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How to reduce bleeding during Endoscopic sinus surgery
Balasubramanian Thiagarajan
Advantages of Bloodless field
Reduces duration of surgery
Improves visibility
Camera chip gets reset during heavy bleeding adding to surgeon's woes.
Classification of surgical bleeding during FESS
Arterial
Venous
Capillary
Areas prone to extensive bleeding
Anterior ethmoidal artery located along the ethmoidal roof
Branch of sphenopalatine artery close to the posterior end of middle turbinate (Injury common in pts with concha)
Damage to sphenopalatine artery while attempting to widen sphenoid sinus ostium
Anterior ethmoidal artery
Anatomy is highly variable
Commonly injured during attempts to access frontal sinus outflow tract
Bony covering is very thin
Anterior ethmoidal artery
Anatomy is highly variable
Commonly injured during attempts to access frontal sinus outflow tract
Bony covering is very thin
Anterior ethmoidal artery
May be close to skull base
Seen in patients with a low ethmoid roof
Space between anterior ethmoid and skull base could be as low as 5 mm
Anterior ethmoidal artery
Avoiding anterior ethmoidal artery
Careful scrutiny of preop CT images
Common seen in the upper medial wall of orbit
Avoid grasping of mucosa in the frontal outflow tract area
Management of anterior ethmoidal artery bleeding
Cauterizing using bipolar cautery
Using ligaclip ligatures
Light packing
If it retracts into the orbit no attempt should be made to search for the bleeder
Posterior orbital decompression can be resorted to
Sphenopalatine artery bleeding
Can be injured close to the posterior end of middle turbinate
Common in concha surgery
Can be damaged while attempting to widen sphenoidal ostium
Concha bullosa
Widening sphenoid ostium
Venous bleed
Can be reduced using High frequency jet ventilation
This lowers lower airway pressure and improves venous return
Lower intrathoracic pressures
Capillary bleed
This is the most troublesome bleed
Difficult to cauterize as it is diffuse
Blood flow through the capillary network is rather high inorder to fulfill humidification of inspired air
How to reduce capillary bleed?
Local anaemization by using cotton pledgets soaked in 4% xylocaine with 1 in 10000 adrenaline
A total of 7 ml of 4% xylocaine should not be exceeded
Maintaining normal body temperture during the entire surgical procedure
Reducing capillary bleed: Pt position
Positioning the pt in head up position helps to minimize capillary bleed
If the surgical field is kept above the level of the heart it causes postural ischemia
Systolic pressure reduces by 2mm of Hg for every inch of head elevation
Mucosal preparation
Pre op treatment of infection / allergy
Steroid therapy
Nasal decongestants before surgery
Role of anesthetist
Hypotensive anesthesia
Use of NTG infusion compensatory tachycardia can be overcome by overnight administration of beta blockers.
Keeping the mean arterial pressure under control
Total Intravenous anesthesia
Use of intravenous anesthetic agents like propofol
Propofol reduces cerebral metabolism and its circulation. Maximum bleeding during FESS surgery occurs from central vessels
Supplemented with fentanyl this makes a good intravenous anesthetic agent.
Surgical techniques
Use of true cut instruments
Use of shavers
Avoiding injury to turbinates
If turbinate is tobe removed it should be done piece meal form anterior to posterolateral since they receive blood supply from the lateral nasal wall
Thank you