This document discusses techniques for achieving hemostasis during surgery. It begins by defining hemostasis and describing the three major steps in the process. Temporary measures for achieving hemostasis include applying local pressure or vascular clamps. Definitive measures include suture ligation, clipping, electrocautery, bipolar devices like Ligasure, ultrasonic devices like Harmonic Scalpel, and hemostatic agents. Common instruments used include Crile forceps, Kelly forceps, Mixter forceps, Adson forceps, bulldog clamps, and electrocautery pencils. Achieving proper exposure, localization, and a precise act are important when controlling bleeding during surgery.

1. Hemostasis during Surgery
UG Batch- 2017
Date- 20/09/21
Dr. Ankita Singh
Assistant Professor
Department of Surgery

2. Learning Objectives
What is haemostasis ?
What is the need ?
Techniques of Haemostasis

3. Haemostasis
Definition:
– Derived New Latin ‘haimo’- Blood & ‘stásis’ - Stasis
– Process to prevent & stop bleeding
Has 3 major steps:
– i) Vasoconstriction ii) temporary blockage by a
platelet plug iii) blood coagulation/ fibrin clot
Pathways of haemostasis:
– i) Intrinsic ii) Extrinsic

4. Why is Haemostasis needed?
Prevention of blood loss & its sequalae

5. Bleeding during surgery??
Not all bleeding vessels require intervention
– <1mm caliber stop bleeding spontaneously
HELP!!!
– Ask for HELP
• Do not panic
– The HELP
• Hemostasis (temporary)
• Exposure
• Localization
• Precise act

6. H - HELP
Temporary Hemostasis:
– Local pressure when source of bleeding is not
apparent
• Hand
• Pressure dressing
• Packing
– When source is visible/ well localized
• Vascular clamps vs. artery/hemostat forceps

7. Artery forceps/ hemostats
CRILE FORCEPS
– Other Names: Hemostat, snap, clamp, Kelly, stat

8. CRILE FORCEPS..
– Use(s): Used for occluding bleeders before
cauterization or ligation
– Description:
• A curved or straight clamp
• horizontal serrations that run the complete length of
the jaws.
– Instrument Insight:
• The curved Crile is the most widely used clamp in all
specialty areas.

9. HALSTEAD FORCEPS
– Other Names: Mosquito

10. HALSTEAD FORCEPS..
– Use(s): Used for occluding bleeders in small or
superficial wounds before cauterization or
ligation. Used often for delicate or small, confined
procedures like; plastics, pediatric, thyroid, and
hand procedures.
– Description:
• A small, curved or straight clamp with fine tips and
horizontal serrations that run the length of the jaws.
– Instrument Insight:
• are much smaller than a Crile or a Kelly.

11. KELLY FORCEPS
– Other Names: Hemostat, Crile, clamp

12. KELLY FORCEPS..
– Use(s): Used for occluding bleeders before
cauterization or ligation.
– Description:
• A curved or straight clamp with horizontal serrations
that run about half the length of the jaws.

13. MIXTER FORCEPS
– Other Names: Right angle, Gemini, Lahey, obtuse
clamp, ureter clamp

14. MIXTER FORCEPS..
– Use(s): used to clamp, dissect, and occlude tissue.
• Is often used to place a tie or vessel loop under and
around a tubular structure such as a vessel or a duct,
• enabling the surgeon to grasp the ligature or loop and
pull it up and around the structure to either ligate or
retract.
– Description:
• A 75°, 90° angle clamp with horizontal serrations that
run the length of the jaws.

15. ADSON FORCEPS
– Other Names: Tonsil Schnidt, fancy clamp

16. ADSON FORCEPS..
– Use(s): Clamps small vessels in a deep wound or
holds tonsil sponges
– Description:
• fine curved or straight clamp
• horizontal serrations running halfway down the jaws
• shanks are longer than those of a Crile or a Kelly.

17. Vascular clamps
VASCULAR CLAMPS
– DEBAKEY BULLDOG

18. VASCULAR CLAMPS
– COOLEY CLAMP

19. VASCULAR CLAMPS
– SATINSKY VENA CAVA CLAMP

20. E- HELP
Exposure of bleeding area when
– Site of bleeding is not apparent
– Achieved by:
• Proper dissection
• Extension of incision
• Conversion of laparoscopic surgery into open surgery

21. L- HELP
Localization
– Bleeding point
• Accurately
• Precisely

22. P- HELP
Precise act of control of bleeding
– Definitive measure of hemostasis
– Irreversible step: bleeding vessel is either
• Repaired – indispensable
• Permanently blocked
– Undertaken by:
• Suture ligation/ tying
• Clipping
• Electrocautery
• Sealing devices
• Hemostatic agents

23. Suture ligation/ tying
Once the bleeding vessel/ bleeder is held by
hemostat, permanent blockage can be
achieved by
– Ligating the vessel proximal to hemostat using
• Sutures- non absorbable vs. absorbable
• Hand tie or instrument tie
• Knotting should be non slipping &, tight

24. Clipping
Once the bleeding vessel/ bleeder is held by
hemostat, permanent blockage can be
achieved by
– Application of clip/ clipping the vessel proximal to
hemostat using
• Clip applicators- single vs. multiload
• Material- metal (stainless steel, titanium, acetyl
polymer)

25. HEMOCLIP APPLIERS
– Other names: Ligaclip applier

26. HEMOCLIP APPLIERS
– Use(s): This instrument is used to clip side
branches on vessels instead of tying with suture
material.
– Description:
• available in small, medium, medium/large, and large
sizes
• can also have an angled end
• The clip bars that hold the actual clips come in the
colors red, blue, green, and orange, and the applier
handles have the same color

27. HEMOCLIP APPLIERS
– Instrument Insight:
• “Load” by pushing instrument jaws onto clip and lifting.
• The surgeon “fires” the clip by squeezing the handles.

