Kapetanakis S, Chalidis B. Beyond visible blood loss: Rethinking perioperative bleeding in endoscopic spine surgery. World J Orthop 2026; 17(8): 123237 [DOI: 10.5312/wjo.123237]
Corresponding Author of This Article
Byron Chalidis, MD, PhD, Assistant Professor, Department of First Academic Orthopaedic, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Exohi, Thessaloniki 57010, Greece. byronchalidis@gmail.com
Research Domain of This Article
Orthopedics
Article-Type of This Article
editorial
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World J Orthop. Aug 18, 2026; 17(8): 123237 Published online Aug 18, 2026. doi: 10.5312/wjo.123237
Beyond visible blood loss: Rethinking perioperative bleeding in endoscopic spine surgery
Stylianos Kapetanakis, Byron Chalidis
Stylianos Kapetanakis, Department of 2nd Orthopaedic, Aristotle University of Thessaloniki, Thessaloniki 54635, Kentrikí Makedonía, Greece
Byron Chalidis, Department of First Academic Orthopaedic, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece
Author contributions: Kapetanakis S drafted the original manuscript; Chalidis B contributed to study design and review and editing; all authors critically revised the manuscript for important intellectual content and approved the final version.
AI contribution statement: The authors declare that no AI tools were used in the development or writing of this manuscript and take full responsibility for its integrity, accuracy, and originality.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Corresponding author: Byron Chalidis, MD, PhD, Assistant Professor, Department of First Academic Orthopaedic, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Exohi, Thessaloniki 57010, Greece. byronchalidis@gmail.com
Received: May 18, 2026 Revised: July 11, 2026 Accepted: July 28, 2026 Published online: August 18, 2026 Processing time: 94 Days and 13.5 Hours
Abstract
Minimally invasive spinal endoscopy is widely perceived as a low-blood-loss procedure. However, this assumption may be misleading. Emerging evidence suggests that hidden blood loss (HBL), rather than visible intraoperative bleeding, constitutes the dominant component of total blood loss in endoscopic spine surgery. The recent study by Ye et al published in the World Journal of Orthopedics on dual-media spinal endoscopy for lumbar spinal stenosis reinforces this concept by demonstrating that HBL accounts for the majority of perioperative blood loss and is associated with operative duration and preoperative hematologic parameters. These findings challenge the reliance on measured intraoperative blood loss as a surrogate for surgical burden. Continuous irrigation and limited visualization may obscure ongoing hemorrhage, creating a false perception of hemostasis. As a result, perioperative blood loss may be systematically underestimated, particularly in elderly or comorbid patients. While current estimations of HBL remain indirect and influenced by fluid dynamics, its consistent presence across endoscopic techniques suggests a need to reconsider how blood loss is defined and monitored. Future studies should clarify its clinical impact and guide perioperative risk stratification.
Core Tip: Hidden blood loss (HBL) represents a substantial and often underestimated component of perioperative bleeding in endoscopic spine surgery. As highlighted by recent evidence, irrigation-based techniques may obscure ongoing hemorrhage, which creates a disconnect between visible and physiological blood loss. While HBL is consistently observed across endoscopic procedures, its predictors remain context-dependent and its clinical relevance is not yet fully defined. Rather than relying on visible intraoperative blood loss alone, clinicians should interpret perioperative bleeding within a broader framework that accounts for procedural complexity and patient factors.
