Basics of Surgery - Oral topics Flashcards
List the periods of the history of surgery! What were the milestones!
3 periods
I. From the primeval times until the middle of the 19th century
*Only removal of injured parts was used
II. From the discovery of narcosis (16.10.1846) until the 1960s
* Included not only removal of the injured parts, but also their reconstruction
* The milestone was the initiation and application of the principles of
asepsis and antisepsis, discovery of blood groups and the development of intensive therapy
III. Lasted from the 1960s until today
* The development of instruments, natural science, researchers, as well as technical development
When was the “Ether Day”? Who did and what on this day?
On October 16. 1846 Dr. William T. G. Morton anesthetized a patient with ethyl ether for
the first time
When and by whom was the chlorinated lime hand-‐washing introduced? What were his
findings?
Ignaz Semmelweis 1847
Doctors went from autopsy to child-delivery, maternal mortality went from 30%→1%
Who created the “antiseptic theory”?
Joseph Lister
Who introduced the “antiseptic theory” in hungarian surgery?
Hümer Hütl
(note that Marius and Stine were wrong on this answer! Check the department book and you can find it. However, this question on the topic list has now changed to not include “in hungarian surgery,” so it’s not totally clear)
Name 4 surgical instruments which refer to doctors involved in the development of
surgery!
- Kocher clamp
- Lumnitzer clamp
- Hagar needle holder
- Péan clamp
What does the acronym “NOTES” mean?
NOTES
Natural Orifice Transluminal Endoscopic Surgery
What is the definition of surgical intervention?
A procedure performed on a living body usually with instruments for the repair of damage or the restoration of health and especially one that involves incision, excision, or suturing
What do the septic and aseptic operating theatres stand for?
In the septic operating room the infected parts of the body are operated (e.g. purulent wounds, gangrenes)
In the aseptic operating rooms the danger of bacterial infection does not usually exist (e.g. varicectomy)
(There is no need to build the aseptic operating room in a separate area; the two different types can even share a common corridor)
How shall the staff and the patient enter the operating room?
Before entering into the operating room you should change your clothes in the locker
room and wear the surgical cap and the face mask
Following this, you can enter into the surgical territory
The patients are brought into the operating room after passing through a separate locker
room
Describe the structure of the operating room!
The operating room is 50-70 m2 , and does usually not have any windows
It is lighted and its walls are covered with light-colored tiles up to the ceiling
There is artificial ventilation and air-conditioning
The operating complex must be architecturally separated from the wards and the intensive care unit, but should be in the vicinity of the ICU
The complex consists of:
- Locker rooms
- Scrub-‐up area
- Preparing rooms
- Operating theatres
The walls and floor of the operating room have no gaps, so they can be cleaned easily (antiseptic gap-‐free floors)
The doors are automatic, and the rooms are equipped with central and portable vacuum systems, as well as pipes for gases
Main layout:
Operating lamp, operating table, Sonnenburg’s table, supplementary instrument stand, kickbucket, suction apparatus, diathermy, microwave oven, portable X-ray, anesthesia machine, and other instruments required during anesthesia
The central supply of electricity is automatically connected to batteries
List 8 equipments /instruments within the operating room!
Operating lamp, operating table, Sonnenburg’s table, supplementary instrument stand,
kick bucket, suction apparatus, diathermy, microwave oven, portable X-ray, anesthesia
machine, and other instruments required during anesthesia
Explain the rules of behaviour in the operating room!
1) Only those people whose presence is absolutely necessary should stay in the OR
2) Activity causing superfluous air flow (talking, laughter, or walking around) should be avoided
3) Entry into the OR is allowed only in operating room outfit and shoes worn exclusively in the OR
a. This complete change to the clothes used in the OR should also apply for the patient placed in the holding area (i.e. locker room)
4) Leaving the OR in surgical outfit is forbidden
5) The doors of the OR must be closed
6) Movement into the OR out of the holding area (locker room) is allowed only in a cap and mask covering the hair, mouth, and nose
Describe the general rules of the aseptic operating room!