28. SURGICLIP APPLIER
• Other Names: Hemoclip, ligaclip

29. SURGICLIP APPLIER
• Use(s): Used for occluding vessels or other
tubular structures.
• Description:
oA sterile, single-patient use instrument, preloaded
with clips
oManufactured in various clip sizes and lengths

30. HEM-O-LOCK APPLIER
• Other Names: Hemolok

31. Electrocautery
First commercial electrosurgical device-
Willaim T Bovie
First use of an electrosurgical generator in O.R.
– Harvey Cushing
Two basic types:
– Monopolar
– Bipolar

32. Electrocautery..
Principle of diathermy:
– When an electrical current passes through a
conductor, some of its energy appears as heat.
The heat produced depends on:
• the intensity of the current;
• the wave form of the current;
• the electrical property of the tissues through which the
current passes;
• the relative sizes of the two electrodes.

34. Electrocautery..
Effects of diathermy:
– Coagulation: the sealing of blood vessels.
– Fulguration: the destructive coagulation of tissues
with charring.
– Cutting: used to divide tissues during bloodless
surgery.
In coagulation- heating leads to cell death by
– dehydration & protein denaturation

35. ELECTROSURGICAL PENCIL
– Other Names: Bovie, cautery, monopolar,
diathermy

36. ELECTROSURGICAL PENCIL..
– Principle: Monopolar cautery uses electrical
current to coagulate and cut blood vessels and
tissues to provide homeostasis
– Description:
• disposable instrument
• blade tip and a holster
• current is activated by a switch or button on the pencil
or with a foot pedal
• different types of interchangeable electrode tips: blade,
ball, needle, and extended blade tips.

37. ELECTROSURGICAL PENCIL..
– Instrument Insight:
• All monopolar electrodes require a dispersive pad
because the electricity enters the patient’s body
• Monopolar current travels from the generator, to the
active electrode, and through the patient’s body; the
current is then captured by the dispersive pad, which
channels it back to the generator, completing the
closedcircuit
• A scratch pad is used to remove charred blood and
tissue from the electrode tip.
• The tip may also be Teflon coated for ease in cleaning.

38. ELECTROSURGICAL PENCIL..
– Caution:
• The tip of the pencil becomes hot after extended use.
• When not in use the pencil should be placed in the
holster to prevent burning the drapes or the patient.

39. BIPOLAR ELECTROSURGICAL DEVICES:
– Bipolar Electrocautary

40. BIPOLAR ELECTROSURGICAL DEVICES:
– Bipolar Electrocautary
– Use(s): Used for coagulating small blood vessels of
the eye and the eyelids.
– Description: Resembles a tissue forceps, is either
insulated or noninsulated, and has straight forceps
with fine tips.
– Instrument Insight: There are many different types
of bipolar forceps that can be used in eye
procedures.

41. BIPOLAR ELECTROSURGICAL DEVICES:
– Ligasure

42. BIPOLAR ELECTROSURGICAL DEVICES:
– Ligasure
– Use(s): LigaSure works by applying a precise
amount of bipolar energy and pressure to change
the nature of the vessel walls.
– The collagen and elastin within the vessel walls
fuse and reform into a single structure,
obliterating the lumen, and creating a permanent
seal.

43. BIPOLAR ELECTROSURGICAL DEVICES:
– Ligasure
– Description:
• The system consists of a bipolar radio frequency
generator and forceps.
• Designed to mimic standard surgical clamps.
– Instrument Insight: Blood and tissue can build up
on the jaws and may need to be removed
periodically with a moistened sponge.

44. HARMONIC SCALPEL
– Other Names: Ultrasonic scalpel

45. HARMONIC SCALPEL..
– Principle: grasping instrument that delivers
ultrasonic energy (20K-50K Hz) between the jaws
to coagulate and divide tissue by low-temperature
cavitation.
– Description:
• has a disposable hand piece,a nondisposable cord and
wrench
– Instrument Insight:
• Blood and tissue can build up on the jaws and may
need to be removed periodically with a moistened
sponge.

46. Hemostatic agents
Gelatin sponge (Gel foam), Oxidised cellulose
(Surgicel)
Collagen sponge (Helistat)
Microfibrillar collagen powdeer (Avitene)
Topical thrombin, Gelatin matrices (Floseal)
Bone wax (derived from bees wax + almond
oil)
Topical EACA, topical cryoprecipitate

47. Blood products
Patients on medications interfering with
normal haemostasis
– Warfarin, Heparin, Direct oral anticoagulants,
Clopidogrel, Aspirin
Altered physiology due to
– Liver disease, bleeding disorders, uncontrolled
HTN, sepsis, haemorrhage etc.

48. Take away message
Minor bleed during surgery may stop
spontaneously
Altered haemostasis due to drugs or
conditions
&
Bleeding vessels >1mm, solid organ injury
H
E
L
P

49. THANK YOU