Principles of Operative Technique Flashcards
1
Q
Halstead’s Principles of Surgery
A
- seven principles of surgery
- minimising tension: decreasing pull on the suture lines
- These principles go across any surgery that you are performing
- must know from anatomy what blood vessels to preserve or ligate
2
Q
Basic Surgical Kit
A
- retractors help move tissues in order to get access to the tissue we want
- needle holders for suturing
- towel clamps involved in draping
3
Q
Scalpel Handle and blades
A
- there are 2 sizes and that relates to what blade will sit on it - blades are made for #3 (small) or #4
- ruler helps for things such as removing skin tumors where you have specific margins that you want to obtain
- # 10 blade is the most common used in SA practice (cutting skin)- cut using curved
- middle blade is not commonly used, maybe for stitch removal
- # 10 blade is good for dogs
- # 15 is similar in function to #10 but smaller- good for cats, rats, mice
- # 20 blade is the only one on this slide that will go on the no. 4 handle (farm, equine)
4
Q
Scalpel
A
- use to go through skin and linea alba
- ex: ventral abdominal wound on dog (top pic) -use scalpel blade to go through the skin + fat to make a single clean line. can then be used again to make a stab incision and go through the linea alba
- not just for skin/linea alba (entry into body) - #11 can be used to make a stab incision into the bladder to make a neat incision (make sure the body wall is under tension to make an effective clean cut)- stretch flaccid bladder with stay suture and tissue forceps
- tissue trauma is minimal unless you cut something that you didnt intend to cut
5
Q
Pencil grip vs. Finger Grip
A
- #10 blade, using the curve of the blade
- finger grip: all your fingers are on the dorsal surface
- pencil grip: some of your fingers are under the blade creating a larger angle to the tissue you are cutting
- when you use a pencil grip the angle is greater than finger grip
- cutting the skin would be appropriate for finger grip - distance between you scalpel blade and hand is actually very small
- whcih grip you tend to use is often personal preference
6
Q
Tissue Scissors - Metzenbaum vs. Mayo
A
- advantage: controlled cutting that is good for flaccid tissues now (don’t need a tissue under tension)
- can get a tissue shearing trauma which is a disadvantage - the way that it cuts is that one blade passes over the other - If the tissue is between these two, we run the risk of getting shear - disadvantage to a scalpel blade that cuts clean
- blade length: go from screw to tell blade length and the difference b/w the two types
- bigger blade for dense tissue, etc. - Mayo
- If you accidentally use the Metzenbaum for tissues that are too thick, it wont be able to cut effectively and all you will be doing is tearing
- Same thing if you use Mayo scissors on tissues that are too thin and you will get subsequent tearing as you are using too big of scissors
- Need to use right instrument for the right tissue
- Also if you use Metzenbaums on tough tissues - you may ruin them and then ruin the purpose they were meant for
7
Q
Tissue Scissors
A
- Mayo scissors being used for linea alba in the ventral portion of the abdomen
- used in the 4 finger grip - always use this to pick up the scissors (thumb in one hole, 4th finger in the other, pointer finger is extended out along the length of the blade to give you better control of the tip of the scissors)
- always use the tips so you dont inadvertently cut something else unintentionally that is lying past the tip
- Metzenbaum scissors being used to cut an adhesion through fine tissues : can see through the tissue - if you turn curved scissors on the side, you can see the full length of what is being cut
- Yet again, a bit of a personal preference on whether you like to use straight scissors or curved scissors
8
Q
Utility Scissors
A
- straight blades
- Instead of sharp tips, have blunt tips
- hooked tip is specific for suture material - using this prevents blunting tissue scissors by cutting blunting suture material
9
Q
Ligature Scissors
A
- Often say suture cutting on the side
- gold and black handle to separate from Metzenbaum scissors (as they look very similar)
- long body to allow cutting of sutures deep in a body cavity
- one of the blades is serrated to cut sutures sharply and cleanely
- however, would not want to use a serrated blade on such things as the bladder as it would cause trauma to the bladder
10
Q
Thumb forceps
A
- used for holding onto tissues
- Dressing forceps do not have teeth at the tip
- Adsons have rat teeth at the tip - will cause greater trauma to a tissue
- Adson Brown- has almost a whole row of rat teeth at the ends
- DeBakey: have fine rows of teeth at the end. Will pick up fine tissues, hold it sufficiently with minimal trauma
- most common in a soft tissue kit would be Adson (rat-tooth) and DeBakey forceps
