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Clips andTies (Arterial Clamps) 67
under tension, this technique requires a return to theatre to have the packs removed and
is, generally, only used in specific circumstances, for example pre- sacral bleeding (Celen-
tano etal.2014).
An alternative form of pressure used to reduce bleeding is the application of a tour-
niquet, which is widely used in limb surgery (Shah etal.2020). The tourniquet pressure
should be greater than the patient’s blood pressure. The standard setting for the upper
limb is a pressure of 250 mmHg and for lower limb, the standard pressure is 300 mmHg
in most cases (BOA2021).
SUCTION ANDVISUAL ACCESS
Suction is not strictly speaking a method of haemostasis as it does not control the
bleeding, but it does aid the surgeon in visualising bleeding vessels and gaining access
to apply the clip, suture or other haemostatic device. The use of suction as guided by
the surgeon is within the scope of practice of the SFA as defined by the PCC position
statement (PCC2018). The responsibility of the SFA here is to use suction to allow the
surgeon to visualise the anatomy and identify the source of the bleeding without
obscuring the surgeon’s view. It is worth noting that the surgeon’s visual perspective
and the SFA’s view may be different, and the aim should be to optimise the view for
the surgeon rather than just for the SFA (Roberts and Westcott2022). Therefore, effec-
tive communication between the surgeon and the SFA is vital to ensure visibility
and access.
In a similar way, small changes such as improving access (e.g. via retraction) or
improving the light may greatly assist the surgeon and the assistant in visualising the
bleeding point and achieving haemostasis (Qureshi and Tai2018).
SUTURES
The most effective method of controlling haemorrhage is to ligate the vessel with a tie
or a suture (Qureshi and Tai2018). Suturing is usually outside of the scope of practice
for SFA’s unless they have received additional training (PCC2018; RCS2023). Suturing
for the purpose of obtaining haemostasis (as opposed to the closure of layers of tissue)
should be performed only by the operator. However, the SFA can assist by ensuring
that there is good visibility to the area, for example by using suction, altering the posi-
tion of the light or through retraction so that the surgeon can gain access to the
bleeding point.
CLIPS ANDTIES (ARTERIAL CLAMPS)
A clip or ‘arterial clamp’ may be applied by the surgeon to a bleeding point of a vessel
to occlude the vessel and then a tie is applied to the tip of the clamp to ligate it.
Ifthe vessel is particularly large, a suture may be used as an alternative to the tie
68 Chapter 6 Assisting withHaemostasis During Surgery
(Qureshi and Tai2018). Unless the assistant is working within an advanced role
such as an SCP, it is not their responsibility to directly apply the clamp (PCC2018;
RCSEng2023). However, the SFA can remove the clamp to facilitate the surgeon in
tying the ligature or suture (See Figure6.2). In some instances, for example during
abdominal hysterectomy an ‘ease and squeeze’ technique may be required. This is
usually reserved for vessels which require double ligation (Konishi 2018). It
requires the assistant to gently loosen the clamp for a brief time while the ligature
is secured and then reapply (or ‘squeeze’) the clamp in the same place ready for the
second ligation by the surgeon. Communication is essential between the assistant
and the surgeon with the SFA waiting for clear instruction as to when to remove
the clip or during the ‘ease and squeeze’ technique to prevent clamps being removed
prematurely.
When removing the clip with your dominant hand, it is advised that the same grip is
used as for using scissors (i.e. be held with the thumb and the middle finger in the finger
holes to grasp the instrument with the index finger along the stem) as this gives support
and means the instrument can be removed in a controlled manner (Whalan2006). How-
ever, where the non-
dominant hand needs to be used, for example to retract tissue, an
alternative technique is recommended as surgical instruments are predominately
designed for right- handed people. Whalan (2006) advises that when using the non-
dominant hand, the SFA pushes down with their thumb while giving counter pressure
with their middle finger in order to prevent an uncoordinated or ‘clumsy’ removal of the
clamp (Beard etal.2016).
FIGURE6.2 Use of vascular clips and ties for haemostasis.
Diathermy 69
SINGLE USE CLIPS
Clips are u- shaped metal or polymer devices which the surgeon applies using an appli-
cator (Frew etal.2021). The clips are single use, but the applicator may be single use or
disposable depending on the device selected. Examples include Hem- O- Lok® and
Ligaclips ®. Clips can be used during both laparoscopic and open surgeries (depending on
the device/applicator being used). They should only be applied by the surgeon
unless the assistant is an SCP (RCS2023). Single use clips are ideal in small spaces, such
as the axilla, where ligation may be difficult, or where the use of diathermy may risk
thermal injuries to nearby tissue. Prior to applying the clip, it is essential that the surgeon
be able to adequately visualise the bleeding vessel, to ensure that only the target vessel or
tissue is within their grasp and to ensure that the clip is correctly applied (Wicker and
Dalby2017). Therefore, the SFA’s role in this instance would assist in using suction or
retraction to ensure the surgeon can adequately visualise the target area.
