The control of bleeding

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1 Assisting Natural Mechanisms 2 Arterial Bleeding o 2.1 Methods for arteries 2.1.1 To tie an artery 2.1.2 To control bleeding from a large pedicle 2.1.3 To control a difficult bleeding artery 2.1.4 To get a ligature round an artery 3 Tying the External Carotid Artery o 3.1 Tying the external carotid artery 4 Tying the Third Part of the Subclavian Artery o 4.1 Tying the third part of the subclavian artery 5 Tying the Internal Iliac Artery o 5.1 Tying the internal iliac artery 6 Tying the External Artery in the Groin o 6.1 Tying the External Iliac Artery 7 Tying the Femoral Artery o 7.1 Tying the Femoral Artery 8 Tying the Popliteal Artery o 8.1 Tying the Popliteal Artery 9 Bloodless Limb Operations o 9.1 Tourniquets 9.1.1 At the end of the operation 9.1.2 Exsanguinating a limb with Esmarch's bandage 9.1.3 Postoperative care all methods 9.1.4 Difficulties with tourniquets 10 Postoperative Bleeding, Reactionary and Secondary Haemorrhage o 10.1 Postoperative bleeding

Assisting Natural Mechanisms

BLOOD LOSS IN ADULTS AND CHILDREN. A, and B, when you operate on a child, make an accurate 'blood balance sheet'. In a major operation measure the blood he loses by weighing the blood-soaked swabs on a balance. Replace blood he has lost with an equal volume of blood as soon as possible. This should be HIV free or from a close relative. C, the balance sheet for an adult need not be nearly so accurate. A fit adult, such as a mother having a Caesarean section, can tolerate a blood loss of up to a litre or even a litre and a half, before you need to give her blood, rather than Ringer's lactate or saline. You can usually measure the blood she loses in a

sucker bottle. When an adult needs blood, he needs at least two units. The transfusion of a single unit is useless. If you are going to operate on a patient you have to cut him, and if you cut him he bleeds, so you have to control this bleeding. He can also bleed from an injury. The body has excellent mechanisms for controlling bleeding, so that your task is mostly to assist them. The main mechanisms are the cascade of enzymic reactions which make his blood clot, and the ability of the muscular walls of his arteries to contract. If you fail to control bleeding adequately he dies, so watch the blood he loses. The loss of a given volume of blood is much more serious in a child (See Blood Loss), than it is in a fit adult, who can usually lose a litre without the need to replace it by blood, whereas a small child can easily bleed to death from what might seem to be a very small loss. The most generally useful ways of controlling bleeding are pressure and haemostats, but there are also special methods for particular parts of the body, such as the scalp (See Some Ways to Control Bleeding in a Head Injury) , the dura (See Some Ways to Control Bleeding in a Head Injury), the gut (See Methods for abdominal surgery) and the liver (See Liver Injuries).Pressure is the simplest and most valuable way to control bleeding. If you press on a tissue, the walls of its vessels will come together, and where their edges are cut, clot will start to form. When you release the pressure you will probably find that bleeding has stopped, or that only the arteries will continue to spurt at you, and these you can tie off. Press with a gauze pack. Some surgeons use warm saline packs, but there is no evidence that these are any better than cold or dry ones, and they are certainly less convenient. 'Hot packs' are therefore going out of fashion. If pressure is to succeed, you must press for long enough - this is normally at least 5 minutes by the clock, which is one reason why every theatre should have a method of recording time. If the tissue behind the bleeding area is firm, as when you press a bleeding scalp against the patient's skull (See Some Ways to Control Bleeding in a Head Injury), pressure is even more effective. In an emergency, you can control bleeding from a patient's uterus by pressing her aorta against her spine through her abdominal wall.A haemostat (artery forceps) can be used to grasp a bleeding vessel, particularly an artery which is spurting blood at you. You can then tie it.Raising the bleeding part will lower the pressure in its veins, and and so minimize bleeding. This is valuable if a patient is bleeding from a limb, or the venous sinuses of his brain (a rare and difficult emergency), when the level of his head in relation to the rest of his body is critically important (See Controling Bleeding in Head Injuries). But there is a risk of air embolism if a rigid vascular channel, such as a sinus, is raised above the level of the heart.Adrenalin, added to the local anaesthetic solution, or to saline used to infiltrate the tissues, will minimise capillary and venous bleeding, when scar tissue is dissected for plastic surgery, or during the repair of a vesicovaginal fistula. Never use adrenalin in the penis, or the distal parts of a limb such as a finger or toe, or in an intravenous forearm block, because it may constrict the vessels so much that the part becomes gangrenous. You can also use an adrenalin soaked pack in a bleeding nose.A vessel can be sutured, either to repair a break in its wall, or to anastomose it end-to-end (See Repairing Blood Vessels). If a limb is severely injured, this may save it.Bone wax can be packed into the bleeding edge of the skull into the diploe (See Controlling Bleeding in Head Injuries), or into the marrow of a bone, if the bleeding area is not too big.Haemostatic gauze ('Surgijel') will eventually stop bleeding from the oozing cut surface of the liver (See Liver Injuries), or the surface of the brain (See Controlling Bleeding in Head Injuries). Unlike ordinary gauze it is slowly absorbed. It is expensive and rarely indicated. A substitute is to cut a piece of muscle, hammer it flat, and use this (See Controlling Bleeding in Head Injuries).The clotting power of the blood can be

