If you can see a bleeding vessel, you can grasp it with a haemostat (locking or artery forceps), which is one of the great inventions of surgery. Tie all larger vessels, either immediately or later. Small vessels, especially those in the skin, seldom need tying. Five minutes or more later, when you remove a haemostat you will probably find that bleeding will have stopped. You can encourage it to stop by twisting the haemostat before you remove it, or if the bite of tissue is too large to twist, you can release the jaws and quickly pinch them together again a few times before you remove them. Either of these methods will encourage the blood in the vessel to clot and will minimize bleeding, so that fewer vessels need tying.
Haemostats can be large or small, straight, or curved, so that they rest over the edge of the wound. An experienced surgeon can go through the skin using few of them or none (pressure from swabs is often enough); a beginner usually needs more.
Haemostats have some disadvantages. Each time you tie off a bleeding vessel you leave some crushed tissue and some suture material in the wound. If this is excessive, it can encourage delayed healing or infection later.
The tips of haemostats, especially small ones, must meet accurately, so good quality instruments are important. Box joints are worth the extra expense. Order them in sixes[md]you can hardly have too many[md]because they will enable you to make up several sets (4.12).
Fig. 3-3 TYING ARTERIES. A, don't leave too long an end; this will leave unnecessary dead tissue in the wound. B, to free a vessel buried in tissue, insert Lahey's forceps and spread the tissues. C, if possible, put the ligature proximal to a branch. D, an artery has been tied and a transfixion ligature is now being inserted; the needle is going through the vessel and its distal end is about to be cut off. E, the completed ligature. FORCEPS, artery, Spencer Wells, box joint, (a) 200 mm, straight, six only. (b) 150 mm, straight, twelve only. (c) 230 mm, curved, six only. (d) 200 mm, curved, eighteen only. (e) 150 mm, curved, six only. (f) 125 mm, curved, twelve only. These are general purpose haemostats. Fifty-four in all is a generous number and could be reduced.
FORCEPS, artery, Crile's, box joint, 140 mm, (a) straight, six only. (b) curved, eighteen only. These are medium sized and are more robust than Halstead's.
FORCEPS, artery, Halsted's, ultrafine, mosquito, haemostatic, (a) straight, (b) curved, box joint, 120 mm, six only of each type. These are some of the finest and most delicate instruments in the list, so use them with care.
FORCEPS, artery, Kocher's, (a) straight, (b) curved, box joint, 200 mm, six only of each type. These are large haemostats with a tooth at the end of their jaws. Use them for a wide vascular pedicle when an ordinary haemostat might slip.
PINS, safety, Mayo's, large, for storing artery forceps, etc., ten only. Use them to keep artery forceps together in bunches during sterilizing.
Fig. 3-4 TWO WAYS OF PASSING A LIGATURE UNDER A VESSEL. A, using an aneurysm needle. This is a left-handed needle. B, a length of suture material held in a curved haemostat. C, another curved haemostat is being passed under the vessel to grasp the suture material. D, pulling the suture material under the vessel.
METHODS FOR ARTERIES TO TIE AN ARTERY use the following materials in this order of preference[md]linen thread, cotton thread, or monofilament. Don't use catgut for larger and more important vessels, it slips off too easily.
Grasp the bleeding artery with a haemostat. Either: (1) Tie it with one firm reef knot. (2) Tie it with a surgeon's knot (4.8) followed by two or three more throws. (3) Transfix it, tie it with a reef knot, then pass one ligature through it with a needle, and tie it with another reef knot. This is the method for critically important vessels, such as those of the renal pedicle. For even more security, tie it proximal to a branch, and then cut it distal to this.
If it is a critically important vessel, ask yourself[md]''Is what I have done enough?'' If it is not, do it again. Put a second tie in a separate groove.
If there is a long length of vessel distal to your tie, shorten it, so as not to leave too much dead tissue in the wound, but don't shorten it too much!
If other methods of controlling severe arterial bleeding have failed, you may, very occasionally, have to expose and tie a major vessel, such as the external carotid artery or the subclavian, as described in the methods which follow. Use linen, silk, or cotton thread, and don't divide it after you have tied it.
TO CONTROL BLEEDING FROM A LARGE PEDICLE, such as that of the spleen or uterus, don't try to use a single ligature. Control of the vessels will be safer if you take one or more bites of the pedicle and tie them separately.
TO CONTROL A DIFFICULT BLEEDING ARTERY, try to get into the correct tissue plane. First find the artery by feeling for pulsation. Push the points of a fine haemostat into the connective tissue around it and separate them to open up a plane as in B, Fig. 3-3. Gradually develop this plane until you can see the artery you are looking for. In this way you will avoid tying some important nerve in the ligature.
TO GET A LIGATURE ROUND AN ARTERY, either use an aneurysm needle, or pass a curved haemostat under it, and ask your assistant to pass into your other hand a curved haemostat with a ligature ''bowstrung' across it, as in Fig. 3-4. This is useful in ''deep' surgery.
Fig. 3-5 TYING THE RIGHT EXTERNAL CAROTID ARTERY. One of the vessels you may very occasionally have to tie is the external carotid artery after a severe maxillofacial injury. Adapted from ''Farquharson's Textbook of Operative Surgery', edited by RF Rintoul. Churchill Livingstone, with kind permission.