Only sterile instruments can be used to perform a sterile operation
Only Sterile personnel can handle sterile equipment
Instruments which are located below the waist arenot considered sterile
If a sterile instrument comes in contact with aninstrument of doubtful sterility, it will lose its sterility
The edges of boxes and pots can not be considered sterile
A surgical area can never be considered sterile
However, the applications of aseptic rules of operations are mandatory
Explain the definition of asepsis!
Includes all the procedures, activities and behaviors designed to keep away the microorganisms from the patient’s body and the surgical wound
In other words, the purpose of asepsis is to prevent contamination (maintain sterility)
In a wider sense, asepsis means such an ideal state when the instruments, the skin, and the surgical territory do not contain microorganisms (prevention)
Explain the definition of antisepsis!
Includes all those procedures and techniques designed to eliminate contamination (bacterial, viral, fungal) present on objects and skin by means of sterilization and disinfection
Because skin surfaces and so the operating field and the surgeon’s hands cannot be considered sterile, in these cases we do not talk about superficial sterilization
In a wider sense, antisepsis includes all those prophylactic procedures designed to ensure surgical asepsis (treatment)
How to prevent the evolution of postoperative wound infections before the surgery?
Careful scrub and preparation of the operative site (cleansing and removal of hair) is necessary
Wearing sterile clothes in the OR
Knowledge and control of risk factors (e.g. normalization of the serum glucose level in case of diabetes mellitus)
In septic and high-‐risk patients: perioperative antibiotic prophylaxis
How to prevent the evolution of postoperative wound infections during the surgery?
Appropriate surgical techniques must be applied
Change of gloves and rescrub if necessary
Optimize body temperature of the patient
Narcosis may worsen thermoregulation
Hypothermia and general anesthesiabothinduce vasodilation, and thus the core temperature will decrease
The oxygen tension must be maintained
How to prevent the evolution of postoperative wound infections after the surgery?
Wound infection generally evolves shortly (within 2 hours) after contamination
Hand washing is mandatory and the use of sterile gloves is compulsory while handling wound dressings and changing bandages during postoperative care
What is the definition of sterilization!
To sterilize means to kill all microorganisms and spores to create a germ-‐free environment
Methods:
o Autoclave (steam with high pressure)
o Gas sterilization with ethylene-‐dioxide
o Cold sterilization with sprecide chemicals
o Gamma and electron radiation
o Plasma sterilization (low temperature
hydrogenperoxidegasplasma - effect of free radicals)
What is the definition of disinfection!
The aim is to decrease the number of or inactivate live microbes
Methods:
o Low temperature steam
o Chemical disinfectants (phenol, chloride containing compounds, alcohols)
Surgical hand-scrubbing is considered a disinfectingprocedure.
Explain the steps of the two-‐phase surgical hand scrub!
1st Phase: Mechanical cleansing
o Wash the hands and forearms thoroughly with soap and warm water
o The first phase has no time limit, only until we are satisfied
o Make sure to wash off all the soap, the disinfectant used in phase two is not
supposed to foam, so if during phase 2 foam appears on your hands, you have not
washed properly in phase 1 and will lose points
o Use tissue paper to dry carefully
2nd phase: Disinfectant phase o Disinfectant hand scrub should be rubbed on your hands 5 x 1 min o The disinfectant area should extend to the elbow and get shorter and shorter for each scrub 1st time: Whole forearm 2nd time: 2/3 of the forearm 3rd time: 1/2 of the forearm 4th time: 1/3 of the forearm 5th time: only hands and wrists
What is the purpose of isolation? How do we do it?
After skin preparation the operating area must be isolated from the non-‐disinfected skin surfaces, and body areas by application of sterile linen textile or sterile water proof paper drapes
The main aim is to prevent contamination from the patients skin
It is generally done with the help of 4 pieces
The scrub nurse and the assistant use a special specially folded first, big sheet to isolate the patient’s legs
The second, horizontal sheet is used to isolate thehead, and is fixed to the guard
Placement of the two sided sheets then follows
The isolated area is always smaller than thescrubbed area
4 Backhaus towel clips will fix the isolating sheets
List the basic surgical instrument groups!