Clipping is considered a ‘cold’ method of achieving haemostasis because unlike dia-
thermy there is no risk of thermal damage to surrounding tissues when applying the clip.
However, care should be taken to prevent subsequent injury when using energy devices
nearby as there is a risk of thermal transfer or coupling towards the clip (if a metal clip
has been used) (El- Sayed etal.2019; Frew etal.2021).
SURGICAL STAPLING DEVICES
Surgical staplers seal structures by compressing the tissue and delivering multiple rows
of small staples before dividing the tissue in the middle. Staplers are commonly used
for gastrointestinal tissue, for example during bowel resection, but in the context of
achieving haemostasis, the more relevant types of staplers are vascular staplers used to
secure vessels (Frew etal.2021). Staplers can be used to achieve haemostasis in both
open and laparoscopic surgeries (Klingler etal.2006; Zhao etal.2018). The assistant
should not directly apply any surgical stapler unless working in an enhanced role such
as an SCP (RCS2023). However, the SFA may assist the surgeon by ensuring that they
have access to the vessel and through effective communication between the parties to
ensure safe application of the stapler. Arguably this is even more important during
robotic surgery, when the surgeon and their assistant may not have the same viewpoint
and it is the assistant applying stapling devices. In this example, it is vital to confirm
verbally when undertaking actions such as applying stapling devices (Brian etal.2023).
DIATHERMY
In relation to the use of diathermy, an SFA can undertake the responsibility of assisting
with haemostasis to secure and maintain a clear operating field including indirect appli-
cation of surgical diathermy by the surgeon but only a surgeon or surgical care practi-
tioner may undertake direct haemostasis, including surgical diathermy (PCC2018).
70 Chapter 6 Assisting withHaemostasis During Surgery
Diathermy is the use of heat generated by high- frequency electric current for
coagulation or cutting of tissue (Qureshi and Tai2018). Electrosurgery can be classi-
fied as either monopolar, in which the current is delivered directly to tissue via an
active device and returns through the tissues to a return plate or bipolar which has
both input and output confined within the instrument and does not require a patient
return electrode plate or ‘diathermy pad’ (El-
Sayed etal.2019).
One of the methods by which an SFA may assist the surgeon is by the surgeon
using forceps to grasp a bleeding vessel and then the SFA using the diathermy to
‘touch’ the forceps. Figure6.3 demonstrates the activation of a handheld diathermy
pencil by the assistant as it touches the forceps held by the surgeon. Effective commu-
nication between the surgeon and the SFA is essential during the application of dia-
thermy via this method to ensure the activation of the current at the correct time and
in the correct place (Wicker and Dalby2017).
Assistants should be aware of the risks associated with the use of diathermy. Most
injuries to patients are related to thermal energy and as such are referred to as ‘thermal
injuries’ (Siddaiah- Subramanya etal.2017). These thermal injuries may be direct or
indirect. Direct thermal injuries result from lateral thermal spread to unintended
tissue near the tip of the instrument during activation. The extent of lateral thermal
spread is dependent on factors such as the device used, the power setting, tissue
impedance and the activation time. Monopolar devices have the greatest degree of
thermal spread compared to bipolar or ultrasonic devices (El- Sayed et al. 2019).
Indirect thermal injuries can occur when structures close to the intended tissue absorb
FIGURE6.3 Application of forceps by Assistant for application of diathermy.
Ultrasonic Devices 71
some of this thermal spread. Indirect thermal injuries are more likely to go unrecog-
nised at the point of surgery and delayed diagnosis is associated with increased mor-
bidity and mortality (El- Sayed etal.2019).
An example of indirect thermal injury, which is particularly relevant in laparo-
scopic surgery, is direct coupling (Siddaiah- Subramanya et al. 2017). Direct coupling
occurs when the active electrode touches another metal instrument. Current from the
active electrode passes to the second instrument and can potentially burn adjacent tis-
sues. To avoid this, active instruments should always be kept in view by the assistant
(El- Sayed etal.2019).
Similarly capacitive coupling is the transfer of current from one conductor (the
active electrode) through intact insulation, into adjacent conductive materials but
without direct contact (El- Sayed etal.2019). As with other forms of indirect thermal
injury, this can be difficult to identify at the time of surgery.
Burns can occur at the site of the diathermy pad, particularly if incorrectly placed
near metal implants or due to poor adhesion to the skin (e.g. if adhered to patient
hair) (Palmer2019). Therefore, care needs to be taken while positioning the patient
and in the immediate pre- operative stage to ensure patient safety by confirming
potential sites of the return electrode and which type of electrosurgery is required by
the surgeon in the Five Steps to Surgery Timeout.
Another hazard of diathermy is the risk of fires. Fires may occur if pools of flam-
mable alcohol- based skin preparation solutions are ignited (Palmer2019). As prep-
ping and draping is also a role of the SFA (PCC2018), additional care should be taken
at all stages of the procedure to reduce the risks for the patient, including preventing
pooling and allowing antiseptic solutions to dry.
