Basic operative techniques

Question 1

Who was William Stewart Halsted?

Answer 1

■ American surgeon who emphasized strict aseptic technique during surgical procedures + developed conduction anesthesia by injecting his own nerve trunks with cocaine.

■ 1852-1922

■ Introduced the fundamental surgical
principles that bear his name.

Question 2

Halsted’s Principles of Surgery first half (5)

exam question!

Answer 2

■ Strict asepsis during preparation and surgery.

■ Handle tissue gentle

■ Preserve blood supply

■ Good hemostasis to improve visibility and limit infection and dead space.

■ Minimize tissue trauma

Question 3

Halsted’s Principles of Surgery 2nd half (5)

exam question!

Answer 3

■ Minimize surgery time through knowledge of anatomy and technique.

■ Appose tissues accurately

■ Keep tissues moist, especially abdominal and thoracic organs.

■ Correct use of instruments and materials.

■ Make pretty skin sutures

Question 4

The scalpel is used for

Answer 4

sharp incisions where the plane of tissue to be cut is known and identified, and the likelihood of damaging adjacent structures is minimal.

In general, tissues that are incised with scalpels are collagen-rich and poorly vascular.

The scalpel is used to make stab incision through tough layers (linea alba,
submucosa of the stomach and bladder wall).

Question 5

The scalpel should NOT to be used for: (2)

Answer 5

■ Extensive subcutaneous exploration

■ Anatomical style dissection to tease tissues apart for greater visualisation.

Question 6

most commonly used scalpel blades

Answer 6

no. 10 and 20

same shape just different sizes.

are generally used to make long straight incisions

Question 7

Smaller blades (e.g.) are useful for

Answer 7

thinner skin, curving incision and those that need to follow contours.

Question 8

Small pointed blades (e.g. No 11) are used to

Answer 8

make stab incisions or for sharp
dissection in restricted areas such as joints.

Question 9

For straight skin incision with a large blade, the scalpel is held in the

Answer 9

palm of the hand with forefinger stabilising grip (palm grip), guiding it and modulating the amount of pressure.

Question 10

For contoured skin incision, or one made with a smaller blade, the scalpel is best
held in a

Answer 10

standard pencil grip, which facilitates using the tip of the blade.

Question 11

Grips of the scalpel (3)

Answer 11

■ Pencil grip

■ Palm grip

■ Fingertip grip

Question 12

Pencil grip allows..?

Answer 12

shorter, finer and more precise incision. Scalpel is 30-40 degree greater angle to the tissue.

Question 13

Palm grip is the strongest..?

Answer 13

grip on the scalpel and allows exertion of great pressure on the tissues. (often unnecessary).

Question 14

Fingertip grip offers the best..?

Answer 14

accuracy and stability for longer incisions.

Question 15

Methods of cutting with scalpel. (3)

Answer 15

Press cutting

Sliding

Stab incision

Question 16

Describe Press cutting. (2)

Answer 16

• Uses the pencil grip and application of increasing pressure in same direction as the proposed motion of the blade.
• Used to initiate incision is hollow, fluid-filled structures (gastrotomy, cystotomy).

Question 17

Describe sliding incisions. (3)

Answer 17

• The safest and most common method of incising tissues with scalpel.
• Uses the pencil grip for short incisions through delicate tissues.
• The fingertip grip is preferred for long incisions.

Question 18

For incising skin - The skin should always be
immobilized by

Answer 18

the thumb and forefinger of the
nondominant hand, to ensure that it does not slide away or bunch up as the
scalpel passes, which would lead to a ragged incision or one that slices
obliquely through the skin,
increasing postoperative inflammation and discharge.

Question 19

Describe Stab incisions.

Answer 19

The layer of tissue to be incised should be immobilized with forceps or stay sutures, and pulled taut to avoid it moving away from the blade.

It should be elevated from underlying structures that could be damaged by the blade. (spleen club!)

Question 20

Parameters of incisions. (3)

Answer 20

■ Length

■ Shape
- Linear incision
- Spindle shaped incision

■ Direction

Question 21

Scissors are best suited for

Answer 21

flaccid tissues

Properly used, scissors stabilize flaccid tissues between the blades during cutting
and provide excellent control over both depth and direction of incision.

Question 22

Scissors are used for either

Answer 22

sharp or blunt dissection.

Sharp dissection: scissor cutting, push cutting.

Question 23

Grips of the scissors.

Answer 23

fingertip grip?

thumb-index backhand grip

Question 24

Blunt dissection means

Answer 24

tearing instead of cutting.

Blunt dissection is a technique for gently separating tissues while avoiding injury to
important nearby structures such as blood vessels, nerves, or veins.

Unless using too much force, subcutaneous tissue and muscle will separate easily,
while the surrounding nerves, vessels, and tendons will remain intact.