- Cutting and dissecting instruments
- Grasping, clamping and occluding instruments
- Hemostatic instruments
- Refracting and exposing instruments
- Wound-‐closing instruments and material
- Special instruments
What is the function of the dissecting instruments? List some of these dissecting
instruments!
Their function is to cut or dissect the tissue and remove the unnecessary tissues during surgery
Scalpel
Scissors (straight/curved blunt/sharp)
Hemostats used for tissue preparation (can be dissecting, grasping, or hemostasis)
Dissector
Diathermy knife
Ultrasonic cutting device
CUSA (cavitron ultrasonic surgical aspirator)
LASER (light amplification by stimulated emission radiation)
Amputating knifes, saws and raspatories
Explain the use of electric/diathermy knife! What kind of diathermy knifes do you know?
Dissects tissue with the help of heat which is generated by electrical current
During the dissection the heat can also coagulate the blood from vessels, giving it a strong advantage by cutting and hemostasis simultaneously
They can be either mono- or bipolar
Bipolar: the electric current is passing between two parts of the instrument e.g. bipolar forceps
* There is a need for smaller voltage and amperages making it possible to perform more precise work and smaller size of burned area
Monopolar: the electric current is passing between the instrument and an indifferent electrode placed beneath the back or one of the limbs of the patient e.g. electrocauter or electrocautery knife
More common in general surgery
(OBS: pacemakers)
Is it accepted to use electric knife on patients with pacemaker?
regarding monopolar electric knives
In patients with old pacemakers the electrical current may cause arrhythmias, and it
must therefore be adjusted prior to surgery
What do you know about the ultrasonic cutting device?
Ultrasonic cutting device (Ultracision) is using ultrasound to cut and coagulate the tissues
It is working similarly to the diathermy but it does not cause thermic injury
It makes possible to have more precise movements during surgery
Name the non‐locking grasping instruments! Explain their functions!
The non-‐locking grasping tools are the Thumb forceps A. Smooth forceps B. Toothed forceps C. Splinter forceps D. Ring forceps (brain tissue forceps) E. Dental forceps
o The simplest form of grasping tools made of different sizes
o They can have blunt (smooth), sharp (splinter) or ring tips
o They are used to hold tissue during cutting and suturing
o The smooth forceps is also called anatomical forceps, the toothed forceps is also called surgical forceps and the splinter forceps is also called ophthalmic forceps
o The forceps should be held like a pencil, compressed between the thumb and index finger
o For holding skin and subcutaneous tissue the toothed forceps is most used
o For holding of sponges, bandages, vessels and hollow organs use the anatomical forceps
o The forceps is not suitable for long continuous grasping and the tissue graspers should be used for this purpose
List organ clamps!
These are instruments used for delicate grasping and holding of the organ
- Klammerintestinal clamp,
- Gallbladder clamp
- Babcock forceps (gallbladder)
- Allis clamp (lungs)
List the hemostatic instruments! Explain their functions!
Vascular clamps (Péan, mosquito, abdominal Péan, Kocher, Lumnitzer, Satinsky, bulldog),
Electrocautery knife, various ligation needles and directing probes (e.g. Deschamp ligation needle, and Payr probe), and argon beam coagulator
List the retracting instruments! Explain their functions!
Retractors are sued to hold tissues and organs aside during surgery in order to improve
the exposure, visibility and accessibility
Hand-‐held retractors
o Skin hook, rake, Roux, Langenback, visceral and abdominal wall retractors
o Held by assistant
o Cause minimal tissue damage because tension is maintained only for as long as necessary
Self-‐retaining retractors
o Weitlaner self-retaining retractor, Gosset self-retaining retractor
o Of great help when applied correctly
o Damage to tissues can occur if not used carefully when placed and removed
Explain the application area of metallic clips!
