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Y3 - Surg Skills > 1. Surgical Dissection Anatomy > Flashcards

1. Surgical Dissection Anatomy Flashcards

1
Q

what are the surgical layers of dissection?

A

(superficial to deep)

  1. Skin
  2. Superficial fascia
  3. Deep fascia
  4. Periosteum
  5. BONE
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2
Q

what is the target tissue of dissection?

A

bone

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3
Q

what is the 1st dissection interval?

A

between the Superficial Fascia and Deep Fascia

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4
Q

what is the 2nd dissection interval?

A

between the Deep Fascia and the Periosteum

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5
Q

what is the 3rd dissection interval?

A

between the Periosteum and the Bone

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6
Q

between which surgical layers of dissection is there

NO DISSECTION INTERVAL?

A

there is no dissection interval between the Skin and Superficial Fascia

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7
Q

describe the histologic anatomy of the FIRST SURGICAL LAYER

A

Recall: the first surgical layer is the SKIN

Histo:

  • Epidermis
  • Dermis
    • Papillary: layer contains (endings of) capillaries, lymph vessels and sensory neurons. It has a loose network of connective tissue, this characteristic separates it from the reticular layer underneath
    • Reticular: lower, reticular layer, is thicker and made of thick collagen fibers that are arranged in parallel to the surface of the skin. The reticular layer is denser than the papillary dermis, and it strengthens the skin, providing structure and elasticity
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8
Q

what is the surgical anatomy of the SKIN?

A

1 layer / 1 incision

(*never divide layers of the skin, except maybe for a skin graft)

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9
Q

describe the first incision made

(location, depth, goal)

A
  • location: over target anatomy
  • depth: completely through all layers of the dermis TO the level of the superficial fascia (but NOT INTO the superficial fascia)
  • goal: “CONTROLLED DEPTH” incision
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10
Q

HAV soft tissue dissection:

what is the First Surgical Layer “Technique Tip #1”?

A
  • “It is helpful to apply TENSION to the skin on EITHER SIDE of the planned incision to help SEPARATE THE TISSUE LAYERS and MAINTAIN CONTROL OF INCISION DEPTH”
    • you can sense a “pop”, which is loss of dermal appendages
    • gets you to superficial fascia
  • Dockery’s
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11
Q

HAV soft tissue dissection:

what is the First Surgical Layer “Technique Tip #2”?

A
  • “Make VERTICAL incisions PERPENDICULAR (or tangential) to the skin plane WITHOUT SKIVING”
    • use subtle movements of wrist to cut exactly perpendicular to curved / unusual surface
    • results in LESS INFLAMMATION and less scarring
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12
Q

HAV soft tissue dissection:

what is the First Surgical Layer “Technique Tip #3”?

A
  • “Tip to belly to tip” technique
    1. tip to controlled depth
    2. flatten belly of blade along course of incision
    3. end with tip of blade
  • Why? -
    • use shape of blade and controlled depth to utilize the whole incision
    • Best is a rectangle (rather than “airplane” shape)
    • Q: 10-blade versus 15-blade? – generally the 10 blade is the skin blade
  • Dockery’s
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13
Q

what is the orientation of instruments, blade, and assistant’s hands during initial incision?

A
  • Instruments are extensions of your fingers
  • Blade should be tangential to the incision
  • Assistant applies LATERAL tension
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14
Q

what structures are found within the

SUPERFICIAL FASCIA

A

Contains

  • cutaneous nerves
  • superficial venous system

Relatively safe dissecting in the superficial fascia

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15
Q

describe the superficial fascia on the dorsal foot

A

thin, yellow, and globular appearance

(superficial fascia of the dorsum of the foot)

*below the superficial fascia is the DEEP fascia, below which is where the tendons lie

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16
Q

what indicates that we’re in the FIRST DISSECTION INTERVAL?

A
  • the layer we’re developing has a “cobweb” appearance, indicates we’re in the right spot
  • a deep layer is a natural plane of dissection –> looks like another layer of skin
  • recall: between superficial fascia and deep fascia
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17
Q

what is the goal with the FIRST DISSECTION INTERVAL?

A

to create a pocket of skin/superficial fascia with as LITTLE DAMAGE TO NEUROVASCULAR STRUCTURES AS POSSIBLE

(relatively predictable); it is pretty reliable and a completely and well-defined continuous layer throughout the entire body

18
Q

describe the different strategies for the first dissection interval:

A

Bear in mind, we CARE about the veins and hemostasis

  • 15 blade
  • dissecting scissors
    • sharp or dull
    • (better off using dissecting scissors than hemostat)
  • “plough and shear”
    • “poke and spread of the scissors to get tissue out of the way”
  • blunt
    • hemostat
    • back of blade
  • finger and 4x4
19
Q

what is found within the DEEP FASCIA?