Blunt dissection can be done by fingers, probe, forceps and scissors. Fingers are the first and best dissecting instrument.

Question 25

Hemostasis is a complex procedure that involves 2 main components.

Answer 25

platelet activation and circulating
clotting factors

Question 26

Good hemostasis is one of the most important principle of surgery.

Hemostasis is important because: (4)

Answer 26

• Bleeding obscures the surgical field, reducing operative accuracy and efficiency.
• Blood on the field, gloves, instruments and drapes provides an ideal environment for bacterial growth and increases the likelihood of infections.
• Extravasated blood is irritating to tissues, prevents proper coaptation of wound
  edges, delays healing and encourages infection.
• Severe or protracted hemorrhage may result in shock, progressive hypoxemia, and
  death of the patient.

Question 27

Methods of hemostasis (8)

Answer 27

■ Digital pressure
■ Haemostats

■ Packing with surgical swabs
■ Lavage with saline

■ Ligatures
■ Topical haemostatic agents
■ Tourniquets

Question 28

Describe Digital pressure

Answer 28

■ Digital pressure stems the flow while platelets accumulate to form a plug, or
a stable clot forms.

■ Pressure should be applied for at least 60 seconds in cases of minor hemorrhage
and up to 5 minutes for more serious hemorrhage.

■ Hemostasis may be assisted by first applying surgical swabs to the site, providing a scaffold upon with the blood clot can form.

■ Digital pressure is recommended as a first strategy for bleeding even from large
arteries and can be effective.

Question 29

Describe hemostasis using hemostats.

Answer 29

Only use “one click”!

■ If simple digital pressure is ineffective, the bleeding point can be identified and a hemostat applied.

■ The hemostat crushes the tissues releasing tissue thromboplastin that further stimulates coagulation.

■ The hemostats are left in position for at least 5 minutes.

Question 30

Describe hemostasis using surgical swabs.

Answer 30

■ If the bleeding point is deep within the tissues, body cavity, or in close proximity to a structure that might be damaged by hemostasis, further pressure may be applied by packing the cavity tightly with surgical swabs.

■ Swabs are packed on top of one another and held in position until blood stops
oozing through the fabric.

■ Packing can be used for single bleeding points, or generalized bleeding from viscera
such as the liver.

■ The packing is left in place for at least 5 – 10 minutes, after which the packing is
removed piece by piece. The last swab is removed carefully to avoid dislodging blood
clots.

Question 31

Describe hemostasis using lavage with saline.

Answer 31

■ If haemorrhage continues in a body cavity or confined space, it can be difficult to
identify the exact point of bleeding.

■ Saline lavage to remove blood clots and clear the field, then flooding the area and
looking down through the saline pool, can be helpful for lifting adjacent flimsy
tissues away from the bleeding point.

■ Ongoing hemorrhage into a saline pool appears as a “chimney smoke” from the
bleeding point.

■ Pressure and the cold temperature of saline, will also help in stopping bleeding.

Question 32

Describe hemostasis using ligatures.

Answer 32

■ Ligatures are used for discrete bleeding points that are unlikely to stop of their own accord, or where it is feared they may resume bleeding during surgery.

■ Simple ligature
■ The source of the bleeding should be grasped by a hemostat with minimal
inclusion of the neighboring tissues.

■ The surgeon passes the thread around the vessel, and ties off the vessel with a knot.

■ After the first knot has been tied, the surgeon removes the artery forceps and ties the second knot, and cuts the threads with scissors just above the knot (leaving as little thread, as possible – foreign material!).

Question 33

identify

Answer 33

simple ligature

Question 34

identify

Answer 34

Transfixing ligatures pass through the structure to be ligated before being wrapped around and tied again.

This serves to reduce the risk of the ligature slipping off the end of pedicle and facilitates maintenance of inward pressure.

Question 35

Transfixion ligatures are appropriate
for

Answer 35

closed castration, particularly in
large dogs, where slippage of the
vessels within the tunica vaginalis
might otherwise occur.

They may be also applied to the
suspensory ligament of the ovary for
ovariohysterectomy, to flat surfaces,
such as liver or a perforated blood
vessel where complete occlusion of
the lumen is not desirable.

Question 36

identify

Answer 36

Mass ligature

Can be used in combination with transfixing ligature.

Question 37

Describe diathermy.

Answer 37

■ Diathermy (electrosurgery) units produce heat at the surgical site for coagulation.

■ Makes use of high-frequency electrical current to:
- Cut
- Coagulate (electrocautery)
- Fulgurate (= “boil”-destroy (small growths or areas of tissue) using diathermy)

Question 38

Describe Monopolar diathermy

Answer 38

■ Pencil instrument

■ The active electrode is placed in the
entry site and can be used to cut tissue and coagulate bleeding.