- in some cases, want to pick up the tissue only once with the Adson rather than cause repeated trauma from slipping out of Debakey (this would also damage the fine teeth of the Debakey forceps)
- soft tissue Adson would be insufficient to pick up skin of a cow
- chunkier adsons are better for picking up scar tissue/bone/foreign material or skin of larger animals (equine or farm)
11
Q
Thumb forceps: pencil grip
A
- allows for fine movements - allows for practice our whole life writing to be transferred to doing surgery in a fine way
12
Q
Tissue forceps
A
- they have a ratchet on them to keep the teeth opposed
- Allis have traumatic teeth: holding tissues firmly that you are intending to take out, not tissues that you want to stay viable in the animal - example: when you are taking out a skin mass and it can hold the edge of the skin that you are removing
- Babcock dont have teeth, but have 3 small lines
- Doyen/Bowel: also longitudinal teeth - intestinal resection in anastomosis or when you are cutting into the intestine to prevent leak of intestinal contents. Note: when you crank them closed they do not initially meet in the middle
13
Q
Haemostatic Forceps
A
- Mosquito: fine and small to hold individual blood vessels (ex: vessels of the spleen)
- Kelly: tips are partially serated face unlike the mosquito which has the full face serrated - meant to hold fat or fascia associated with blood vessels
- Rochester: larger, longitudinal teeth with some more teeth at the tips to hold stronger tissues. Hold tissues as well as blood vessels (ex: uterus)
14
Q
Needle holders: personal preference
A
- Types you find in a practice depend on personal preference
- Mayo and Olsen Hegar are the most common
- first three are held in the four fingered grip
- Olsen-Hegars dissimilar from the Mayos have a cutting blade - so you can have cut suture as well as holding the needle
- Some people think the Gillies are more comfortable in hand but may limit the flexibility of your hand bc your hand is fixed in one position due to the structure of the ring holes
- Mathieu forceps would be used by large animal surgeons
15
Q
Retractors - Hand held
A
- disadvantage to these is that they are hand held, you need an assistant to keep them out of the way
- personal preference to what you are doing!
16
Q
Self Retaining Retractors
A
- push tissues out of the way when you have a solo surgeon
- Gelpi retractor ends are sharp (you can get blunt ones for areas of concern such as the neck where there are imp. BV’s you wouldnt want to pierce)
- Adson and Weitlaner have more teeth to hold a greater width of tissue apart - more specialist type of retaining retractors, used more to access such places as the vertebrae bc there is a lot of muscle around the neck/spinal cord (vertebral canal)
17
Q
Self retaining Retractors - Abdominal
A
- these are much more common
- really useful for retracting the abdominal wall and allow you to see everthing in the abdomen
- Balfour has the side and cranial retraction (from spoon edge) - held open by the pressure of the body wall on the two side edges. Spoon edge can freely slide along
- Gossets are also held open by the pressure of the body wall
- Finochietto is special for the thorax- for the thorax, there is nothing pushing to keep it open like the others -has a ratchet and teeth as a result to keep open
18
Q
Towel Clips
A
- required to hold the drapes onto the skin
- bit of a personal preference to what is used in the clinic - all do the same job
- Backhaus is by far the most common
19
Q
Haemorrhage and haemostasis
A
- if there is blood everywhere, bleeding obscures the surgical field –> cant see anything, leads to complications during routine spays and castrations even
- blood provides an ideal medium for bacterial growth - more likely to get an SSI
- inflammatory reaction leads to even more adhesion issues
- If there is severe blood loss you will lead to hypovoelemia which can lead to shock - decrease of oxygen to the tissue and the possibility of death
- best to not control while it is happening but to prevent before happening
- primary hemorrhage = breakage of vessels
20
Q
Haemostasis Options
A
- load of options available
21
Q
Blood vessel ligation - vessels of any size
A
- gauze: when you have a pool of blood it is hard to actually identify the BV, so look for origin of bleeding
- Once you have identified the source of bleeding (BV) it is ideal to use some haemostats
- vicryl is a good choice for ligating
- one haded and two handed ties are taught because they are rapid and they are reliable - you have a sense for how tight when you hand tie that suture
- Instrument ties are more economical for suture bc you dont need as much suture to tie an effective knot- it is dependent on your instrument actually holding onto the suture material so that you have an accurate sense on tension
- hands may be quicker to use than instruments - need to know how to do both!
