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Say No to Blood

Bloodless surgeries are here, giving an alternative to blood transfusions and avoiding the risk of transmission of blood borne diseases. K Deepalakshmi explains the new age surgical procedure

Firstly, India is devoid of enough blood banks and the quality standards maintained at most of the blood banks is questionable. Added to all these woes is the fact that blood transfusions continue to hold a risk of transmitting infections like HIV, Hepatitis B, STD etc. A study in US states that one in 50,000 cases where blood transfusion is more than 10 units is prone to risk of infected by HIV. The medical field has found an answer— 'Bloodless surgery,' an approach that eliminates the use of blood transfusion.

Alternatives to Blood Transfusion

Bloodless surgery is a term used to refer those surgeries that are performed without transfusion of allogenic (obtained from a donor) blood. This means, with the aid of technology, the need of donor's blood is eliminated by using autologous (one's own) blood and ensure minimal blood loss.

Questions on blood safety, led to the concept of auto banking of blood. Dr Mohan Thomas, Consultant— Cosmetic Surgery, Breach Candy Hospital, Mumbai, explains the concept of auto banking, "In case of non-emergency surgery, a patient can save up to two units of blood, prior to one month of the scheduled surgery. This blood, known as autologous blood is considered the most risk free blood."

Next way to avoid donor's blood is to reuse the lost blood during a surgery. This method is called intraoperative blood salvage or cell salvage. Equipment, called 'cell saver' is used for this

purpose. "Cell saver is a suction machine that absorbs the patient's blood that is lost during the surgery. It then purifies the blood that can be transfused back to the patient," says Dr Umesh Gupta, Director of Medical Service and Chief Quality Officer, Apollo Hospitals, Bangalore. Since the blood is recirculated, there is no limit to the amount of blood that can be given back to the patient.

No Blood Procedures

Although autologous blood is an effective alternative, since they eliminate the risk of infection, they do not eliminate the need of blood. For instance, Jehovah's Witnesses, a denomination of Christians, reject blood transfusions in any form on religious grounds. For the benefit of these patients, minimal invasive surgical options are available in various specialties. These surgical methods demand a smaller incision, which reduces the loss of blood and eliminates the need for blood transfusion.

The amount of blood is increased by administering medicines. A drug called erythropoietin stimulates the bone marrow to produce more blood. This drug is given two or three weeks before and after the surgery. The blood formation would replace the blood loss. Similarly iron administration is also given.

Anaesthesiologists use a method called 'hypotensive anaesthesia', where the blood pressure is lowered safely with medications during surgery.

Another method is haemodilution, where a large amount of IV fluids are administered intravenously to dilute the blood at the beginning of surgery, so that during surgery, less red blood cells are lost.

Bloodless Procedures in Orthopedics

Dr Thomas Chandy, Director and Chief of Orthopedics, Hosmat Hospital, Bangalore, has been performing bloodless surgeries since 1980, when he was practicing in New York. He introduced the concept in Hosmat hospital in 1993. Recalling the connection between bloodless surgery and orthopedics, Dr Chandy says, "The term bloodless surgery was in fact first used by Dr Adolf Lorenz, an orthopaedic surgeon from Vienna, at the beginning of the 20th century."

Dr Chandy explains various methods used in orthopedics surgeries in order to carry it out bloodless. A tourniquet is used for arm and leg, to prevent blood loss during surgery. "In fact, with a tourniquet a total knee replacement surgery, does not involve any blood loss during surgery," says he. Even if there is a loss, it is so minimal that it can be collected in a small sterile tube or container.

Arthroscopic, and minimally invasive surgeries, were devised in the 1970's in the US for sportspersons, so that they can get back to playing as soon as possible. "Arthroscopic surgery, involves inserting a small scope, varying from 2-4 mm, into the knee or shoulder, to repair cartilage, reconstruct ligaments, and stabilise the joints, without opening the joint. This way it is bloodless," explains Dr Chandy, who has done a fellowship in sports medicine.

Bloodless surgery is possible even in trauma cases too. "Hosmat being a trauma care centre has conducted bloodless surgery in trauma cases," says Dr Chandy and explains the technique, "With the use of the C arm image intensifier, or a TV X-ray used in the operation theatre, a rod can be inserted, into a broken bone, without opening the broken part. Also pins and screws can be inserted for broken bones, using the C-arm, without even exposing the bones. For screws, a technique called cannulated screw fixation, involves inserting a fine pin, with a C-arm, and then over this pin, a screw with a small canal in the middle of it, is screwed into the bone, over this pin."

