Bleeding from small and moderately sized blood vessels can be controlled by grasping them with bipolar forceps or a dissecting/grasping instrument equipped with monopolar electrosurgery (Figure 6.12). Small vessels can usually be coagulated by using the tip or side of an endoscopic scissor equipped with monopolar electrosurgery. When applying electrosurgery, the cautery tip should be fully visible to avoid inadvertent tissue damage. We avoid the application of electrosurgical current directly to staples or clips. Larger vessels (>3 mm in diameter) should be clipped with endoscopic clips, stapled with endoscopic staplers, or ligated with a LigaSureTM device or Laparoscopic Coagulating Shears™.

If a moderately sized or large blood vessel is injured inadvertently and bleeding occurs, the bleeding vessel should be precisely grasped at the puncture site. This action usually stops the bleeding so that clips may be safely applied on both sides of the vessel or LigaSureTM may be applied properly. If the puncture site cannot be located precisely, the bleeding vessel is grasped on both sides of the bleeding area and the vessel temporarily occluded. Further dissection can then be performed and the vessel clipped, stapled, or sealed with LigaSureTM. After hemo-stasis is achieved, the operative site is aspirated and irrigated. With good assistance and laparoscopic exposure, nearly all points of hemor-

Figure 6.12. Controlling a bleeder by pin-point grasping.

rhage may be accurately identified and safely controlled. If the surgeon believes that the bleeding cannot be controlled with laparoscopic techniques, the surgeon should first grasp the surrounding tissue with endoscopic graspers to occlude the vessel temporarily before possibly converting the surgery to an open procedure. The graspers will mark the region of concern and control the bleeding vessel until a final decision as to what type (open or closed) of surgical techniques should be applied.

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