22
Q
Swabs
A
- When you are using swabs in a surgery, it is important to count how many you are actually using - worse thing you could do is leave a swab inside!
- some swabs have a line on them that you can see on radiograph - so if you leave a swab inside, it is then possible to detect it without having to open up the animal
- Better to count at the beginning and the end because then you know you arent missing any swabs once you start closing
- dont wipe! Pressure is enough to stop bleeding, If you wipe - can be traumatic and you wipe away the blood clot
- openinig up the swabs to use may be less traumatic than using them folded
23
Q
Blood vessel ligation- vessels of any size
A
- Remember: you blot and stop the bleeding, you pick up the swab to find the bleeding vessel and then use hemostats to hold vessel closed
- then ligation:
- If it is a big blood vessel -double ligating may give you added security
- If you have a blood vessel and all the fascia all around it- the first ligature may just tightening down to get rid of all that fat that is around the BV which isnt closing the BV and the second ligature actually closes the BV
- double ligating can be good in some situations where if one fails the other compnsates- for important big arteries or veins (splenic artery/splenic vein)
- Transfixing is good for the ligatures that may slip (not transfixing the vessel itself but the fascia around it) - put the needle through part of the vessel and tehn do a simple encircling after that
- as you take that needle through that BV like this transfixing ligature, then youll start to bleed where you just passed that needle through that vessel
24
Q
Cautery of blood vessels - vessels up to 2mm
A
- very effective for vessels up to 2mm (very small vessels where ligatures may not work- also ligatures are time consuming and require suture material)
- Monopolar: just one blade, passes a current from the instrument through the animal into a plate below the animal. disadvantage: not as fine since it is a broad base (may use instrument to make more fine such as mosquito forceps to hold vessel itself)
- Bipolar: two blades (looks like forceps) - less current used as current does not pass through animal, passes through two blades of the forceps.
- there is reduced tissue trauma and it is effective in a wet field (AKA a pool of blood) - with the monopolar you need to blot to get rid of the pool of blood, otherwise it will not be effective
- bipolar in the picture is being used for the body wall
- bipolar is a good choice for tissues you do not want a current to run through (NEUROSURGERY-nerves are very good at carrying a current)
25
Q
Metal clips
A
- another way that you can seal BV’s (vessels that are less than a half to three quarters the width of the clip)
- Ligaclips are preloaded into instrument and then will be closed around the vessel
- Ligate-divide stapler places two staples and cuts in between to speed up the surgery that you are performing
26
Q
Haemostatic Agents
A
- Don’t actually have clotting factors in them - cant compensate for a coagulopathy
- Important thing is that they mop up blood so don’t pick up with your fingers or else they will stick to your fingers (even through a gloved hand as they stick to moisture)
- pick them up with forceps and place over the bleeding area - going to facilitate coagulation
- Surgicel: can be good for packing into a small hole - blood vessel coming out from a little fossa in a bone to pack that into the hole/fossa may be easier
27
Q
Vessel sealing devices
A
- can be a bit $$ as they need specialized equipment
- seal vessels by coagulation of proteins and you can also use them to cut
- Can be used for rather big vessels (up to 7mm)
- one solution for endoscopic surgery, you are trying to seal BV’s within an abdomen without actually being able to pick up the vessel- practices who are doing laproscopic spays - seal the ovarian pedicle without the suture material
28
Q
Haemostasis: dealing with excessive blood loss
A
- If you do have a bleeding, you need to get rid of the blood obviously to see what in fact is bleeding
- # 1 way in practice would be gauze swabs
- different sizes: the most common (10x10)
- 20cm x 20cm or laporotomy swabs (used for body cavity surgery)
- Important to have suction available if you have any degree of bleeding: Poole tip attached to suction pump (vacuum and active suction attached to it)
- Pooled tips can be plastic or metal (as long as they are sterilized)
29
Q
Surgical Drains
A
- How we deal with dead space
- primarily with surgical drains!