restored. When you have given a patient many units of blood, the citrate in it will lower his blood calcium and prevent his blood clotting. So don't forget to give him 10 ml of 10% calcium gluconate after every fourth unit of blood. The only other thing you may be able to do when his blood fails to clot is to give him fresh blood, but this may be impractical. You are unlikely to have individual clotting factors to give him, except, if you are fortunate, fibrinogen.Arteries and veins can be formally exposed, clamped andtied high above a bleeding lesion. You will only need to do thison unusual and desperate occasions. The classical sites for doing it are the external carotid (See Tying the External Carotid Artery) (rare), the third part of the subclavian (rare, see Tying the Third Part of the Subclavian Artery), the internal iliac (for obstetric haemorrhage, much the most important, see Tying the Internal Iliac Artery), the external iliac (rare), the femoral (uncommon, see Tying the Femoral Artery) and the popliteal artery (rare, see Tying the Popliteal Artery).A tourniquet will control bleeding from the distal part of a limb: (1) You can use a pneumatic tourniquet to control bleeding during an operation as described in Bloodless Limb Operations. This is very valuable, and for many operations it is essential, because it enables you to operate in a bloodless field (See Bloodless Limb Operations). (2) A tourniquet can be used as a first aid measure. This is so dangerous that many surgeons consider that first aid workers should never use one, but should rely on direct pressure instead (See Immediate Treatment for a Severely Bleeding Wound). The common mistakes are: (1) To panic when there is severe bleeding. (2) Not to apply pressure when this is indicated, or not to apply it for long enough. (3) To grasp wildly with a haemostat in a pool of blood, to fail to grasp the bleeding vessel, and perhaps to injure some important structure. (4) Not to apply the special methods for special sites.Gauze, haemostatic, surgical, 'Surgijel' or equivalent, 5 packs only. A story about bleeding: A surgeon went to an international meeting on prostatectomy. He got bored and said to a friend I amhaving a bit of trouble with my waterworks, whom should I see? Go to Mr. X he was told, he is the best in town. So our surgeon visited Mr.X and said Could you show me your method of prostatectomy? The answer was Yes certainly, but my only secret is, that I drink more teathan the others!. So it proved. At the end of the operation when theprostatic bed was bleeding, Mr. X just put in a monster pack, and had a leisurely cup of tea. When he and his assistant rescrubbed and came back 20 minutes later, the pack was taken out and there were no bleeding points to tie off! Lessons: When you control bleeding by pressure or with a pack sufficient time (5 minutes by the clock) is all important. Gauze packs will control oozing. Press dry gauze onto the bleeding area, or wring out gauze or any piece of cloth in hot water, and press this on the wound. If the operation is difficult, and you need a rest, this may be the time to go out to the changing room for a break and a cup of tea, while your assistant applies pressure. This will make sure that pressure is applied for the necessary time. When you come back, instead of finding the whole area pouring blood, you will probably find one one or two tiny bleeders, which you can pick up in mosquito forceps and tie off. Because fewer ligatures are needed, there will be less chance of sepsis.Dry firm pressure packs can be used to compress a large bleeding vessel against something solid such as the spine.Packing a wound at the end of an operation is sometimes necessary. If, for example, you remove sequestra under a tourniquet, you can pack the wound tight, and remove the pack 24 or 48 hours later. Don't leave a pack in longer than 48 hours, or it will promote sepsis, and there may be severe bleeding when you remove it.Leaving clamps in the wound: Very ocasionally, if you are inexperienced and desperate, you may have to clamp a vessel, and send the patient back

to the ward with the handle of the haemostat protruding from the wound under a dressing. Remove it cautiously 24 hours later and close the wound. This is indeed a measure of desperation. It may be useful for a bleeding cervix and for a bleeding renal pedicle (See Operations for Kidney Injuries). Most experienced surgeons have never had to do it.

Arterial Bleeding

HAEMOSTATS. If you can see a bleeding vessel, you can usually grasp it with these locking forceps, which are one of the great inventions of surgery If you can see a bleeding vessel, you can grasp it with a haemostat (locking or artery forceps), which is one of the great inventions of surgery. Tie all larger vessels, either immediately or later. Small vessels, especially those in the skin, seldom need tying. Five minutes or more later, when you remove a haemostat you will probably find that bleeding will have stopped. You can encourage it to stop by twisting the haemostat before you remove it, or if the bite of tissue is too large to twist, you can release the jaws and quickly pinch them together again a few times before you remove them. Either of these methods will encourage the blood in the vessel to clot and will minimize bleeding, so that fewer vessels need tying. Haemostats can be large or small, straight,