Diathermy smoke has been shown to reduce visualisation and irritate the eyes
and upper respiratory tract of the surgical team. To reduce these risks, smoke evacua-
tion systems should be considered (Williams2022). Additionally, unwarranted use of
electrosurgery has been associated with an elevated incidence of secondary haemor-
rhage, pitiless burns, delayed wound healing, increased rates of wound infection and
should therefore be avoided (El- Sayed etal.2019).
ULTRASONIC DEVICES
Ultrasonic devices work by using high- frequency vibration to both cut and cauterise
tissue. These devices generate friction between molecules resulting in heat produc-
tion and protein denaturation (Frew etal.2021). Most devices are capable of sealing
vessels up to 7mm. Ultrasonic energy has been shown to have less lateral thermal
spread damage while cutting and coagulating tissues compared to traditional dia-
thermy (McCarus and Parnell 2019). Although the risks associated with thermal
spread are less than with diathermy, it is still vital that the assistant is observant and
communicates with the surgeon if they identify structures which may be injured by
thermal spread by the ultrasonic device. Additionally, while the risk of thermal
spread- related injuries is reduced by using ultrasonic devices, some studies show that
72 Chapter 6 Assisting withHaemostasis During Surgery
the device itself can retain a higher residual heat on the tips (El- Sayed etal.2019)
meaning that additional care needs to be taken not to touch vital structures or even
the skin with the tips of the device while it remains hot.
As with other devices discussed in this chapter, the SFA should not use the device
directly but can assist the surgeon by ensuring adequate access for application and
utilising effective communication.
LAPAROSCOPIC ANDHAEMOSTASIS
As discussed elsewhere in this chapter, most of the techniques used to achieve haemo-
stasis can be utilised for laparoscopic procedures as well as open surgery. However, it is
worth noting that in laparoscopic surgery even minor bleeding may result in reduced
light due to dark blood absorbing the available light and therefore reduce the ability to
visualize the surgical field (Klingler etal.2006; Madhok etal.2022). This can increase
the risk of needing to convert from laparoscopy to an open technique (Van Goethem
and Katic2022). Therefore, it is advantageous to have an assistant who is familiar with
the equipment and adept at problem- solving to facilitate safe surgery (Hall etal.2016).
PHARMACOLOGICAL METHODS ANDHAEMOSTATIC AGENTS
Haemostatic agents can be a valuable adjunct to haemorrhage control but are not a
substitute for comprehensive operative haemostasis (Qureshi and Tai2018). This is
because they are useful for controlling small amounts of bleeding or ‘oozing’ but will
not be sufficient for treating heavy bleeding. A range of products are available ranging
from absorbable topical haemostats such as gelatin, microfibrillar collagen and
regenerated oxidized cellulose, to biologically active topical haemostats such as
thrombin, biological adhesives and other combined agents (Pereira etal.2018).
Absorbable agents include products such as Surgicel™, Interceed™ and Cura-
cel™. These products are made of regenerated oxidised cellulose which comes in the
form of interwoven fabric or a mesh-
type structure which forms a support to aid clot
formation (Pereira etal.2018).
Gelatin- based haemostatic agents include Surgifoam™, Gelfoam™ and FloSeal™.
Gelatin is made from hydrolysed and purified animal collagen. The gelatin matrix can
be used in different forms including sponges, powder or a foamed solution (Pereira
etal.2018). Gelatin- based haemostatic agents form a mesh- like framework that holds
clotting molecules in the body to allow the formation of a clot. The gelatin matrix also
expands as it continues to absorb blood, leading to the formation of a physical struc-
ture that prevents further bleeding (Irfan etal.2022).
Fibrin Sealants include products such as Tisseal™ and Quixil™ (Pereira
et al. 2018). Fibrinogen and thrombin are the functional components in different
products with some products including additional factor XIII for greater tensile
strength (Beudert etal.2022).
References 73
Antifibrinolytics, such as tranexamic acid, are synthetic lysine analogues which
provide clot stabilisation. They are administered intravenously as opposed to the pre-
viously described topical haemostats. The use of tranexamic acid has been shown to
reduce perioperative blood loss and reduce the need for blood transfusion (Shah
et al. 2020). Tranexamic acid is recommended for all surgery where blood loss is
expected to be greater than 500 ml (Shah etal.2020). However, this recommendation
is specific to the UK and does not apply in North America where tranexamic acid is
not approved for this use. The North American recommendations are to use epsilon-
aminocaproic acid (aprotinin) as an alternative, although this has been associated
with increased postoperative mortality rates (Spahn etal. 2013). Administration of
these medications is unlikely to be by the SFA directly, but it is important for the
assistant to be aware of the treatment options and can suggest their use (if appropriate).
CONCLUSION
In this chapter, the role of the SFA in assisting with haemostasis has been discussed
including a review of the principles of haemostasis and the methods used to achieve
surgical haemostasis. The SFA is expected to work within their own scope of practice
and in accordance with their job description and the PCC statement (2018). Assisting
with haemostasis is a key skill for the SFA and as such it is hoped that this chapter will
contribute towards the knowledge and skills required to be an effective assistant.
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