learn about energy devices and haemostatic agents

1. Intra-operative Haemostasis in
Thoracic Surgery
Dr K Khaing Saw Lwin
MBBS,MRCSEd,MMedSc(Thoracic Surgery)

2. Haemorrhage
• According to bleeding vessels
1. Arterial
2. Venous
3. Capillary
• According to time  during surgery  primary
haemorrhage
• Haemorrhage is treated by arresting the bleeding
– not by fluid resuscitation or blood transfusion

3. 1. According to bleeding vessel
1. Arterial Haemorrhage
- bright red blood, spurting as jet, which rises and falls in time with the
- pulse (except dark red in bleeding from the pulmonary artery)
- In protracted bleeding it can become watery in appearance
2. Venous Haemorrhage
- darker red and is a steady and copious flow
- Blood loss can be rapid when large vessels are opened
- Venous bleeding can be under increased pressure as in asphyxia or
from ruptured varicose veins.
3. Capillary Haemorrhage
- Capillary haemorrhage is bright red ooze
- It can be serious in cases of haemophilia

4. 2. According to time of haemorrhage
a. Primary haemorrhage – occurs at the time of injury or operation.
b. Reactionary haemorrhage –
i. Occurs within 24 hours.
ii. Usually due to slipping of ligature, dislodgement of clot or cessation of
vasospasm.
iii. Precipitated by rise in BP on recovery from shock and restlessness,
coughing and vomiting which raise the venous pressure.
c. Secondary haemorrhage
i. Occurs after 7 – 14 days and is due to infection and sloughing of part of the
wall of an artery.
ii. Predisposes by pressure from a drainage tube, fragment of bone, a ligature
in an infected area or cancer. It is also a complication of arterial surgery or
amputation.
iii. It is heralded by ‘warning’ haemorrhages, which are bright red stains on
thedressing, followed by a sudden severe haemorrhage, which may be fatal.

5. 3. According to visibility
a. External Haemorrhage – is visible revealed
haemorrhage.
b. Internal Haemorrhage – is invisible concealed
haemorrhage as in ruptured spleen,liver or
fractured femur.
c. Concealed haemorrhage may become
revealed as in haematemesis and melaena from
bleeding peptic ulcer.

6. Haemostasis
• The process of forming clots in the walls of
damage blood vessels and preventing blood
loss while maintaining blood in a fluid state
within the vascular system.
• (balance between coagulation and
anticoagulation)

7. 1

11. Methods for haemostasis

12. No Methods Applicable in thoracic
surgery (+/-)
1. Pressure and packing (+)
2. Position and rest (-)
3. Clamping and Ligation of bleeding vessel (+)
4. Electro-cauterization (+)
5. Topical Haemostatic agents (+)
6. Sclerotherapy
7. Cryotherapy
8. Laser photocoagulation
9. Excision of whole or part of organ

13. Electrocauterization

14. Energy Devices
Monopolar
diathermy
Eg. Shears,
scissors, hook,
spatula
Bipolar
Classical
Eg. Keppinger
bipolar foceps
Modern ones
Bipolar + USG
tech
Egs,Ligasure, Harmonic,
Thunderbeat

15. Electrical frequency (300kHz to 3 MHz)

17. Device Mechanism Vessel
diameter
Harmonic
scalpel
-High freq USG transducer
-Active blade titanium bladevibrate 55.5kHz or
55,000 vibrations/sec
-USG energy - Mechanical energy
-Sealingdenatured protein coagulum which occurs d/t
temponade and coaptation
(Temp b/t 8’C to 250’C)
5mm
Ligasure -high current, low voltage (180V ) along with pressure
-during the generation of tissue temp under 1000°C,
First ruptured of hydrogen cross-links then renatured,
high tensile strength vascular seal
- Real time t/s sensing technology constant delivery of
Watts over broad range of tissue
7mm
Thunderbeat -simultaneously delivers ultrasonically generated
frictional heat energy and electrically generated bipolar
energy
7mm

18. Differences between Thunderbeat, LigaSure and Harmonic Scalpel Energy System in
Minimally Invasive Surgery, George Chilaka Obonna, RK Mishra

19. Ligasure
Jaw of different devices

20. Topical haemostatic agents

21. Topical haemostatic agents
• To supplement endogenous blood clotting
activity
• 3 Types
- Active haemostatic agents
- Non- active haemostatic agents
- Flowable haemostatic agents

22. Flowable HA
promoting thombus
production at the
bleeding site

23. Indication
1. Pt with coagulopathies
2. Pt receiving anti-thrombotic medications
Active haemostatic agents
Action Fibronogenthrombin Fibrin

24. Non-active
haemostatic
agents
Mechanical HAs
Synthetic
sealants

25. Indications
1. Minimal bleeding
2. Pt with adequately functioning coagulation system
Mechanical HAs
Actions
1. Forms a physical matrix barrier over the bleeding site
2. Provide additional scaffolding for plt aggregation
accelerate clot formation
3. Polysaccharide beads absorb free water, concentrating
proteins and platelets locally at bleeding site
*(need to left in place until clot formation)

26. Indication
- To prevent suture hole bleeding in vascular procedures
Synthetic sealents
action
1. Forming water tight barrier
2. Adhesive

27. Fig: Tropical hemostatic agent
selection flowchart

28. References
• The Use of Topical Hemostatic Agents in
Cardiothoracic Surgery (ArtBraceyMD) Annals of
thoracic surgery 2017
• Ganong’s Review of medical physiology 23rd
edition
• Bailey & Love 27th edition
• Prevention and Management of
Laparoendoscopic Surgical Complications, Third
Edition (PM3),Chapter 11 LAPAROSCOPIC VESSEL
SEALING DEVICES

29. • Differences between Thunderbeat, LigaSure
and Harmonic Scalpel Energy System in
Minimally Invasive Surgery;George Chilaka
Obonna, RK Mishra
• Surgical tutor

30. Thank you!!