This document summarizes different methods of hemostasis used to stop bleeding. It discusses direct pressure, sutures, electrocautery including monopolar and bipolar methods, ultrasonic and laser devices, various topical hemostatic agents including thrombin products, sealants, and absorbable materials like collagen. It also reviews different clotting factors involved in the coagulation cascade and pharmacological agents that can influence hemostasis like vitamin K, protamine, and desmopressin. Surgical techniques for controlling bleeding are compared including their advantages and appropriate clinical applications.

1. Dr. Ashok Pradhan
2nd YR Surgery JR
UCMS,TH

2. INTRODUCTION
is the process of forming clots in the
walls of damaged blood vessels

3. 1. Vascular constriction
2. Platelet plug
3. Blood clot
4. Growth of fibrous tissue into the clot

4. Platelet adhesion

5. Clotting factors
• Factor i(fibrinogen)
• Factor ii(prothrombin)
• Factoriii(tissue factor)
• Factor Iv(calcium)
• Factor v(labile factor)
• Factor vii(stable factor)
• Factor viii(antihemophilic factor)
• Factor ix (christmas factor)
• Factor x (stuart power factor)
• Factor xi( plasma thromboplastin acntecedent)
• Factor xii (hageman factor)
• Factor xiii ( fibrin stabilizing factor)

6. Cont

8. • Mechanical
• Thermal
• Chemical
• Topical

10. Methods of hemostasis
•
• Direct pressure
• gauge pads/sponges
• Sutures/ staples/ ligating clips
• Electrosurgery
1. monopolar
2. Bipolar
3. Bipolar vessels sealing device
4. Argon enhanced coagulation
• Ultrasonic device
• laser

11. • Epinephrine
• Vitamin k
• Protamine
• Desmopressin
• Lysine analogue

12. Cont.
• Passive
• Active
• others
• Collagens based agent
• Cellulose
• Gelatin
• Polysaccharide spheres
• Thrombin products
• Sealants
• Glutaraldehyde
• cynoacrylate

13. 1 Direct pressure
• Simplest & fastest
• Arterial bleeding better controlled than venous
2 Gauzes pads/sponges
• Application of direct pressure
• Packing of body cavity
• Temproary method
3 Sutures/staples/ligation clips
• Sutures and ties used as ligatures to tie off blood vessels
• Nonabsorbable sutures are used, chances of foreign body reaction
• For staples-stapling device used, faster than suture application
• Ligation clips –quick and easy to apply

14. • most frequently used, composed of generator, electrode for application and
electrode for returning current to complete the circuit
• Grounding pad used to function properly and prevent thermal burn
• short circuit between the tips of instrument without grounding pad
• Mechanical advantage of compression of tissue between tips of instrument to
thermal coagulation
• better on delicate tissues/small anatomical structures
and transecting vessels upto 7mm diameter.

15. Monopolar
• Monopolar electrosurgery can be used for several modalities
including cut, desiccation, and fulguration
• Using a pencil instrument, the active electrode is placed in the
entry site and can be used to cut tissue and coagulate
bleeding.
• The return electrode pad is attached to the patient, so the
electrical current flows from the generator to the electrode
through the target tissue, to the patient return pad and back
to the generator.

16. Bipolar
• Bipolar electrosurgery uses lower voltages so less energy is required
• Because it has limited ability to cut and coagulate large bleeding
areas, it is more ideally used for those procedures where tissues
can be easily grabbed on both sides by the forceps electrode.
• Electrosurgical current in the patient is restricted to just the tissue
between the arms of the forceps electrode. This gives better
control over the area being targeted, and helps prevent damage to
other sensitive tissues.

17. • LigaSure Atlas is a surgical endoscopic device (diameter: 10 mm, length: 37 cm)
that seals and divides vessels up to 7 mm in diameter
• LigaSure V is a single-use endoscopic instrument (diameter: 5 mm, length: 37 cm)
able to seal and divide
• LigaSure Lap is a single-use endoscopic instrument (diameter: 5 mm, length: 32 cm
• LigaSure Precise is a single-use instrument (length: 16.5 cm) for open procedures
specifically designed to provide permanent vessel occlusion

18. • Technique is different from the conventional coagulating methods that it achieve
vessel sealing by tissue carbonization
• Heat generated from the bipolar energy determines the fusion of collagen and
elastin in the walls of the vessel with the creation of a permanent sealed zone.
• The system detects the thickness of tissue to be coagulated and automatically
defines the amount of energy required and the delivering time.
• An acoustic signal informs the surgeon when the vessel obliteration is complete
and its division is possible.
• The seal zone shows a translucent appearance that is easy to recognize.
Furthermore, this sealing system has a minimal thermal effect on the tissues
surrounding the sealing line.

19. Argon based coagulation
• Argon based coagulator creates monopolar electric circuit
between hand held probe and target tissue by establishing a
steady flow of electrons through a channel of electrically
activated and ionised argon gas
• High flow argon gas conducts electric current to the target
tissue and generates thermal coagulation
• Paranchymal hemorrhage, especially lungs

20. Cont.

21. – Causes direct vasoconstriction
– Administer pre operatively to reverse the effect of warfarin
– Loading dose(0.75mg/kg)
– Reverse the action of heparin(1mg /100U)

22. Cont.
– Stimulates release of von willebrand factor and enhance primary
hemostasis
– Aminocaproic acid, tranexamic acid
– Antifibrinolytic

23. • Acts passively through contact
with bleeding sites and
promotion of platelets
aggregation
• Intact coagulation cascade
• Absorb several time its weight in
fluid
• Eg : Collagen, Cellulose, Gelatins
and Polysaccharide spheres
• Acts biologically on clotting
cascade
• Not affected by deficiency in
clotting factor and platelet
• Activated within 10minutes of
application
• Eg : thrombin and its products

24. • Derived from purified bovine tendon
• Collagen sponge gets absorbed into 8-10 weeks(slowly)
• Foreign body reaction

25. Cont.
• Absorbs many times of whole blood by capillary action
• No significant inflammatory reaction
• Derived from vagetables starch
• Contains no human or animals component

26. • Applied directly to the dressing, dissolved in saline or sprayed onto wound
• Results in formation of inhibitors to thrombin or factor v
• AES: coagulopathy, allergic reaction and death
Viral or prion related disease
• Reduced risk of antibody formation and eliminates risk of viral or prion disease transmssion

27. • Consist of conc human fibrinogen and human thrombin
• Fibrin sealants can be used in patient with coagulopathies
• Clinical concerns: difficulty of reconstruction, time taken for
surgeon to learn
• Ads: viral or prion disease transmission

28. • Contain 10%glutaraldehyde sol and 45% bovine serum albumin
• Glutaraldehyde cross links the residual proteins in albumin to cell proteins
at wound site and forms a tough scaffold to which clot can adhere
• Commonly used for sealing holes around suture or staples lines
• AEs : Muscle necrosis, delayed pseudo-aneurysm formation

29. Consists of 2 cyanoacrylate monomers
– 2octyl cyanoacrylate
– Butyl lactoyl cyanoacrylate
 Product to be used as sealant or plug ( forms viscous semiliquid tissue
glue)
 applied over suture lines, fistula tract or cavity, prevent lymphatic
leakage, adapt to seal terminal bronchial

30. Thank you