The Michel clips can be used with the help of a Michel clip applicator or remover
They are used to close a skin wound and any luminal structure, vessel, duct etc.
Other uses:
In the wound stapler making it possible with atraumatic and fast wound closure
In hemostasis (can occlude lumen)
As a marker because it can be seen on the X-‐ray (e.g. bed of a tum0er
What do you know about the CT and MRI examination of patient carrying metalic clips?
CT:
The clip disturbs the picture only in the vicinity of it and so examination can be done
MRI:
The clips make it impossible to perform the examination because these metals
can move in the magnetic field
The clips can become wandering within the body
Due to this it has become more common to use the non-‐magnetic clips like
titanium, platinum and absorbable clip
What is the Steri-Strip? When to use it?
Usually produced from fibrin, collagen or thrombin and induces the last phase of blood coagulation producing fine fibrin mesh
Application
o Hemostasis in operations done on solid organs
o Close the place of air leakage in lung surgeries
o Wound closure
Disadvantage: can increase the degree of infection in infected wounds and lead to abscess formation
List special instruments!
Volkmann curette
Main application:
*Skin tags, e.g. condyloma, warts, removal
*Clean the base of the infected wound
*Remove infected bone in case of osteomyelitis
Round-‐ended probe
Use to gauge depth or direction of a sinus or cavity
Payr clamp (crushing)
Use it before resecting the intestine
Suction set
X-‐raying set
The metallic screws and pins, joint prosthesis, hernial meshes, vascular grafts and silicon implants
Describe the conventional (close-eye, French-eyed) needles!
Needs to be threaded
The needle and two arms of the thread goes through the tissue
Danger of untying
Re‐sterilization
Describe the atraumatic needles!
Has less thickness going through tissue due to no arms of the thread, resulting in less tissue damage
The thickness of the thread is slightly thicker than the whole made by the needle, making the tissue pack around the thread and avoiding leakage
-No threading time
-No re-sterilization
-No danger for corrosion and untying
-Be careful to not pull to hard, the thread may detach from the needle
What are the main groups of the circular needles?
Has 3 main groups; taper-point, taper‐cutting and blunt tape
-Circular needle classically refers to taper-‐point circular needle
Both the tip and the body of the needle are circular. The needles are so thin that they separate tissue fibers without cutting them
They are generally used in easily penetrable tissue, like peritoneum, abdominal organs, myocardium, and subcutaneous tissue
At the tip of the taper-‐cutting needle there are 3 cutting edges
- The edges gradually becomes more flattened and are finally obliterated at the body
- They are developed to sew sclerotic, scarred and classified tissues
- The diameter caused by the needle is smaller than the thread
The blunt taper needles have a circular body and a blunt end
It serves to prevent the danger of needle stick and is used a lot in patients with HIV or hepatitis
The tissues are pushed aside and no separating in their structure is caused
Explain the difference between conventional and reverse cutting needles!
In the conventional needle the third edge is facing the internal part of the curving body
In the reverse needle the third edge is facing the external part of the curving body
What are the main characteristics of the surgical suture materials?
Physical: caliber, tensile strength, elasticity, capillarity, structure, water absorbent capacity, sterilizability
Application properties: flexibility, capability to slip in tissue, knotting properties, knot security
Biological properties: absorbent capacity
What are the advantages and disadvantages of natural and synthetic suture materials?
Natural materials have good knotting
properties and are easy to handle
The main disadvantage with natural
substances is that they contain proteins, which our immune system will target as non-self
They are absorbed by macrophages and other phagocytic cells leading to a strong inflammatory response
Most synthetic materials cause only small reactions in the living tissues
Their absorbance is done by hydrolysis and there will be no cellular response and tissue damage
What does the term “thread memory” stand for?
Thread memory is the capacity of the suture thread to return to its former, packaged shape
(monofilaments have thread memory)
What are the advantages of monofilament threads?
Smooth surface Smaller friction Smaller resistance Smaller tissue injury No spreading of bacteria No capillarity Not transporting the tumor cells
