BLEED-LESS: a scoping review on blood loss elimination in endoscopic decompression-lessons and literature on endoscopic spine surgery.

Background: Endoscopic spine surgery has emerged as a significant advancement in minimally invasive spinal procedures, with advantages including reduced tissue trauma, faster recovery, and improved patient outcomes. A critical component of these surgeries is effective haemostasis, essential for maintaining visual clarity, ensuring surgical efficiency, and minimising perioperative complications. A scoping review was conducted to examine current clinical practices and research on haemostasis in endoscopic spine surgery, with the aim of synthesising existing knowledge into a practical framework to guide surgeons in managing intraoperative bleeding in endoscopic spine surgery. Methods: A comprehensive literature search was conducted across PubMed, Embase and Cochrane Library, guided by the Population-Concept-Context (PCC) framework. Studies were included if they reported on techniques to achieve haemostasis in endoscopic spine procedures. Data were extracted on study design, surgical technique, haemostatic tools or agents used, and bleeding-related outcomes. Results: The review identified various haemostatic methods including bipolar and radiofrequency cautery, tranexamic acid, gelatin-thrombin matrix sealants, bone wax, irrigation pressure modulation, and absorbable hemostatic agents. The review highlights that no single haemostatic method can be applied to all cases of endoscopic spine surgery. Instead, a multimodal approach is necessary to effectively achieve haemostasis. Based on this synthesis, we propose the FIBRE protocol, encompassing fluid management, initial exposure, bone bleeding control, red-out scenarios, and extra considerations, as a practical framework for managing haemostasis. Conclusions: The proposed FIBRE protocol is a framework for controlling bleeding, improving visualisation, and enhancing surgical outcomes. By integrating these practices, surgeons can refine their techniques and contribute to enhanced patient outcomes in minimally invasive spine surgery.