Bleeding is a common concern during surgical procedures, and excessive intraoperative hemorrhage can significantly impact patient outcomes. While patient-related factors such as coagulation disorders and medication use are often considered, surgical factors also play a crucial role in determining bleeding risk. A clear understanding of these operative variables allows for improved surgical planning, risk stratification, and the implementation of appropriate hemostatic strategies.
One of the most critical factors affecting bleeding risk is the type and extent of the surgical procedure. Major surgeries involving highly vascularized tissues or organs, such as liver resections, cardiovascular surgeries, or orthopedic joint replacements, are inherently associated with greater blood loss. The extent of tissue dissection and manipulation directly influences vascular injury and the number of open vessels that must be managed during the procedure 1–5.
In a similar vein, the anatomical location of the surgery strongly influences bleeding risk. Regions with rich vascular networks pose a greater challenge in maintaining hemostasis. Additionally, surgeries involving tumors may present increased bleeding risk due to tumor-associated angiogenesis and fragile neovascularization. Prior surgeries or radiation in the same area can also alter normal anatomy and vascular patterns, making bleeding more difficult to control 6,7.
The surgeon’s technique significantly affects bleeding outcomes as well. Meticulous dissection, careful handling of tissues, and appropriate use of cautery or ligation can minimize vessel damage and hemorrhage. In contrast, aggressive or imprecise manipulation can lead to unintended vascular injury. The choice between open surgery and minimally invasive techniques also plays a role. Indeed, laparoscopic and robotic-assisted procedures tend to result in less blood loss due to smaller incisions, limited tissue trauma, and improved visualization 8–11.
Longer surgical times are also, naturally, a factor associated with an increased risk of bleeding. Prolonged exposure of tissues can lead to desiccation and capillary bleeding, while increased fatigue among the surgical team may contribute to decreased precision. In addition, extended surgical time may be associated with more complex or technically demanding procedures, which are themselves risk factors for hemorrhage 9.
While primarily a patient-related factor, the intraoperative continuation or reversal of anticoagulant or antiplatelet agents is often influenced by surgical decisions. For example, cardiac and vascular surgeries may necessitate ongoing anticoagulation, increasing bleeding risk during the procedure. The surgical team must balance the risks of thrombosis versus hemorrhage when making these decisions 12.
Surgical bleeding is a multifactorial challenge influenced by the type, extent, and duration of surgery, the surgical technique, and the vascularity of the operative field. While patient factors remain crucial, these surgical elements must be carefully considered in preoperative planning and intraoperative management of bleeding risk. By optimizing technique and preparing for high-risk scenarios, surgical teams can minimize blood loss and improve patient outcomes across a range of procedures.
References
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2. Bodur, M. S. et al. Effects of intraoperative blood loss during liver resection on patients’ outcome: a single-center experience. Turk J Med Sci 51, 1388–1395 (2021). DOI: 10.3906/sag-2008-78
3. Marietta, M., Facchini, L., Pedrazzi, P., Busani, S. & Torelli, G. Pathophysiology of bleeding in surgery. Transplant Proc 38, 812–814 (2006). DOI: 10.1016/j.transproceed.2006.01.047
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6. Liu, W. et al. Prediction of intraoperative bleeding and blood transfusion in patients with recurrent retroperitoneal liposarcoma: a retrospective study. Ann Transl Med 10, 986 (2022). DOI: 10.21037/atm-22-4222
7. Atzori, G. et al. A Case of Life-Threatening Bleeding Due to a Locally Advanced Breast Carcinoma Successfully Treated with Transcatheter Arterial Embolization. Current Oncology 30, 2187–2193 (2023). DOI: 10.3390/curroncol30020169
8. Ashley. 8 Surgery Incision Tips To Reduce Bleeding. Redirect Mastery Hub https://testredirects.colgate.com/8-surgery-incision-tips-to-reduce-bleeding.
9. Urabe, M., Ohkura, Y., Haruta, S., Ueno, M. & Udagawa, H. Factors Affecting Blood Loss During Thoracoscopic Esophagectomy for Esophageal Carcinoma. Journal of Chest Surgery 54, 466–472 (2021). DOI: 10.5090/jcs.21.047
10. Coccolini, F. et al. Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus paper. World Journal of Emergency Surgery 19, 26 (2024). DOI: 10.1186/s13017-024-00554-7
11. Nelson, C. L. & Jerrel Fontenot, H. Ten strategies to reduce blood loss in orthopedic surgery. The American Journal of Surgery 170, S64–S68 (1995). DOI: 10.1016/S0002-9610(99)80062-2
12. Shah, A., Palmer, A. J. R. & Klein, A. A. Strategies to minimize intraoperative blood loss during major surgery. BJS (British Journal of Surgery) 107, e26–e38 (2020). DOI: 10.1002/bjs.11393