Basic mechanical methods of hemostasis
Four main groups of methods are used for reliable hemostasis in surgery. The largest and most significant group consists of mechanical methods.
Basic manipulations include:
- Ligation of a vessel in the wound. This is the most reliable method. The surgeon isolates the central and peripheral ends of the torn vessel, grasps them with hemostatic clamps, and applies ligatures.
- Twisting of a vessel. Used for injuries to small-caliber vessels. The end is grasped with a clamp and rotated until the bleeding stops completely.
- Wound tamponade. Indicated for minor wounds and bleeding from small vessels. Dry tampons or gauze moistened with an antiseptic are inserted into the cavity. Classic examples include anterior and posterior packing for epistaxis, as well as uterine tamponade.
- Clipping. Used when ligating the source is difficult or technically impossible. Metal (often silver) clips are applied to the vessel. Once hemostasis is achieved, surgical tactics may involve partial organ removal (gastric resection for ulcer), complete removal (splenectomy for splenic rupture), or suturing (of injured liver tissue).
Complex cases and ligation in continuity
Sometimes standard ligation directly in the wound is impossible to perform. In such situations, alternative techniques are used:
- Ligation in continuity. Indicated when the ends of the vessel cannot be found (e.g., in carotid artery injuries) or in secondary hemorrhage when the wall is destroyed within a dense inflammatory infiltrate. The vessel is exposed and ligated proximal to the injury site. The main drawback of the method is the lack of a guarantee of complete cessation of bleeding from the peripheral end of the artery and via collaterals.
- Suturing (circumferential transfixation). If the ends cannot be reliably isolated, the vessel is ligated along with the surrounding soft tissues.
- Leaving a clamp in the wound. In severe cases, when a clamp is applied but a ligature cannot be placed, the instrument is left directly in the wound for a prolonged period (8–12 days). This time is sufficient for a stable thrombus to form.
Vascular suture
When it is necessary to restore patency and maintain normal blood flow through a major artery, vascular suturing is used.
Rigid requirements are imposed on the suture:
- Perfect airtightness.
- Minimal presence of suture material inside the vessel lumen.
- Preservation of laminar blood flow (without luminal narrowing or pathological vortices).
Sutures can be manual (performed with atraumatic needles) and mechanical. An end-to-end anastomosis is considered the optimal type of connection. For circular suturing, Donetsky rings or tantalum staples can be used. Mechanical suturing is considered very advanced as it practically does not narrow the lumen.
For tangential wounds, a lateral vascular suture is applied, which is additionally reinforced with muscle tissue or fascia for reliability.
Repair of large defects and embolization
For large vascular wall defects (after injuries or radical tumor removal), a single suture is not enough. In these cases, reconstructive techniques are used:
- Biological patches. Fragments of fascia, muscle, or vein walls are used. The most frequent plastic material is an autologous vein (e.g., the superficial forearm vein or the greater saphenous vein of the thigh).
- Grafts. For large-scale reconstructions, auto- and allografts of vessels, as well as synthetic prostheses, are used. They are either sewn into the defect or end-to-end anastomoses are formed.
A separate high-tech category is represented by artificial vascular embolization. The method is used for pulmonary and gastrointestinal bleeding, as well as lesions of the bronchial arteries and cerebral vessels. Under X-ray guidance, a catheter is inserted into the artery and emboli (gelatin sponge, silicone or polystyrene spheres) are introduced. They obstruct the lumen, causing local thrombosis and reliably stopping the bleeding.
Briefly: answers to topical questions
What physical (thermal) methods are used for the definitive cessation of bleeding?
Various types of coagulation are used for definitive hemostasis. Physical (thermal) methods include:
- Electrocoagulation — used both independently and during endoscopic hemostasis.
- Thermocoagulation — used for endoscopic bleeding arrest.
- Laser photocoagulation — used for endoscopic arrest of bleeding.
- Argon plasma coagulation — used to stop active bleeding.
- Diathermocoagulation — used as a thermal method in combination therapy.
Which local biological agents are used for definitive hemostasis?
Special biological agents and materials are used for definitive local hemostasis. These include:
- Fibrin film — used for tamponade.
- Biological antiseptic tampon — used for capillary and parenchymal bleeding.
- Hemostatic collagen sponge — an agent for tamponade.
- Hemostatic gelatin sponge — used to stop bleeding.
- Hemostatic gauze — for example, the preparation "Oxycelodex".
Also, gauze soaked in a solution of thrombin, hemophobin, epsilon-aminocaproic acid, or the drug «Kaprofer» is used.
What materials and synthetic prostheses are used for the repair of large vascular defects?
For the repair of large vascular wall defects, the following are used:
- Biological material patches — fascia, vein wall, muscle. Autologous vein is most commonly used.
- Auto- and allografts of arteries or veins.
- Prostheses made of synthetic materials.
What substances and materials are used as emboli in endovascular embolization?
Various materials and substances are used as emboli in endovascular embolization. These include:
- Synthetic polymers — silicone and polystyrene beads, gelatin.
- Particles (particulate matter) — for example, polyvinyl alcohol (polyvinyl alcohol).
- Liquid agents (liquids) — sclerosants, such as absolute alcohol (absolute alcohol) and sodium tetradecyl sulfate (sodium tetradecyl sulphate).
- Adhesive compositions (glues) — Histoacryl, Onyx, n-butyl-2-cyanoacrylate (n-butyl-2-cyanoacrylate).
- Mechanical devices — embolization coils (coils) and occluders (plugs).
What types of classic manual circular sutures are used for end-to-end vascular anastomosis?
The following manual suture options are used for vascular anastomosis:
- Interrupted nodal sutures according to Carrel.
- Single U-shaped sutures.
- Continuous overhand suture.
- Continuous U-shaped suture.
Manual suturing is performed using atraumatic needles, with an end-to-end anastomosis considered the gold standard.
How is bleeding from damaged spongy bone tissue stopped?
The following methods are used to stop bleeding from bone tissue:
- Compression of the bleeding bone area with bayonet or bone-holding forceps.
- Tamponade with a hemostatic sponge for capillary bleeding from bones.
- Hemostatic materials for tamponade: fibrin film, biological antiseptic tampon, hemostatic collagen or gelatin sponge.
To remember the basic requirements for a vascular suture, use the rule "HMS": Hermetic sealing (leak-proof), Minimum suture material in the lumen, Preservation of flow (without stenoses and turbulence).
Class and exam questions
In which cases is proximal and distal vessel ligation indicated?
The method is used if the vessel ends cannot be found directly in the wound (e.g., in carotid artery trauma) or in case of secondary bleeding within a pronounced inflammatory infiltrate.
What are patches made of for large vascular defects?
Fascia, muscle tissue, or venous wall is used to close extensive defects. The most popular material is an autologous vein, such as the greater saphenous vein of the thigh.
What are the risks of major vessel ligation in continuity?
The main disadvantage of this method is the lack of a full hemostasis guarantee. Bleeding may persist from the peripheral end of the damaged artery due to collateral circulation.
What is the purpose of artificial embolization?
It is indicated for pulmonary and gastrointestinal bleeding, as well as injuries to bronchial arteries and cerebral vessels. Emboli are delivered via a catheter to occlude the lumen and induce thrombosis.
What else to study on this topic
- Technique of Carrel suture and mattress vascular sutures.
- Features of electrocoagulation as a physical method of heostasis.
- Types of synthetic materials for major artery grafting.
- Detailed classification of chemical and biological methods of hemostasis.
- Mechanisms of thrombus formation during artificial vascular embolization.
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