or curved, so that they rest over the edge of the wound. An experienced surgeon can go through the skin using few of them or none (pressure from swabs is often enough); a beginner usually needs more. Haemostats have some disadvantages. Each time you tie off a bleeding vessel you leave some crushed tissue and some suture material in the wound. If this is excessive, it can encourage delayed healing or infection later. The tips of haemostats, especially small ones, must meet accurately, so good quality instruments are important. Box joints are worth the extra expense. Order them in sixes - you can hardly have too many - because they will enable you to make up several sets (See Basic methods and instruments). Forceps, artery, Spencer Wells, box joint, (a) 200 mm, straight, six only. (b) 150 mm, straight, twelve only. (c) 230 mm, curved, six only. (d) 200 mm, curved, eighteen only. (e) 150 mm, curved, six only. (f) 125 mm, curved, twelve only. These are general purpose haemostats. Fiftyfour in all is a generous number and could be reduced. Forceps, artery, Crile's, box joint, 140 mm, (a) straight, six only. (b) curved, eighteen only. These are medium sized and are more robust than Halstead's. Forceps, artery, Halsted's, ultrafine, mosquito, haemostatic, (a) straight, (b) curved, box joint, 120 mm, six only of each type. These are some of the finest and most delicate instruments in the list, so use them with care. Forceps, artery, Kocher's, (a) straight, (b) curved, box joint, 200 mm, six only of each type. These are large haemostats with a tooth at the end of their jaws. Use them for a wide vascular pedicle when an ordinary haemostat might slip. Pins, safety, Mayo's, large, for storing artery forceps, etc., ten only. Use them to keep artery forceps together in bunches during sterilizing.

TYING ARTERIES. A, don't leave too lng an end; this will leave unnecessary dead tissue in the wound. B, to freee a vessel buried in tissue, insert Lahey's forceps and spread the tissues. C, if possible, put the ligature proximal to a branch. D, an artery has been tied an da transfixion ligature is now bein inserted; the needle is going through the vessel and its distal end is about to be cut off. E, the completed ligature.

Methods for arteries

To tie an artery To tie an artery, use the following materials in this order of preference-linen thread, cotton thread, or monofilament. Don't use catgut for larger and more important vessels, it slips off too easily. Grasp the bleeding artery with a haemostat. Either: (1) Tie it with one firm reef knot. (2) Tie it with a surgeon's knot (See Basic methods and instruments) followed by two or three more throws. (3) Transfix it, tie it with a reef knot, then pass one ligature through it with a needle, and tie it with another reef knot. This is the method for critically important vessels, such as those of the renal pedicle. For even more security, tie it proximal to a branch, and then cut it distal to this.If it is a critically important vessel, ask yourself - Is what I have doneenough? If it is not, do it again. Put a second tie in a separategroove.If there is a long length of vessel distal to your tie, shorten it, so as not to leave too much dead tissue in the wound, but don't shorten it too much!If other methods of controlling severe arterial bleeding have failed, you may, very occasionally, have to expose and tie a major vessel, such as the external carotid artery or the subclavian, as described in the methods which follow. Use linen, silk, or cotton thread, and don't divide it after you have tied it.

To control bleeding from a large pedicle

TWO WAYS OF PASSING A LIGATURE UNDER A VESSEL. A, using an aneurysm needle. This is a left-handed needle. B, a length of sutrue material held in a curved haemostat. C, another curved haemostat is being passed under the vessel to grasp the suture material. D, pulling the suture material under the vessel. To control bleeding from a large pedicle such as that of the spleen or uterus, don't try to use a single ligature. Control of the vessels will be safer if you take one or more bites of the pedicle and tie them separately. To control a difficult bleeding artery To control a difficult bleeding artery, try to get into the correct tissue plane. First find the artery by feeling for pulsation. Push the points of a fine haemostat into the connective tissue around it and separate them to open up a plane as in Tying Arteries, B. Gradually develop this plane until you can see the artery you are looking for. In this way you will avoid tying some important nerve in the ligature. To get a ligature round an artery

To get a ligature round an artery, either use an aneurysm needle, or pass a curved haemostat under it, and ask your assistant to pass into your other hand a curved haemostat with a ligature 'bowstrung' across it, as in Passing a Ligature. This is useful in 'deep' surgery.

Tying the External Carotid Artery

TYING THE RIGHT EXTERNAL CAROTID ARTERY. One of the vessels you may very occasionally have to tie is the external carotid artery after a severe maxillofacial injury. Adapted from 'Farquarson's Textbook of Operative Surgery', edited by RF Rintoul. Churchill Livingstone, with kind permission. The methods in the sections which follow for exposing and tying major vessels are among the classical methods of surgery. They are very seldom needed, yet no textbook of surgery is quite complete without them. After a severe maxillofacial injury you may have to tie the external carotid artery. This arises from the common carotid at the upper edge of the thyroid cartilage. It runs upwards behind the neck of the mandible, and ends by dividing into the maxillary and superficial temporal arteries. It lies under the posterior belly of the digastric muscle, and its upper part lies deep to the parotid gland.

Tying the external carotid artery

Tilt the table 10 head up to minimize venous bleeding; but not more, because this increases the risk of air embolism. Turn the patient's head to the opposite side, and extend it slightly. Make an oblique incision from just below and in front of his mastoid process, almost to his thyroid cartilage. Divide his platysma and deep fascia in the line of the incision, and dissect flaps upwards and downwards. Free the anterior border of his sternomastoid and retract it posteriorly. You will see his common facial vein. Divide this between ligatures. Carefully retract his internal jugular vein backwards, to see his common carotid artery bifurcating to form his internal and external carotid arteries. If you have difficulty in deciding which artery is which, find some branches of the external carotid and follow them backwards to the main stem (the internal carotid artery has no branches in the neck). Pass an aneurysm needle round it, tie it with zero silk or linen, and don't divide it. Tie it as close to its origin as you can. CAUTION! (1) Tie the external carotid just proximal to the origin of the lingual artery. (2) Avoid the patient's hypoglossal nerve which crosses his external and internal carotid vessels and then runs anteriorly to lie on his hyoglossus muscle in company with his lingual vein. (3) Avoid irritating his carotid sinus and body in the bifurcation of his internal and external carotid vessels.