30
Q
Surgical Drains: Indications
(contaminated or infected wounds)
A
- wound that may have gotten bacteria in it or know it has
- want to get bacteria out and not seal it in
- penetrating foreign body: most likely took bacteria into the wound upon entry and there is now bacteria in the wound
- ex: cat bite abcess
- ex: traumatic wound that is several days old
- these are examples of where you may consider using a drain if you perform surgery
31
Q
Surgical Drains: Indications
(dead space)
A
- another indication–> dead space- space that may accumulate fluid
- If you have a pocket of fluid–> increases the risk of infection
When might you have a dead space?
- If you perform an amputation there will be dead space left behind even if you are a perfect surgeon due to the closure of all that skin and the muscles
- tumor removal (ex: large lipoma removed that leaves space behind, this remaining space could act as a dead space and accumulate serumen fluid)
32
Q
Types of Surgical drains
(2 main types)
A
Penrose drain is really common in practice - passive
- it depends on gravity and capillary action (aka when a fluid will move along the tube due to the fact that there is no fluid at the end of the tube and at the beginning of the tube there is some fluid)
Active, a common one is a Jackson Pratt drain:
- actively remove fluid against gravity if necessary
- they are closed: collect fluid into a specific chamber
- with the jackson pratt- the part that goes into the body is silicon and has small holes
- tube then exits the skin and enters a small chamber- (often called a grenade) can be compressed, will create a vacuum to pull out fluid from inside the body out
33
Q
Passive vs. active drains
A
passive:
- use gravity to help that drain to work (needs to be below wound)
- risk of ascending infection but if fluid is really coming out that is going to decrease the chance of bacteria moving the other way
- you cant measure how much fluid is exactly coming out (can use absorbant dressing to help give approximation- but can only measure area absorbed)
- will always work though if used with gravity and are dirt cheap.
- passive is good for wounds that are already infected! - as the risk of ascending infection is rather low as the wound is already contaminated
active:
- you use only when the wound can be sealed completely (can’t have 2 holes) as it is required for the vacuum effect to work - would suck air through the wound
- can assess fluid production to know when to remove the drain
- failure of drainage is a big thing: drain tubing is often much finer than a penrose drain
- there are definite benefits to the passive but the active always works
- for clean and wounds that can be completely sealed
34
Q
Timing of Drain Removal
A
- basically remove once you get to a steady low level (may never get to less than 2ml a day so steady low works) - you are never going to get no fluid
- may be able to do cytology to show that the bacteria is no longer present or if the wound is no longer swollen/red
- If you are using an active drain you can actually look at the fluid for WBC count decrease and being healthy (daily cytologies)
- If you have a large wound with a dead space (amputation) it will
- Most penrose drains are removed in 1-3 days
- large dead space (ex: amputations or large skin reconstruction) –> 3-5 days
- If it is drainin for longer than a week, is there an additional infection present causing the production of more fluid?
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52
Q
Passive v. Active Drains
A
- Dog on the left: had the foreign body in its side so we removed the foreign body, closed the wound, but there is still concern of infection present–> treat with AB’s therapeutically but then placed a Penrose drain below (exited ventral so it is going to work)
- Dog on the right (amputation): wound is 100% clean, ventral is where the surgical wound is so you don’t really want a drain coming out of the surgical wound site as it needs to heal - in this case better to place an active one so that it can exit dorsal to amputational wound
- also if we get an infection into the wound, will be a much bigger deal than the other dog, active draining with lower risk of ascending infection
