*This page provides a practical framework for selecting topical hemostatic agents in HPB surgery.* ### Core Principle > [!info] Core Principle > Topical hemostatic agents are adjuncts. They should not replace fundamental surgical hemostasis. > > First consider: > - exposure > - pressure > - suture repair > - clips > - energy > - vascular control > - correction of systemic coagulopathy The correct agent depends on: - bleeding pattern - anatomy - ability to compress - coagulation status - cost / availability --- ### Passive Hemostatic Agents Passive agents provide a **scaffold for native clot formation**. They require functioning platelets and coagulation factors. Examples: - **Oxidized regenerated cellulose (ORC)** - Surgicel - Nu-Knit - SNoW - **Gelatin** - Gelfoam - **Collagen** - **Polysaccharide powders** - Arista - PerClot Best for: - low-pressure oozing - liver transection surfaces - capsular bleeding - raw surface bleeding Strengths: - inexpensive - widely available - easy to use Limitations: - weaker in coagulopathy - not for active vessel bleeding - swelling/mass effect possible - may mimic abscess or tumor on imaging Persistence: - ORC: ~1–2 weeks - gelatin: ~4–6 weeks - polysaccharide powders: days --- ### Active Hemostatic Agents Active agents deliver **thrombin** to accelerate fibrin clot formation. Examples: - topical thrombin - thrombin + gelatin matrix - Floseal - Surgiflo Best for: - venous oozing - parenchymal bleeding - irregular cavities - mild coagulopathic bleeding Strengths: - more effective than passive agents - conforms to difficult surfaces - works despite some coagulation impairment Limitations: - higher cost - requires direct contact - requires compression - not for named vessel bleeding Persistence: - gelatin matrix resorbed over weeks --- ### Fibrin Sealants Fibrin products provide **fibrinogen + thrombin**, recreating the final step of coagulation. Examples: - Tisseel - Vistaseal Best for: - broad surface sealing - adjunct after surgical hemostasis Strengths: - biologically creates clot - less dependent on patient coagulation Limitations: - expensive - weaker mechanical strength - requires dry field/apposition --- ### Hybrid Patch Products Physical scaffold + fibrin components. Examples: - TachoSil - EVARREST Best for: - liver transection surfaces - broad persistent oozing - difficult raw surfaces Strengths: - strongest topical surface agents - provides mechanical + biologic effect Limitations: - highest cost - requires compression - needs good tissue contact - not for vascular repair --- ### Quick Selection | Problem | Agent | | ----------------------- | ----------------------------- | | Mild liver surface ooze | ORC | | Broad raw surface | Passive sheet or fibrin patch | | Irregular cavity ooze | Flowable thrombin matrix | | Coagulopathic bleeding | Thrombin/fibrin product | | Needle-hole bleeding | Flowable thrombin matrix | | Named vessel bleeding | Suture / clip / repair | --- **Page Information** Last Updated: June 2026 Content: HPB Compendium Editorial Board