A

Contents

  • muscles/ tendons
  • arteries
  • deep veins and nerves

So need to be careful cutting through superficial fascia

20
Q

what are the strategies for dissection into the SECOND DISSECTION INTERVAL?

A

Recall: second interval is between deep fascia and periosteum

  • scissor “poke and slide”
  • blunt dissection

Then retract/reflect the deep fascia out of the way

21
Q

describe the fourth surgical layer

A

PERIOSTEUM:

a dense layer of vascular connective tissue enveloping the bones except at the surfaces of the joints

CONTENTS: cartilage is found here

22
Q

what is the goal of the 3rd dissection interval?

A

Recall: the 3rd dissection interval is between the periosteum and the bone

Goal:

  • raise the deep fascia and periosteum as a single layer to EXPOSE THE OSSEOUS STRUCTURE of the head of the metatarsal
23
Q

what are the strategies for the THIRD DISSECTION INTERVAL?

A

Recall: b/w the periosteum and the bone (aka the 3rd and 4th layers)

Strategies:

  • 15 blade - need the blade to remove the sharpey’s fibers
  • Elevator - (concave side ON THE CURVATURE of the bone); this is a cleaner dissection, but can’t completely do so
    • the moving freer elevator makes a scraping noise
    • can use freer, key, or cobb elevators
24
Q

what are the important discussion points of the 5th dissection layer?

A

Recall: 5th layer is the bone

Discussion points:

  • Capsular incisions
  • Resident’s pocket - all skin –> periosteum has been removed; developing as a uniform layer and want to keep it intact to put it back in place (can’t necessarily be sutured back together)
  • Degree of exposure
  • Benefits of a single flap
25
Q

in summary,

how many surgical LAYERS?

A

5 surgical layers:

  1. skin
  2. superficial fascia
  3. deep fascia
  4. periosteum
  5. bone
26
Q

in summary,

how many surgical INTERVALS, and where are they?

A

3 SURGICAL INTERVALS

  1. 1st is between layer 2 & 3 (superficial fascia/ deep fascia)
  2. 2nd is between layer 3 & 4 (deep fascia/ periosteum)
  3. 3rd is between layer 4 & 5 (periosteum/ bone)
27
Q

in which layer are ALL NEUROVASCULAR ELEMENTS

of the digits?

A

all neurovascular elements are found in the SUPERFICIAL FASCIA

28
Q

define: Sharpey’s fibers

A

a matrix of connective tissue consisting of bundles of strong predominantly type I collagen fibres connecting periosteum to bone

29
Q

overview:

what are the important surface anatomy features for a HAV soft tissue dissection?

A
  • target tissue
  • exposure
  • incision planning
  • relaxed skin tension lines
  • anatomic landmarks
  • neurovascular elements
    • peripheral nerve blockade
    • vascular anatomy
30
Q

what is the target tissue

in an HAV soft tissue dissection?

A
  1. distal 1/3 of the 1st metatarsal
  2. and proximal phalanx base
  • exposes the entire joint
31
Q

what are the ANATOMIC LANDMARKS

in an HAV soft tissue dissection?

A
  • distract it to see “puckering”
  • mark the MPJ (it is more proximal than you think)
  • centered over 1st MPJ
  • medial to EHL tendon
  • lateral to “bump”
32
Q

where do you make the HAV soft tissue dissection?

(draw the incision first)

A

dosromedial incision centered over the shafts of the first metatarsal and hallux proximal phalanx between the medial “eminence” and EHL tendon

33
Q

what is important when considering peripheral nerve blockades and vascular anatomy?

A

need to consider the surface anatomy during an HAV soft tissue dissection

34
Q

what factors should be considered when

planning an incision?

A
  • target tissue
  • exposure
  • relaxed skin tension lines
  • neurovascular elements
35
Q

how deep should the first incision be

in the HAV soft tissue dissection?

A

our incision should be COMPLETELY THROUGH the dermis

TO the level of the superficial fascia

36
Q

what are the strategies for the 3rd and 4th dissection layers

with 2nd dissection interval?

A
  • transverse tenotomy
  • J-maneuver
37
Q

what dissection technique is pictured?

A

transverse extensor tenotomy

38
Q

what dissection technique is pictured below?

A

“J” maneuver

to release the collaterals

39
Q

describe the 5th dissection layer

in a digital procedure soft tissue dissection?

A

exposed bone and PIPJ ready for work

you are now at the target tissue

40
Q
A

Y3 - Surg Skills (6 decks)

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