Tying the Third Part of the Subclavian Artery

EXPOSING THE THIRD PART OF THE SUBCLAVIAN ARTERY. If a fracture of the neck of the humerus tears the axillary artery (rare), it may cause an arterial haematoma which you can only control by tying the subclavian artery. Adapted from 'Farquarson's Textbook of Operative Surgery', edited by R F Rintoul. Churchill Livingstone, with kind permission.

If a fracture of the neck of a patient's humerus tears his axillary artery, it may cause an arterial haematoma which you can only control by tying his subclavian artery. You will find this a desperate procedure, if you ever have to do it. The subclavian artery crosses the cervical pleura in the root of the neck. It passes over the first rib behind scalenus anterior which divides it into three parts. The first part is medial to this muscle, the second part is behind it. The third part of the artery, lateral to his scalenus anterior, is the part you can most easily tie. The subclavian vein lies in front of the artery and slightly inferior to it. The phrenic nerve runs down the front of scalenus anterior. Very occasionally, you may have to explore a patient's subclavian artery in his axilla, by removing the middle piece of his clavicle and splitting the fibres of his pectoralis major, so that you can reach it.

Tying the third part of the subclavian artery

This is not an easy operation, even for experienced surgeons, so avoid it if you can! If you have to do it, start by tilting the table 10 head up. Put the patient's arm by his side, and draw it downwards to depress his shoulder. Turn his head to the opposite side. Make an incision 2 cm above his clavicle from the sternal head of his sternomastoid to the anterior border of his trapezius. Incise his superficial fascia, his platysma, and his deep fascia in the line of the incision. If you see his external jugular vein crossing the field, divide this between ligatures. Retract his omohyoid upwards and you will see the third part of his subclavian artery, with scalenus anterior medially, and the trunks of his brachial plexus laterally. His subclavian vein lies in front of the artery and below it. Don't cut his transverse cervical artery under his omohyoid muscle, or his suprascapular artery crossing his subclavian artery, because they help to maintain the collateral circulation to his arm. If necessary, split his clavicle, divide his pectoralis major in the line of its fibres, lay his whole axilla open, and get proximal control of the artery. Pass an aneurysm needle round it, tie it with zero silk or linen, and don't divide it.

Tying the Internal Iliac Artery

TYING THE LEFT INTERNAL ILIAC ARTERY. A, the ureter crossing the bifurcationof the common iliac artery. B, the ureter retracted and the peritoneum incised. C, the bifurcation exposed. D, a haemostat has been passed under the internal iliac artery. E, grasping the other end of the ligature. F, the ligature ready to tie. After Lees DH and Singer A, Colour Atlas of Gynaecological Surgery, Vol. 6, p. 108. Wolfe Medical Publications, with kind permission. Tying the internal iliac artery is the most common emergencyarterial ligation. If a patient has severe and continuing uterinebleeding, after delivery for example, you may have to tie her internal iliac arteries on both sides. When her uterus has ruptured, so that its wall hardly feels any more substantial than blood clot, this is one of the few things you can do. It is not an easy procedure. She is likely to be very ill, your anaesthetist may not be able to give her an adequate anaesthetic, her pelvic wall is difficult to get at, and her pelvic retroperitoneum is difficult to work in. If you are expert, doing a hysterectomy may be easier. So start by getting good exposure, and identify the main trunks clearly before you tie them. The collateral circulation is so good, particularly during pregnancy, that tying both iliac arteries is very unlikely to be harmful.

Tying the internal iliac artery

Indications: (1) Tearing into the lower segment during or base of the broad ligament during a difficult Caesarean section. (2) Severe and persistent PPH when packing fails to control bleeding. (3) Persistent bleeding from an abortion continuing after evacuation. (4) Rupture of the uterus. (5) Trauma to the uterus. Method: If you already have the patient's abdomen open, tying her internal iliac arteries is quickly done. But don't be in too much of a hurry: you must not damage the accompanying vein. Often, you need to tie them when you have not already got the abdomen open. If so make a quick

lower median incision. Hold back her abdominal contents and examine her pelvic brim. You will see her ureter crossing her common iliac artery at the point where it divides into its internal and external iliac branches (See Tying the Internal Iliac Artery, A). Open her peritoneum and lift up her ureter (See Tying the Internal Iliac Artery, B). Insert a haemostat under her internal iliac artery (See Tying the Internal Iliac Artery, C), and tie it. Do the same thing on the other side. CAUTION! (1) Don't tie her internal iliac vein which is closely related to the artery posteriorly. Doing so will increase the venous pressure in her uterus and make bleeding from it worse. (2) Don't damage her internal iliac vein. If you do, bleeding from the tear will be difficult to control and you will have to tie it. On both sides, if necessary, also tie the anastomotic vessels that connect her ovarian arteries with her uterine arteries. Find them in her broad ligaments under the cornual ends of her tubes.

