Instrument and Tissue Handling

Question 1

List Halsted’s Principles

Answer 1

• Gentle tissue handling
• Meticulous haemostasis
• Strict aseptic technique
• Preserve blood supply
• Eliminate dead space
• Accurate tissue apposition
• Eliminate tension

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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

What are the 2 clamping techniques for haemostats?

Answer 9

• Tip-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

What are the 2 options of gripping a haemostat?

Answer 10

• Tripod grip
• Palmed grip - for removing a haemostat with your nondominant hand

Question 11

What is a common hazard of self-retaining retractors?

Answer 11

Ischaemia at the pressure points

Question 12

Name the three main types of suction tips

Answer 12

• Poole
• Frazier
• Yankauer

Question 13

What is considered ideal dissection technique?

Answer 13

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

Question 14

What are the characteristics of an ideal closure technique?

Answer 14

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

Question 15

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

Answer 15

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

Question 16

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

Answer 16

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 17

How many throws is considered gold standard?

Answer 17

5 throw square knot

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

Question 18

What are the 5 principles of knot tying?

Answer 18

• The simplest secure knot for the suture material and the situation is the goal
• 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

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Question 19

What is the weakest point of the suture line?

Answer 19

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 20

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

Answer 20

• Modified millers knot
• Constrictor knot
• Strangle knot

Question 21

Name the 3 main types of transfixation ligatures

Answer 21

• Halstead transfixation ligature
• Modified transfixation ligature
• Figure-of-eight