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