Tying the External Artery in the Groin

EXPOSING THE EXTERNAL ILIAC ARTERY. If a wound is so high up in a patient's thigh that cannot control bleeding by tying his femoral artery below its profunda branch, you may have to tie his external iliac artery. Adapted from 'Farquarson's Textbook of Operative Surgery'. Edited by RF Rintoul. Churchill Livingstone, with kind permission. If a wound is so high up in a patient's thigh that you cannot control bleeding by tying his femoral artery below its profunda branch (which is the main source of his collateral circulation), you may have to tie his external iliac artery instead. Be careful not to injure his external iliac vein and

femoral nerve as you do so. This is a difficult procedure, if you are inexperienced. The external iliac artery arises at the brim of the pelvis from the common iliac artery and runs to the mid inguinal point, where it becomes the femoral artery. The external iliac vein lies medial to it, and the psoas muscle behind it. The femoral nerve lies about a centimetre lateral to it, with the genitofemoral nerve in between them. The peritoneum lies in front of the artery, until the point at which it turns upwards on to the anterior abdominal wall. Below this point, and immediately above the inguinal ligament, the external iliac artery is related from within outwards to: (1) the transversalis muscle, (2) the internal oblique, and (3) the external oblique muscles. Two branches arise from the external iliac artery: (1) The inferior epigastric artery, which runs upwards into the rectus sheath. (2) The deep circumflex iliac artery, which runs laterally along the back of the inguinal ligament.

Tying the External Iliac Artery

Put the patient into a moderate Trendelenburg position. Make an incision above and parallel to the middle of his inguinal ligament. Open his inguinal canal and divide the muscular fibres of his internal oblique above his inguinal ligament. Incise his transversalis fascia, and retract his spermatic cord upwards and medially. Gently raise his peritoneum and you will see his external iliac artery and vein. As you do so, try not to cut his inferior epigastric artery and its vein. Separate the artery carefully from the vein, pass an aneurysm needle round it, tie it with 1 silk or linen, and don't divide it.

Tying the Femoral Artery

EXPOSING THE FEMORAL ARTERY is one of the more useful of the arterial exposures described here, because you will need it in an above-knee amputation, and you may need it in a penetrating wound of the thigh. Adapted from 'Farquarson's Textbook of Operative Surgery', edited by RF Rintoul. Churchill Livingstone, with kind permission. If a patient has a penetrating wound of his thigh, you may need to tie his femoral artery. If possible, tie it in his subsartorial canal, below its profunda branch, so that this can supply his leg via the anastomoses that its perforating branches make with the arterial plexus round his knee. If you tie it above its profunda branch, his circulation may be be maintained via the cruciate anastomosis with branches of his internal iliac artery, but this is less reliable. The femoral artery starts at the mid inguinal point as a continuation of the external iliac artery. It runs down the thigh obliquely, first across the femoral triangle, and then underneath the sartorius muscle. It ends at the junction of the middle and lower thirds of the thigh, by going through a hole in the adductor magnus, and becoming the popliteal artery. As the femoral artery crosses the femoral triangle, the femoral vein lies medial to it, becoming posterior distally; the femoral nerve lies about a centimetre laterally. Further on, when the femoral artery is in the canal underneath sartorius, the adductor longus and adductor magnus muscles lie behind it; vastus medialis lies anterolaterally. The femoral vein now lies posterolaterally, the nerve to vastus medialis laterally, and the saphenous nerve anteromedially. The superficial epigastric artery, the superficial circumflex iliac artery, and the superficial and deep external pudendal arteries all arise from the femoral artery close to its origin. The profunda femoris artery arises about 3 cm below the

inguinal ligament, runs medially behind the femoral artery, and finally breaks up into branches which run into the adductor muscles.

Tying the Femoral Artery

Flex the patient's thigh slightly, and rotate it laterally. If you plan to tie his femoral artery distal to his mid thigh, apply a tourniquet. Draw a line from his mid inguinal point to his adductor tubercle. His femoral artery lies under the upper two-thirds of this line palpate it. Make an adequate incision at a suitable place along this line. His long saphenous vein lies in the superficial fascia. Try not to cut it. If by any chance you have to to tie his femoral vein, this will form the main venous collateral. Incise his deep fascia, mobilize his sartorius muscle, and reflect this laterally to expose the upper part of his femoral and profunda arteries. To expose the lower part of his femoral artery, reflect his sartorius medially, and divide the bridge of fibrous tissue which roofs his subsartorial canal. His femoral artery may be very difficult to find. If it is, release the proximal tourniquet (if you have applied one), and feel for pulsations. Separate his femoral artery and vein carefully. Preserve the vein if you can. Proximally, they lie together within the femoral sheath, distally this becomes the femoral fascia. Pass an aneurysm needle round the artery, tie it with zero silk or linen, and don't divide it.

