Ch 17 Instrument and tissue handling techniques

Question 1

List Halsted’s Principles 7

DoGBAATH

Answer 1

Eliminate Dead space
Gentle tissue handling
Preserve Blood supply
Strict aseptic technique
Accurate tissue apposition
Eliminate tension
Meticulous haemostasis

Question 2

What grips are acceptable for scaple handles?

Answer 2

Fingertip grip - Places maximum length of blade in contact with the tissue. Offers greatest accuracy and stability

Pencil grip - Uses finger motion, more accurate for short and delicate maneuvers

Question 3

What are the 4 motions of a scapel?

Answer 3

sliding - precise depth, length and control of direction
Pressing - stab incisions into a chamber
Sawing - continuation of a cut without removal and reinsertions of the blade ie. pedicle cut
Scraping - seperating tissue layers

Question 4

What forces are used when cutting with scissors?
What grip is recommended?

Answer 4

Closing
Shearing
Torque
Tripod grip (thumb-ring finger) - provides maximal control

Question 5

What are the benefits of curved and straight scissors?

Answer 5

Curved - greater maneuverability and visibility
Straight - greater mechanical advantage for cutting dense tissue

Question 6

What part of the scissors should be used to cut and why?

Answer 6

Close to the tips

Cutting near the fulcrum results in greater crushing, injury to the tissue, jagged incisions and potential inadvertent trauma

Question 7

What are the recommended suture tag lengths?

Answer 7

Synthetic material - 3mm
Surgical gut material - 6mm

Question 8

What are the 4 acceptable grips for needle holders?

Answer 8

Tripod - fast grasping and release, good for delicate work
Thenar grip - Saves time during continuous patterns but needle release is less precise
Palmed - strongest, provides greatest needle pressure and control in dense tissue and maximal wrist rotation. Needle release and grasping requires adjusting
Pencil grip - For spring handles in ophtho surgeries

Question 9

2 clamping techniques for haemostats?

Answer 9

ip-clamping - haemostats with transversely oriented serrations. Tip pointing down towards the vessel tip
Jaw clamping - Haemostats with longitudinally orientated serrations (Rochester-Carmalts). Designed to grasp larger amounts of tissue with the tips pointing away. Facilitates ligature placement but causes increased tissue trauma

Question 10

common hazard of self-retaining retractors?

Answer 10

Ischaemia at the pressure points

Question 11

ideal dissection technique?

Answer 11

Bloodless and precise dissection, causing minimal complications, including seroma and haematoma incidence

Question 12

what are the characteristics of an ideal closure technique?

Answer 12

Maintains tensile strength throughout healing
Technically quick and simple
Precise wound edge approximation

Question 13

Name these interrupted suture patterns and state whether they are apposition, everting or inverting

Answer 13

A - Simple interrupted (appositional)
B - Modified Gambee - Appositional
C - Horizontal mattress (everting)
D - Vertical mattress (appositional)
E - Cruciate (appositional)
F - Lempert (inverting)

Question 14

Name the continuous suture patterns and state if they are appositional, inverting or everting

Answer 14

A - Simple continuous (appositional/everting)
B - Fords interlocking (appositional)
C - Continuous horizontal mattress (everting)
D - Purse-string (inverting)
E - Cushing - (appositional?)
F - Connell - (everting?)
G - Continuous lembert - (inverting)

Question 15

How many throws is considered gold standard?

Answer 15

5 throw square knot

Require 2-3 additional throws at the end of a continuous pattern

Question 16

What are the 5 principles of knot tying

Answer 16

The simplest secure knot for the suture material

Avoid friction between strands as suture weakening may occur

Use appropriate tension

Pull the 2 suture ends in opposite directions with uniform rate and horizontal tension

Never apply needle holder to any suture which is going to remain in the patient

Question 17

What is the weakest point of the suture line?

Answer 17

The knot

Synthetic absorbable sutures tend to have a relative knot security of 67% (deined as the knot-holding capacity in percent of the tensile strength of the suture. Ranges from 51-92%)

Question 18

Name three types of circumferential knots which are useful on vascular pedicles

Answer 18

Modified millers knot
Constrictor knot
Strangle knot

Question 19

Name the 3 main types of transfixation ligatures

Answer 19

Halstead transfixation ligature
Modified transfixation ligature
Figure-of-eight