"The Computer Aided Navigation System (CANS) can give more information on the bone, or joint that a C-arm, or X-ray in the OT can," says Dr Chandy. It uses the principle of Global Positioning System (GPS) where a laser eye and computer tracks the patient's anatomy, and guides the surgeon, with special minimally invasive instruments, to get an effective bloodless surgery, where precision is excellent.

Innovation in Cardio Surgery

Wockhardt Hospitals Ltd, Bangalore, has recently conducted a bloodless by-pass surgery successfully on a Jehovah's Witness patient. Dr V Murali Manohar, Consultant Cardiothoracic Surgeon, who was a part of the team that conducted this surgery summarises the protocols used in the procedure.

• Meticulous haemostasis, that is, minimising the blood loss during the procedure by using electrocautery from the beginning.
• Use of beating heart procedure for bypass surgery.
• Use of intra coronary shunts and vessel loops during procedure.
• Accepting a haemoglobin percentage of 10gms, which means, blood will be given only if the haemoglobin is less than 10gms per cent.
• Use 2mg per kg heparinisation during the procedure and reversing it before chest closure.
• Use erythropoietin injections, if required.
• Prescribing oral iron supplements for two months post-operatively.

Dr Manohar says, "This procedure can be offered to most of the young individuals and I feel, in all elective surgeries performed, we have to plan and prepare the patient by improving the haemoglobin percentage so that blood loss up to 800ml to a litre is well tolerated."

Bloodless Procedures in Neurosurgery

"Bloodless surgery is the best option in cancer operations, as blood transfusions increase the chances of recurring cancer" - Dr R Kannan Consultant - Laparoscopic surgeon, Billroth Hospital Chennai

"In case of non-emergency surgery, a patient can save up to two units of blood, prior to one month of the scheduled surgery. This is the most risk-free blood" - Dr Mohan Thomas Consultant - Cosmetic Surgery, Breach Candy Hospital, Mumbai

"Cell saver absorbs the patient's blood that is lost during the surgery. It then purifies the blood that can be transfused back to the patient" - Dr Umesh Gupta Director of Medical Service and Chief Quality Officer Apollo Hospitals, Bangalore

Dr Anupam Jindal, Consultant, Consultant - Neurosurgeon, NINS, Chandigarh, a pioneer in opting the bloodless procedure in spine and brain surgery says, "Bloodless procedure is being routinely done at our hospital for brain and spine surgery," and adds, "In this, we reach the target area through a safe route directly, causing minimal tissue trauma and hence less post-operative pain." For example, in disc surgery the incision length is just 1.5 mm. Hence, the muscles are not detached from the normal attachment. Therefore, post-operative pain is much less and many patients do not take any pain killers in the post operative period. Further, there is less damage to normal brain tissue dependent on the case. In pituitary tumors, which are approached through the nose endoscopy, provides access without opening skull, evading blood loss. In case of colloid cysts a major craniotomy can be avoided and whole surgery can be done through a small hole.

Hosmat Hospital performs microsurgery using surgical microscope for neurosurgery.

A surgical microscope is a big instrument that is wheeled onto the operative field, and the surgeon looks through the binocular eyepiece. The field is magnified many times, and through a tiny incision, accurate, precision surgery is performed.

Operating through Keyhole

Laparoscopy, popularly known as keyhole surgery is one of the most common form of bloodless surgery. "Use of high precision optics and surgical devices like surgical laser, Argon Beam Correlation (APC), harmonic scalpel and Ultrasonic Surgical Aspirator (CUSA), reduce the need for open surgeries, thus reducing the blood loss drastically," says Dr R Kannan, Consultant— Laparoscopic surgeon, Billroth Hospital, Chennai.

Addition to minimal or no blood loss, Dr Kannan points out the advantages of laparoscopy as, "shorter hospital stay, less morbidity, minimal tissue trauma, minimal pain, early return to work, less post operation complication and minimal or no scar."

He explains some of the popular procedures in laparoscopy that are bloodless.

Abdomino Perennial Resection (APR): Removal of patient's body wastes by making an opening in the abdomen wall of the lower rectum portion.

Fundoplication: A surgery that controls Gastroesophageal Reflux Disease(GERD), by wrapping the fundus of the stomach with esophagus.

Heller's Cardiomyotomy: A surgery performed on the muscle around the oesophagus.

Common bile duct (CBD) exploration: A procedure to detect gall bladder stone.

Gastrojejunostomy (GJ): A procedure to treat malignant pyloroduodenal obstruction, cancerous formation between pylorus and duodenum.

"Bloodless surgery is the best option in cancer operations, as blood transfusions increase the chances of recurring cancer," says Dr Kannan.