Tying the Popliteal Artery

EXPOSING THE POPLITEAL ARTERY is difficult, because, although the popliteal fossa looks easy in a diagram, in real life its contents are cramped together. A vertical incision is shown. A 'lazy S' incision is better. Adapted from 'Farquarson's Textbook of Operative Surgery', edited by RF Rintoul. Churchill Livingstone, with kind permission. You may need to expose a patient's popliteal artery in wounds of his popliteal fossa. This is difficult. Although the popliteal fossa looks easy in diagrams, in reality all its contents are cramped together. Nerves, arteries, and veins all look much the same until you dissect them out carefully. Unless you have previously exsanguinated the patient's leg with an Esmarch bandage, blood will flood up everywhere, and you can easily injure his common peroneal nerve. The popliteal artery begins as the continuation of the femoral artery, at the opening in adductor magnus. It then runs downwards in the popliteal fossa until it reaches the lower border of the popliteus muscle, where it divides to form the anterior and posterior tibial arteries, and the peroneal artery. The popliteal vein lies medial to the lower end of the popliteal artery and crosses it posteriorly to lie posterolateral to its upper part. The medial popliteal nerve crosses the popliteal artery and vein posteriorly from the lateral side above, to the medial side below. The lateral popliteal nerve lies more superficially in the lateral part of the fossa.

Tying the Popliteal Artery

Lay the patient prone. If he is having a general anaesthetic he must be given a relaxant and intubated, and his respiration controlled. Exsanguinate his leg with an Esmarch bandage and apply a tourniquet. Make a 15 cm 'lazy S' incision over the centre of his popliteal fossa, with the distal end on the medial side, so as to avoid his superficially placed lateral popliteal nerve. Carefully cut through his superficial fascia. Find his sural nerve and hold it aside. Now incise the fascial roof of his popliteal fossa vertically, and retract his hamstring muscles and the two heads of gastrocnemius. CAUTION! Before you tie his popliteal artery, carefully separate it from the vein and nerves which accompany it. If necessary, you can carry the incision downwards to expose the lower part of his popliteal artery and the origin of his two tibial arteries. Divide the fibrous arch which crosses these vessels and the fibres of his soleus muscle which arise from it. The popliteal artery has few collateral branches, so preserve as much of its length as you can by by tying it close to the lesion. Pass an aneurysm needle round it, tie it with zero silk or linen, and don't divide it.

Bloodless Limb Operations

TOURNIQUETS. A, don't use Samway's tourniquet, or you may injure the patients limb. B, a pneumatic tourniquet is much the best. C, Esmarch's bandage is a roll of red rubber. D, the site to apply it in the arm. E, the site in the leg. F, use a rubber catheteras a finger tourniquet. G, and H, when you apply a tourniquet, take the time and record it. I, if you want to exsanguinate a patient's arm, raise it and then apply Esmarch's bandage, starting in the patient'shand. J, blow up the pneumatic tourniquet, then unwind the bandage, starting proximally in his limb. K, you can use Esmarch's bandage as a tourniquet. One of the great advantages of operating on a patient's limb is that you can use a tourniquet to prevent bleeding. This will save blood and enable you to see his tissues more clearly. You can use any of these:A special pneumatic tourniquet which resembles the cuff of a sphygmomanometer. The pressure at which a tourniquet is applied is important; this is more easily controlled pneumatically, so a pneumatic tourniquet is much the best. Also you can, if necessary, let it down rapidly during an operation to perfuse the tissues, or to find arteries that need tying.An Esmarch's bandage which is a strip of red rubber 7 cm wide and 2 metres long. It is satisfactory, provided: (1) You spread it out carefully over an encircling cotton wool pad. (2)

You don't put it on too tight, especially on a thin limb.A reliable sphygmomanometer. You may not have a special pneumatic tourniquet, so this is probably what you will have to use.Never use a Samway's tourniquet. This is a rubber tube with a hook at one end. It too easily injures the tissues underneath it. A tourniquet will prevent blood entering a limb, but it will not remove blood which was already there when you applied it. You can remove this blood in two ways: (1) You can raise the patient's limb for at least a minute to help the blood to drain away from it before you apply the tourniquet. This is the only safe thing to do if there is sepsis. It will leave a little blood in his vessels, which can be an advantage, because you can more easily see where they are. (2) You can wind an Esmarch bandage round his limb from its distal to its proximal end to squeeze out the blood. Then you can apply a pneumatic tourniquet (or a sphygmomanometer) round the base of his limb to stop blood entering it. Finally, you can remove the Esmarch bandage. This will provide an almost totally bloodless field, but is only safe if there is no sepsis. A tourniquet has disadvantages: (1) If you apply too much pressure for too long over too narrow an area, you may injure the nerves to the limb, and cause a paresis; this is usually only temporary, but it may be permanent. A transient radial nerve palsy is common, even if you apply a tourniquet correctly. (2) If you forget to take a tourniquet off, so that it is left on for 6 hours or more, Volkmann's ischaemic contracture, myoglobinaemia, or gangrene may follow. This happens more easily if a patient has arterial disease. So apply a tourniquet carefully; record the time when you applied it, and don't leave it on too long (arm 1 hours, leg 2 hours, shorter times and lower pressures in children). (3) If a tourniquet is too loose, it may obstruct only the veins, and increase bleeding. Tourniquet Conn, improved pneumatic with dial, in case complete, (a) adult, (b) child. One only of each size. A pneumatic tourniquet is one of the most useful surgical instruments, and is almost essential. Alas, few district hospitals have them. Bandage, rubber, Esmarch 3 m 75 1 mm, fitted with tapes, two only. If you don't have an Esmarch bandage, cut one spirally from the inner tube of a motor cycle tyre, leaving out the elliptical pieces shown as in More Tourniquets. The tube from an ordinary car tyre is too thick.

