Advances in the field of surgery have revolutionized care for millions of individuals. From the development of modern cardiac surgical techniques to the removal of abdominal malignancies and repair of orthopedic fractures, the depth and scope of modern surgical practice is immense. With the more recent advent of minimally invasive laparoscopic and endovascular procedures, surgery continues to expand therapeutic boundaries while also minimizing overall pain, disability and scarring following invasive operations.
Despite these achievements, evolution within the field is marked by periods of significant patient pain and suffering. Much of this morbidity and mortality can be attributed to one of two critical obstacles that hindered progress for thousands of years. The first was management of pain in a conscious patient undergoing surgery. To minimize pain, surgeons had to operate at such a rapid pace that interventions remained limited to basic amputations and excisions, rather than more delicate and intricate procedures. Beginning in 1846, however, this obstacle was overcome when the American dentist Dr. William Morton performed a tooth extraction under ether anesthesia, and soon after Dr. John Warren performed the first successful public surgery using general anesthesia at what is now called the Ethe Dome at Massachusetts General Hospital
The second obstacle was controlling lethal surgical site infection. The risk of overwhelming sepsis from operative wounds long precluded anything but the most urgent and lifesaving of interventions. Approximately two decades after the successful demonstration of general anesthesia, Sir Joseph Lister spearheaded the development of surgical antisepsis with the introduction of carbolic acid to sterilize surgical wounds, instruments and even surgeons’ hands. While this breakthrough was met initially with skepticism, antiseptic practices eventually led to dramatic reductions in infection-related morbidity and mortality.
Patient outcome and quality data now suggest that surgery is as safe and effective as ever (1). Notwithstanding, we contend that a third major obstacle remains to be solved. This ubiquitous but often ignored, minimized or “expected” complication is bleeding. All surgical procedures carry at least some risk of hemorrhage, even when performed by the most experienced of surgeons. Bleeding risk can range from minor wound hematomas to potentially life-threatening exsanguination. Bleeding can be lethal even without excessive blood loss, as intracerebral hemorrhage can cause death through brain herniation.
Currently, more than 50 million inpatient surgeries are performed annually in the United States, with millions more occurring worldwide (Centers for Disease Control and Prevention [CDC], 2010 Data). The safety and efficacy of these procedures clearly depends upon surgeons’ awareness of the risks of bleeding, along with the implementation of a broad therapeutic arsenal to manage intraoperative hemorrhage. Indeed, the 1912 Nobel Prize in Physiology or Medicine was awarded to the French surgeon and biologist Alexis Carrell for his pioneering work with vascular suturing techniques. Electrosurgical devices to cut tissue while limiting blood loss were introduced by Dr. William Bovie in 1926, and can now be found in just about every modern operating theater. Most recently, topical prothrombotic sealants, glues and gauzes have been introduced to aid in surgical hemostasis (3,4).
If surgeons recognize the inherent and potentially lethal risk of bleeding, then the question remains why not attempt to prevent this complication before it occurs? Curiously, there are no specific therapies administered to patients before surgery to prevent hemorrhage. This stands in stark contrast to the near-universal use of pain medications, anesthesia, antibiotics and antimicrobial agents to limit pain and prevent infection, respectively. For patients receiving systemic anticoagulants or suffering from thrombocytopathies and coagulopathies, there is the option of replacing inactivated clotting factors with exogenous blood components. The vast majority of surgical procedures, however, are performed on individuals with seemingly normal he-mostatic and clotting pathways.
While the majority of surgical patients maintain effective hemostasis, many do not, and a significant portion of morbidity and mortality following surgery can be attributed directly to bleeding and/or subsequent blood transfusion practices. On average, more than 20% of patients undergoing colorectal surgery require perioperative red blood cell transfusion, whereas patients undergoing primary pancreaticoduodenectomy surgery can receive up to double that number of transfusions (5,6). Patients who do receive blood products are at significantly increased risk for serious perioperative morbidity and mortality (7,8). Moreover, the additional health care costs associated with hemorrhagic complications are substantial (9).
Specific surgical disciplines are associated with high risks of hemorrhage. Trauma is the fifth leading cause of death in the United States, and the number one cause of death of people under the age of 45 (10,11). Bleeding is the most common preventable cause of death following traumatic injury. The military also faces enormous challenges to limit bleeding. Uncontrolled hemorrhage from noncompressible internal organ injury remains the leading cause of preventable soldier death on the battlefield (12). Therapies to improve hemostasis following traumatic injuries, such as administration of recombinant Factor VIIa or the antifibrinolytic agent tranexamic acid, remain limited (13–16). As a result, surgeons still rely on tourniquets, body cavity packing and holding direct pressure to manage uncontrolled traumatic hemorrhage until definitive surgical control is obtained.