Peroperative Complications Bleeding

Bleeding can be minimized by maximizing preoperative medical treatment and removing tissue with through-cutting forceps or a shaver to avoid tearing the mucosa. The other main causes of bleeding, besides those caused by a coagulopathy, are related to the sphenopalatine artery and the anterior ethmoidal artery.

The Sphenopalatine Artery

The anterior branches of the sphenopalatine artery come through the lateral nasal wall horizontally, just above the attachment of the inferior turbinate. If the middle meatal antrostomy is opened widely posteriorly to come to a level in the coronal plane that is less than 0.5 cm away from the posterior wall of the maxillary antrum, a branch of the sphenopalatine artery will often be cut and require cautery. Alternatively, you can damage a branch that comes through the inferior turbinate, but this branch is rarely traumatized in en-doscopic sinus surgery.

Another branch of the sphenopalatine artery comes through the middle turbinate, and if more than half of the anterior part of the middle turbinate is removed, this artery often bleeds.

The septal branch from the posterior tributary of the sphenopalatine artery runs across the anterior wall of the sphenoid. If the sphenoid ostium is opened lower than halfway up its height, this branch will be found and it can bleed substantially.

The Anterior Ethmoid Artery

Damage to the anterior ethmoid artery can have serious consequences. If the artery retracts into the orbit, this can cause a marked increase in pressure in the

Table 12.1 Peroperative and postoperative complications (after Johnson and Jones, 2002)

Peroperative

Postoperative

• Bleeding

• Bleeding

• Fat herniation

• Adhesions

• CSF leak

• Epiphora

• Retro-orbital hemorrhage

• Periorbital emphysema

• Medial rectus damage

• Anosmia

• Optic nerve lesion

• Frontal recess stenosis

• Crusting

• Infection

• Osteitis

• Neuropathic pain

posterior compartment of the eye. This will compromise the vascularity of the optic nerve and retina and result in blindness if not recognized and dealt with. The main reasons for complications are poor visibility and blood on the lens. It is important not to operate, probe, remove, or grasp anything that you cannot see. Curved probes, giraffe forceps, and 90° forceps are all too easily placed where they should not be. If it is not possible to see—stop. If there is excessive bleeding, check that the patient is 20° body-up and that the arterial mean pressure is kept between 65 and 75 mmHg. Use a 6 mm ribbon gauze soaked in cophenylcaine or 1:10000 epinephrine on the side with the bleeding and move on to work on the other side while the bleeding abates. It is possible to work from side to side, transferring the pack periodically.

If in spite of these measures there is still bleeding that cannot be controlled by diathermy, cleared with a larger sucker, or reduced by placing a catheter through the other nostril into the nasopharynx while it is on suction to remove the reservoir of blood, then stop operating. Normally with this amount of bleeding it is best to stop and have a further trial of medical treatment. It is surprising how often the patient is delighted and symptomatically improved although the surgeon feels that the ethmoidectomy that they have undertaken is incomplete. This does not matter as much as the patient's safety, which should be put first. It is good to recognize when little progress has been made during a procedure. In a polypectomy, for example, when little tissue has been removed in the previous 5 minutes, it may be worth stopping. Re-

Diathermy During Internal Bleeding
Fig. 12.1 Bipolar suction diathermy works well as the ends are not immersed in blood that dissipates the current.

member that most of the complications are likely to occur toward the end of the procedure when the surgeon is fiddling about clearing small areas of polyps on the skull base, which may in itself produce little benefit.

To stop bleeding from these discernible vessels, you can use either bipolar forceps (Fig. 12.1) or unipolar suction diathermy (Fig. 12.2a, b). Some of the bipolar suction forceps now available help to remove the blood and smoke at the same time. The bulbous head of the unipolar suction device allows cautery of a sizable vessel anywhere in the nose, and its large suction channel is less likely to become blocked by congealed blood (Fig. 12.3 a, b).The anterior ethmoid artery is rarely responsible for postoperative bleeding but, if it is, this can be diathermied (Fig. 12.4a, b). ¡T/l> 12,13

Sphenopalatine Artery Diathermy Forceps
Fig. 12.2a, b Unipolar suction diathermy being used to coagulate the septal branch of the sphenopalatine artery during a large sphenoidotomy.
Sphenopalatine Artery Cadavers
Fig. 12.3 a A cadaver injected with latex to show the position of the septal branch of the sphenopalatine artery cut while enlarging the sphenoidotomy inferiorly and b a clinical case.
Ethmoid Artery

Fig. 12.4a, b A cadaver injected with latex to show the position of the right anterior ethmoid artery (arrow). Note the sul-

cus terminalis on the left and a large supraorbital cell (*) in front of the anterior ethmoid artery.

Fig. 12.4a, b A cadaver injected with latex to show the position of the right anterior ethmoid artery (arrow). Note the sul-

cus terminalis on the left and a large supraorbital cell (*) in front of the anterior ethmoid artery.

Supraorbital Cell
Fig. 12.5 a A peroperative view of fat herniating through a defect in the lamina papyracea (arrow). b Ballotte the eye so the surgeon can see whether there is a dehiscence of the lateral nasal wall.
Ethmoid Sinus Dehiscense Artery
b

If by some misfortune there is torrential bleeding because of trauma to the internal carotid artery in the sphenoid, then prompt packing of the sphenoid sinus is required with a firm gauze pack. The patient is then resuscitated and the help of an interventional radiologist is sought. Blood is sent for cross-matching and when there is sufficient blood available the pack may gently be removed to see whether the bleeding continues. If not, then the sinus is best repacked with fascia and fat followed by oxidized cellulose, and an antibiotic-impregnated pack is left in position for a week.

If bleeding continues when the pack is gently removed, the radiologist should be asked to do an occlusion study under EEG control. If that is not possible and the situation is not stable, then the patient must be transferred to a unit where this can be done. If there are no EEG changes after the occlusion, it is best to seal the artery using angioplastic techniques, otherwise the help of a neurosurgeon may be needed to undertake a transcranial approach. Tying off the internal carotid artery in the neck is not a good option because of the back pressure from the cerebral circulation.

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