HANK (42 years) was to have a bunion removed. The junior resident was asked to apply an Esmarch tourniquet. He had never applied one before, so he just wound the whole bandage round the patient's unpadded leg. 10 days later at the follow up clinic the patient had a numb foot. LESSON Learn how to apply a tourniquet, before you apply one.

If you applied a tourniquet, it is your responsability to remove it!

Tourniquets

MORE TOURNIQUETS. A, you can cut an Esmarch bandage from the inner tube of a motor cycle tyre (a car inner tube is too thick). B, when you apply a tourniquet, tie it to the operating table, to that you do not leave it on by mistake. C, using a discarded glove as a finger tourniquet. B, after Sally Piper from the British Journal of Anaesthesia. Indications: (1) A wound toilet in a patient's injured limb, particularly if this has to be followed by the repair of his vessels, nerves, and tendons. (2) Any hand operation, other than a very small one. Hand injuries, and hand sepsis. (3) The exploration and drainage of bones and joints, when this is anatomically possible, as in a patient's lower humerus, his elbow and parts distal to it. Or his lower femur, his knee, and parts distal to that. Contraindications: (1) The SS and CS varieties of sickle cell disease, but not AS heterozygotes. (2) Impaired circulation due to arterial disease. Sepsis is not usually considered a contraindication to the use of a tourniquet, but it is to exsanguination with an Esmarch's bandage. CAUTION! Never use a rubber tube tourniquet (such as Samway's), except on a finger, where you can use a catheter for a few minutes. Anywhere else, a rubber tube may damage the nerves of the limb.

Anaesthesia: A tourniquet is painful and a conscious patient will not usually tolerate one for more than 5 minutes. So the practical methods of anaesthesia are: (1) General anaesthesia. (2) Ketamine. (3) Axillary block. Sites for applying a tourniquet: There are only four of these: (1) The middle of a patient's upper arm (See Tourniquets, D). (2) His finger (See Tourniquets, F). Use a rubber catheter. This is only safe for a short procedure, such as draining a pulp infection. (3) His upper thigh, a hand's breadth below his groin if he is an adult (See Tourniquets, E). At this point the femoral artery lies close to the femur and is easily compressed. CAUTION! (1) Don't apply a tourniquet anywhere else. A tourniquet on the forearm is dangerous, so is one on the lower leg, because you may damage the common peroneal nerve as it winds round the neck of the fibula. (2) Tie a tourniquet to the operating table, to prevent anyone forgetting it, because the patient cannot later be lifted off the table without removing it. A tourniquet hidden under drapes can easily be forgotten. The safe times for an adult of average build are the arm 1 hours, the leg 2 hours. Shorten these times by 60% in a thin adult. Halve them in an 8 year old child. Apply a tourniquet to a finger for a few minutes only. The responsibility for keeping within these times lies with the anaesthetist, who should remind the surgeon every 15 minutes how long a tourniquet has been applied. Elevate the patient's limb for a few minutes before you apply any kind of tourniquet. If you are going to apply an Esmarch's bandage, now is the time to apply it. Pneumatic tourniquet: Place a folded towel, or a thin layer of cotton wool, around the limb at the site where the tourniquet is to be applied. Wrap this snugly round the patient's limb - it must not be loose. Pump it up to the appropriate reading for 'arm', or 'leg', on the scale. For a child use a lower presure as indicated on the scale. Drape it out of the way of the operation, but keep the dial where you can read it. If the bag becomes contaminated, autoclave it. Using a sphygmomanometer as a tourniquet: On a patient's leg apply the cuff over his femoral artery. On his arm apply it as if you were taking his blood pressure, or if necessary higher up his arm. Bandage it in place with a firm unyielding bandage, and fix this with adhesive strapping. Blow up the cuff until his distal pulses just disappear. Remember the pressure, and let the cuff down again. When you want to use it, blow it up to 80 or 100 mm above the pressure which just stops the pulses. This is about 200 mm for the arm in an adult and 180 mm in a child. For an adult leg blow it up to 250 mm. Ask an assistant to keep the cuff at this pressure, and to inflate it as necessary. CAUTION! Don't inflate any cuff to more than 80 to 100 mm above the pressure that will just obliterate the pulse. Using an esmarch bandage as a tourniquet: Tape a folded towel or a thin layer of cotton wool in position over his limb. Apply Esmarch's bandage over about 12 cm. Put on the first two layers of the bandage without pulling. Next, do a trial run to find how many turns are necessary to obliterate the pulse. Pull out the bandage to about three- quarters of its potential expansion length with each wind. Count the number of winds you need to obliterate the pulse. When you want to apply it, apply five more winds than are necessary to obliterate the pulse. When you have finished, it should feel moderately firm, but not rock hard. CAUTION! (1) Don't apply a tourniquet over too narrow a band of muscles. (2) Don't ever wind on more than five turns after you have obliterated the pulse. Every turn may add 100 mm more pressure.

