How to reduce bleeding during Endoscopic sinus surgery

How to reduce bleeding during
Endoscopic sinus surgery
Balasubramanian Thiagarajan

drtbalu's otolaryngology online

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


● 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


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


How to reduce bleeding during Endoscopic sinus surgery

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How to reduce bleeding during Endoscopic sinus surgery