Bloodless surgery is a term that was popularized at the beginning of the 20th century by the practice of an internationally famous orthopedic surgeon, Adolf Lorenz, who was known as "the bloodless surgeon of Vienna."[1][2][3][4] This expression reflected Lorenz's methods for treating patients with noninvasive techniques. His medical practice was a consequence of his severe allergy to carbolic acid routinely used in operating rooms of the era. His condition forced him to become a "dry surgeon".[5]
Contemporary usage of bloodless surgery refers to both invasive and noninvasive medical techniques and protocols. The term is somewhat confusing.[6] The expression does not mean "surgery that makes no use of blood or blood transfusion". Rather, it refers to surgery performed without transfusion of allogeneic blood.[7][8] Champions of bloodless surgery do, however, transfuse products made from allogeneic blood and they also make use of pre-donated blood for autologous transfusion.[9] The last twenty years have witnessed a surge of interest in bloodless surgery, for a variety of reasons. Jehovah's Witnesses reject blood transfusions on religious grounds; others may be concerned about bloodborne diseases, such as hepatitis and AIDS.
During the early 1960s, American heart surgeon Denton Cooley, successfully performed numerous bloodless open-heart surgeries on Jehovah's Witness patients. Fifteen years later, he and his associate published a report[10] of more than 500 cardiac surgeries in this population, documenting that cardiac surgery could be safely performed without blood transfusion.
Ronald Lapin (1941–1995) was a maverick Israeli-born American surgeon, who became interested in bloodless surgery in the mid 1970s. Best known as a "bloodless surgeon" due to his willingness to perform surgeries on severely anemic Jehovah's Witness patients without the use of blood transfusions.
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Several principles of bloodless surgery have been published.[11]
Preoperative techniques such as erythropoietin (EPO) or iron administration are designed to stimulate the patient's own erythropoiesis.
In surgery, control of bleeding is achieved with the use of laser or sonic scalpels, minimally invasive surgical techniques, electrocautery, low central venous pressure anesthesia (for select cases), or suture ligation of vessels.[12] Other methods include the use of blood substitutes, which at present do not carry oxygen but expand the volume of the blood to prevent shock. Blood substitutes which do carry oxygen, such as PolyHeme, are also under development. Many doctors view acute normovolemic hemodilution, a form of storage of a patient's own blood, as a pillar of "bloodless surgery" but the technique is not an option for patients who refuse autologous blood transfusions.
Intraoperative blood salvage is a technique which recycles and cleans blood from a patient during an operation and redirects it into the patient's body.
Postoperatively, surgeons seek to minimize further blood loss by continuing administration of medications to augment blood cell mass and minimizing the number of blood draws and the quantity of blood drawn for testing, for example by using pediatric blood tubes for adult patients.[12]
Bloodless medicine appeals to many doctors because it carries low risk of post-operative infection when compared with procedures requiring blood transfusion. Additionally, it may be economically beneficial in some countries. For example, the cost of blood in the US hovers around $500 a unit, including testing.[13] These costs are further increased as, according to Jan Hoffman (an administrator for the blood conservation program at Geisinger Medical Center in Danville, Pennsylvania), hospitals must pick up the tab for the first three units of blood infused per patient per calendar year. By contrast, hospitals may be reimbursed for drugs that boost a patient's red blood cell count, a treatment approach often used before and after surgery to reduce the need for a blood transfusion. Geisinger Medical Center began a blood conservation program in 2005 and reported a recorded savings of $273,000 in its first six months of operation.[14]
Health risks appear to be another contributing factor in their appeal, especially in light of recent studies that suggest that blood transfusions can increase the risk of complications and reduce survival rates.[15] Thus the recovery rate is faster with bloodless surgery allowing the patient to leave earlier.
In cases where a significant amount of blood is lost, the unwillingness to transfuse a patient could lead to ex-sanguination and death.