig. 2 ( A ) Intraoperative photograph showing the subperiosteal dissection technique to protect the vertebral artery and minimize the bleeding from the paravertebral plexus. ( B ) The sufficient posterolateral exposure was obtained with minimal bleeding. C1, C1 lamina; C2, C2 lamina; Occ, occipital bone. Conclusion Controlling extradural venous congestion is essential to obtain a clear operative field in cases of arteriovenous shunt disease at the craniovertebral junction. The link to the video can be found at: https://youtu.be/fCT69WtAQbo .

Gas (Oxygen) insufflation: A new technique for the visualization of the operative field during hypospadias surgery.

Maintaining a bloodless operative field is a crucial step in achieving success and reducing complications in hypospadias surgery. So, far, the most harmless and least damaging technique in terms of penile tissue oxygenation during hemostasis has not still been defined. We aimed to present our new technique of gas (oxygen) insufflation for better visualization of the operative field, and to compare this with the control group, where a wet sponge was used for hemostasis. A total of 28 patients with primary distal hypospadias who were treated with modified tubularized incised plate urethroplasty (TIPU) repair between March 2017 and October 2018 were evaluated prospectively. The patients were divided randomly into two groups. While only a wet sponge was used to clean hemorrhagic area in the control group (group I) (n=12), gas (oxygen) insufflation was used to visualize the operative field during the operation in the patient group (group II) (n=16). The patients' ages, operation time, follow-up durations, and postoperative complications were documented and statistically compared. The mean ages and follow-up durations of both groups were found to be similar. The operation time was statistically shorter in group II than in group I (p=0.01). Eight patients (66.7%) in group I showed a complication, while 2 patients (12.5%) in group II showed a complication (p=0.005). The gas (oxygen) insufflation technique provides good visualization during the dissection step of hypospadias surgery and results in better postoperative outcomes. Therefore, we think that this technique can be preferred as an alternative method for the visualization of the operative field in hypospadias surgery.