■ The return electrode pad is attached
to the patient, so the electrical current flows from the generator to the electrode through the target tissue, to the patient return pad and back to the generator. Do not place the return pad under the patients heart.

■ There’s a risk of patient burns.

Question 39

Describe Bipolar diathermy

Answer 39

■ Forceps electrode

■ Used for those procedures where tissues can be easily grabbed on both sides.

■ The current moves through the tissue that is held between the forceps.

■ Gives better control over the area
being targeted, and helps prevent damage to other sensitive tissues.

■ The risk of patient burns is very low compared to the monopolar diathermy.

Question 40

Action to take when you have bleeding from the skin edges. (3 steps)

Answer 40

1. Apply pressure
   - Most bleeding from skin edges stops on its own after pressure is applied over the
   area for a few minutes with a swab.
2. If you have access to an electrosurgery device
   - Wipe away the blood, and touch the bleeding spot with the electrode. The bleeding usually stops.
3. Close the wound with a continuous suture.

Question 41

Action to take when you have Bleeding from a blood vessel. (3 steps)

Answer 41

1. Apply pressure
   - It prevents further blood loss and may allow the vessel to clot, thereby stopping the bleeding.
   - Try this for at least 2–3 minutes
   - If it is unsuccessful, the following alternatives should be tried.
2. If you have access to an electrosurgery unit,
   - If the vessel is a vein or small (1–2 mm) artery.
3. If you do not have access to an electrosurgery unit or if the vessel is a larger vein or larger (3–4 mm) artery, the end of the vessel should be ligated off with a suture for secure hemostasis.

Question 42

Describe care and handling of tissue. (9)

Answer 42

■ Avoid excessive blunt dissection

■ Avoid excessive traction

■ Handle tissues only when absolutely necessary

■ Separate only those tissue planes necessary for visualization excision.

■ Keep tissues moist with the regular application of saline.

■ Avoid exposure to irritant or inflammatory substances (e.g. talc, lint, urine, bile, blood, intestinal contents).

■ Avoid repeated changes in retractor position.

■ Do not allow retractors to tear or stretch tissue excessive.

■ Use appropriate instruments.

Question 43

Toothed forceps are designed to

Answer 43

grasp the tissue and prevent it sliding between the jaws.

While the use of toothed forceps might be seem to be overly traumatic, it is preferable to using blunt forceps and having to reapply them as they lose their grip.

Question 44

Atraumatic forceps are indicated for

Answer 44

fragile tissues such as the liver, lung or blood vessels, where perforation will result in leakage of air, blood or other fluid.

These forceps are used for grasping and tissue manipulation but are not appropriate for tissue retraction.

Question 45

Goals of closure of tissue planes. (6)

Answer 45

■ Immediate restoration of function (muscle bellies, pleural space).

■ Eliminate risk of displacement of contents (abdominal wall, hollow organs).

■ Elimination of dead space.

■ Hemostasis (particularly in subcutis).

■ Relief of tension of other layers.

■ Restoration of epithelial coverage.

Question 46

Describe Closure of tissue planes. (3)

Answer 46

■ The number of layers and types of suture pattern should be chosen to fulfil the
above goals in a timely fashion without excessive tissue handling and without
leaving inappropriately large amounts of suture material in the wound.

■ It is not always necessary to close every tissue plane that was incised, and some
individual tissue planes may be combined for closure.

■ Closure of tissue planes should ideally not impede normal movement of the tissue
(gliding of tendons, independent action of muscles).

Question 47

Explain why we should minimize operative time. (5)

Answer 47

■ Increased surgical time leads to higher infection rate.

■ Tissues dry out.

■ There is more opportunity for tissue handling (which in itself causes trauma).

■ There is more bacterial contamination from the environment.

■ The patient is subjected to a longer anesthetic time with greater risk of hypotension, hypothermia, hypoxia and dehydration.

Question 48

Common mistakes that prolong surgical
time. (6)

Answer 48

■ Poor positioning on the operation table
■ Poor understanding of local anatomy

■ Fear of cutting the wrong thing
■ Poor retraction and visualization

■ Keeping an untidy instrument table
■ Not establishing adequate hemostasis

Question 49

Recommended Simple principles for the surgeon. (6)

Answer 49

■ Develop a surgical plan preoperatively.

■ Make sure that the person positioning the patient on the table knows exactly what is required for the given procedure.

■ Review the important anatomy!

■ Practice skills in identifying and dividing tissue planes.

■ Use the surgical assistant.

■ If nervous or flustered, take time out! Take a few deep breaths. Enjoy yourself!
DON’T PANIC

Question 50

What’s the most important biochemical parameters for a surgical patient?

Answer 50

TP - total protein