Bloodless Solution in Ophthalmology

"The need for blood transfusion is almost nil in ophthalmology," says Dr Amar Agarwal, Joint Managing Director, Dr Agarwal's Eye Hospital Ltd, Chennai and adds, "However, latest innovations make sure that there is no scar and no blood loss."

Even in cataract surgeries like, Intra-Capsular Cataract Extraction (ICCE) and Extra Capsular Cataract Extraction (ECCE), which were prominent in olden days, though there was excessive bleeding due to large incision and sutures, there was no blood transfusion in most of the cases. Today, phacomulsification is the procedure to treat cataract, where a 3.2 mm incision is made on the cornea. The blood vessels are not touched and there is not blood loss. This method is sutureless. Dr Agarwal developed phanonit, a new procedure involving needle insertion technology, where the incision is just 0.9 mm. Later, he developed microphaconit with 700 microns wide incision. Being a tiny incision, the opening closes by itself and heals faster. A day care surgery, the patient can walk out after the surgery and recovers in a week's time. The duration of the operation is less than 10 minutes.

"When the incision is smaller, the blood loss is minimal. On the other hand when the incision is larger, it is easier to extract the foreign particle. In case of smaller incision, the result is achieved with higher magnification with machine's assistance," explains Dr Agarwal.

For vision correction, LASIK (Laser-Assisted in situ Keratomileusis), a photo abalation laser surgery performed using eximer LASER. This procedure is also carried out in less than 10 minutes and absolutely bloodless. In cases of presbyopia, presbyopic lasik conductive keratoplasty is carried out to correct the near vision.

Glued Intraocular Lens (IOL) is another bloodless and sutureless procedure, where fibrin glue is used for IOL implantation.

Femtosecond Assisted Lamellar Keratoplasty (FALK) is another bloodless procedure for cornea transplantation where cutting of cornea takes place layer by layer with the help of femtosecond laser.

No Bloodshed in Cosmetic Surgery

Likewise, cosmetic surgery, today, is a no blood loss surgery. "There is no need for blood transfusion in cosmetic surgery and there is no blood loss in complex surgeries," says Dr Mohan Thomas, Consultant Cosmetic Surgeon, Breach Candy Hospital and President, Indian Society of Cosmetic Surgery, who had pioneered the minimal access cosmetic surgery in India.

Most of the cosmetic surgeries are daycare. "In some cases, like liposuction, when the volume is more than five liters, the patient is kept for one night observation, not for blood loss but to check the fluid change." There is a possibility of blood loss in certain cases, confides Dr Thomas. For instance, in the case of breast reduction there is a chance of drain, which is below 70cc. They do not require a transfusion and the patients go home, the same day. "Blood transfusion occurs in the rarest of rare cases when the patient is affected by thalassemia or depression of bone marrow," says Dr Thomas.

Since, the patient cannot regain the lost blood, unlike normal cases, blood transfusion is inevitable."Even in trauma cases, blood loss can be controlled by reducing the pressure to a reasonable level," says Dr Thomas and adds, "It is a multi-disciplinary approach involving a good surgeon, good anaesthesian and good medicine.

Advantage

Though bloodless surgery became popular due to religious reasons, this surgery scores over other factors that makes it win over the conventional ones. "Bloodless surgery is a solution to the huge demand-supply gap of allogeneic blood and helps in conserving blood," says Dr Gupta. The risk of blood borne diseases like Hepatitis, HIV, cancer and malaria is completely eliminated by this procedure.

"There is a complication called anaphylaxis, an allergic reaction that leads to rejection of allogeneic blood by the body. Such cases are also averted by bloodless surgery," says Dr Kannan. Moreover, there is not much significant difference in the cost factor between bloodless surgery and the ones involving transfusion. "It is true that the surgical procedure might cost more because of the cost of the instruments, consumables and medications," says Dr Gupta and adds "On the other hand the allogenic blood and blood components are also expensive." Further, the hospital stay and the duration of the surgery is lesser in bloodless procedures, which reduces the overall cost. Bloodless approach is not free from complications. There could be a difficulty in viewing, which is rectified by using high precision optics. There are chances of wound related infections when the incisions, though smaller in size are not closed properly. Blood transfusions are unavoidable when loss is excessive and in cases of thalessimia. Auto banking of blood cannot be opted if the patient is anemic or when the pack cell volume is not optimum. Research in these areas can lead to a solution to these problems. Bloodless surgery could replace the conventional methods and blood transfusions could be a history in the future.

k.deepalashmi@expressindia.com