Foot and ankle surgery, like all surgical procedures, necessitates meticulous attention to controlling bleeding, also known as hemostasis. Effective hemostasis is crucial not only for the surgeon’s ability to see and operate clearly but also for reducing the risk of complications, such as hematoma formation, infection, and delayed healing. Here, we discuss the various methods surgeons employ to manage bleeding during foot and ankle surgery.
Mechanical Methods
Mechanical methods are often the first line of defense against surgical bleeding. These techniques physically obstruct or compress blood vessels to stop the flow of blood.
- Tourniquets: A tourniquet is a tightly applied band around the limb, usually around the thigh, to temporarily occlude blood flow. By constricting blood vessels, it creates a bloodless field, allowing for clearer visibility and easier manipulation of tissues. However, tourniquets must be used judiciously to prevent tissue damage due to prolonged ischemia.
- Sutures and Ligatures: For larger blood vessels, surgeons may use sutures to tie off (ligate) the vessels. This is a direct and effective way to ensure that blood flow from a specific vessel is permanently stopped.
- Hemostatic Clamps: Clamps, such as hemostats, are used to compress blood vessels temporarily. This is often a preparatory step before ligation or cauterization.
Thermal Methods
Thermal methods involve the use of heat to coagulate (clot) blood and seal blood vessels.
- Electrocautery: This technique uses an electrically heated instrument to burn and seal the ends of blood vessels. Electrocautery is highly effective for controlling bleeding from smaller vessels and for achieving precise hemostasis in delicate surgical fields.
- Laser Coagulation: Laser technology can also be employed to coagulate blood vessels. The high-intensity light energy effectively seals vessels and minimizes bleeding, though it is less commonly used in foot and ankle surgery compared to other methods.
Chemical Methods
Chemical hemostatic agents play a significant role in controlling bleeding, particularly when mechanical and thermal methods are insufficient or impractical.
- Topical Hemostatic Agents: These include materials like gelatin sponges (Gelfoam), oxidized cellulose (Surgicel), and thrombin-based products. When applied to a bleeding site, these agents promote clot formation and provide a physical barrier to further bleeding.
- Fibrin Sealants: These are adhesive agents that combine fibrinogen and thrombin to form a clot. Fibrin sealants are particularly useful in areas where suturing or mechanical methods are challenging.
Pharmacological Agents
Certain medications can enhance the body’s natural ability to form clots.
- Tranexamic Acid: Administered either orally, intravenously, or topically, tranexamic acid helps reduce bleeding by inhibiting the breakdown of fibrin clots. It is increasingly used in orthopedic surgeries, including foot and ankle procedures, to minimize intraoperative and postoperative bleeding.
- Antifibrinolytics: Similar to tranexamic acid, these drugs prevent the dissolution of fibrin clots, thereby stabilizing the clot and reducing bleeding.
Conclusion
Effective hemostasis in foot and ankle surgery requires a multifaceted approach, incorporating mechanical, thermal, chemical, and pharmacological methods. Surgeons must be adept at utilizing these various techniques, often in combination, to ensure optimal outcomes for their patients. Continuous advancements in surgical technology and techniques promise to further enhance the precision and effectiveness of hemostasis, ultimately improving patient care in foot and ankle surgery.