At the end of the operation There are two ways of controlling bleeding after you have applied a tourniquet. You can release it, either: (1) Just before you close the patient's wound. Use this method when you do a fine operation on his hand, for example. It will reduce the blood clot in his tissues, and the stiffness and fibrosis that this might cause. Release the tourniquet, raise his limb, apply large swabs to the wound, and press them for five minutes. Lactic acid will have accumulated in his anoxic limb and will make its vessels dilate immediately the tourniquet is released. As this is metabolized, they will contract again. Remove the swabs and tie any bleeding vessels that remain. Expect him to bleed into his dressings. Or, (2) at the end of the operation after you have closed his wound. Use this method after operations in which clot in his tissues will be less important, as when you do a sequestrectomy (See Chronic Osteomyelitis). Tie any tie major vessels when you come to them during an operation. When the operation is complete, sew up the wound, apply a pressure dressing, and let down the tourniquet. Remove the pressure dressing 48 hours later. Usually, this is all that is necessary. Occasionally, the wound will bleed, so that you have to remove the dressing, open it and tie the bleeding vessel. If you need to immobilize an open fracture, loosely apply a well padded cast. Exsanguinating a limb with Esmarch's bandage Indications: Any operation in which you want a completely bloodless field, particularly orthopaedic operations. Contraindications: (1) Sepsis. (2) Amputations for malignancy. It may spread both of these. Method: Apply a pneumatic tourniquet round the base of the patient's limb but don't blow it up. Raise his limb and wind Esmarch's bandage tightly round it from the distal end proximally. As you do so it will squeeze the blood out of his veins. Blow up the tournqiuet. Finally, remove the Esmarch bandage to expose his bloodless limb. Postoperative care all methods Raise his arm in a roller towel (See Raising an Injured Upper Limb), for his leg raise the foot of his bed. Observe the circulation in his limb at least hourly; the capillary reflex is important, so pinch his nail beds. If necessary, remove a pressure bandage or split a cast lengthways and open it at least 2 cm. Difficulties with tourniquets If he cannot extend his wrist after the operation, he has a tourniquet palsy. The higher the pressure and the thinner he is, the greater the risk. Fortunately, this is usually temporary and recovers within 3 weeks and occasionally up to 6 months; but it can be permanent. 1 hours in the arm and 2 hours in the leg.Less for thin adults and children

Postoperative Bleeding, Reactionary and Secondary Haemorrhage

When you have closed an operation wound it may start bleeding: (1) During the first 48 hours (reactionary haemorrhage) because a clot in a vessel has been displaced, or a ligature has slipped. Or, (2) 8 to 14 days later (secondary haemorrhage) when the wound has become infected and eroded a vessel, usually quite a small one, sometimes a larger one. One of the purposes of monitoring a patient immediatelay after an operation is to watch for reactionary haemorrhage, so make sure your staff observe him carefully, and take his pulse and blood pressure regularly.

Postoperative bleeding
See also particular operations, particularly Caesarean section (See The surgery of labour) and prostatectomy (See Urology). If a patient's wound bleeds, try firm local pressure and packing. If it bleeds briskly, you may have injured an artery, such as his inferior epigastric. Minor bleeding is probably coming from his subcutaneous tissues, and is unlikely to be serious. If local pressure fails to control bleeding, take him back to the theatre and open his wound. You can usually do this under local anaesthesia. Remove the sutures and tie or coagulate his bleeding vessels. Make sure he is on antibiotics (See Antibiotics in Surgery). If his blood pressure falls postoperatively, he may be hypovolaemic because: (1) The blood he lost at the operation has not been replaced, especially if he was hypo-volaemic before it began. (2) The fluid which he lost into his sequestrated gut has not been replaced. (3) He was anaesthetised too deeply and his respiration is still depressed, leading to hypoxaemia and hypotension. (4) He has been given large doses of opioids, such as morphine or pethidine. (5) He has had a high subarachnoid (spinal) anaesthesi. (6) He may be septicaemic. (7) His gut may have been roughly handled. (8) He has been roughly handled on a trolley. If necessary, restore his blood volume, and nurse him with his legs raised.If he goes into shock with a fast pulse, pallor, perhaps with abdominaldistension, or bright red blood from a drain incision, he has probablybled into his peritoneum. If two units of blood do not restore his blood pressure, consider reopening his wound to control the bleeding.If, after a stomach operation, you aspirate quantities of freshblood from his nasogastric tube, he has probably bled from theanastomosis in his stomach. If his blood pressure is only a little depressed, perform gastric lavage every half hour with iced water containing 8 mg of noradrenalin 200 ml. If he has required more than 3 units of blood to maintain his blood pressure above 100 mm, and you are still aspirating fresh blood an hour later, reexplore him and revise his anastomosis. He is unlikely to stop bleeding spontaneously. A complete mucosal layer may have missed getting sutured. See also The gallbladder, pancreas, and spleen.If he bleeds from his gut some days after the operation, the blood may be coming from a stress ulcer, or from a pre-existing duodenal ulcer. It may threaten his life. Monitor his pulse, his blood pressure, and his urine output. Keep a good drip going, and measure his haematocrit 3-hourly. Have at least two units of blood cross-matched for him. Irrigate his stomach with iced saline or tap water containing noradrenalin 8 mg in 200 ml every half hour. See also The gall-bladder, pancreas, and spleen.