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Year 3 MOD > SA Soft Tissue Surgery: General Surgical Principles and Basic Wound Management > Flashcards

SA Soft Tissue Surgery: General Surgical Principles and Basic Wound Management Flashcards

1
Q

Name Halsteads 7 principles of Surgery

A

Gentle tissue handling- reduced trauma

Meticulous haemostasis- haemorrhage can obscure

Preservation of blood supply- dissect as little as possible

Strict asepsis- prevents surgical wound infections

Minimal tension- wounds under tension will heal more slowly or not at all

Accurate tissue apposition- suture tissues planes back together in same position

Obliteration of dead space

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2
Q

What is the least traumatic cutting instrument?

A

Scalpel

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3
Q

What are the different grips of holding a scalpel?

A

Pencil Grip

Fingertip Grip

Palm Grip

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4
Q

What is the purpose of the pencil scalpel grip?

A

Used for cutting short and precicse incisions due to the small contact area of the scalpel from the anlge

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5
Q

What is this grip and when it it used?

A

Fingertip grip

Blade to tissue contact is maximised making this a versatile grip used for most scalpel incisions over 3cm

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6
Q

When is the palm scalpel grip used?

A

Rarely used- allows substantial force but is imprecise

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7
Q

What is press cutting?

A

Using the pencul grip, apply a gradual increase in pressure in the direct motion of the blade- eg linea alba

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8
Q

What is side cutting?

A

Using any grip apply pressure at 90 degrees to the direction of the motion of the blade, while other hand tenses the tissue laterally to seperate wound edges incresing cutting efficiency. Only do a single pass, to prevent jagged edges.

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9
Q

What kind of scissors should be used for fine dissection and what for dissecting connective tissue and fascia?

A

Metzenbaum (top) for fine dissection

Mayo (bottom) for connective tissue and fascia

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10
Q

What kind of dissection are curved scissors better for?

A

Curved scissors are better for fine dissection.

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11
Q

How should you hold scissors to cut towards your dominant hand?

A

Backhand thumb-third finger tip is better

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12
Q

When would this technique be used?

A

To cut across the table towards your body

use the back thumb-index finger grip

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13
Q

Where along the sharp edge of scissors should you cut?

A

Use the scissor tip rather then near hinge- cutting forces highest at tip

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14
Q

What are the three techniques of cutting with scissors?

A

Scissor cutting- normal- avoid complete closure of jaws

Push cutting- wrapping paper- useful for cutting sheets of tissue

Blunt dissection- insert closed blades of scissors anf then open them

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15
Q

How do electrosugical instruments work?

A

Use a radiofrequency electrical current to heat tissues and destroy cells/coagulate protein

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16
Q

What is the difference between monopolar electrocuautery and bipolar?

A

Monopolar electrocautery has an electrode in a hand peice and a ground plate and can both cut and coagulate

Bipolar cautery is only used for coagulation and haemostasis

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17
Q

When should electrosurgery not be used?

A

If the patient is not anaesthetisesd

If there is presence of volatile/flammable gases or liquids

The ground plate for monopolar systems is not in complete contact with the animal

If the power lead is wrapped in a coil around around towel clips

The electodes are not clean

With an innapropriate power setting- keep as low as possible

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18
Q

What forceps are most commonly used for handling tissues?

A

Thumb forceps

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19
Q

What are the types of thumb forceps?

A

Toothed- adson, debakey

and Non-toothed

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20
Q

What type of thumb forceps are these?

A

Adson forceps

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21
Q

What type of thumb forceps are these?

A

DeBakey vascular forceps

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22
Q

When should non-toothed thumb forceps be used?

A

When handling inanimate objects- dressings, pathology specimens

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23
Q

Name the three types of tissue forceps?

A

Allis tissue forceps- jaws traumatic

Babcock forceps- slightly more delicate jaws

Doyen forceps- designed for holding and occluding lumen of bowel

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24
Q

Name these forceps

A

Allic tissue forceps

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25
Q

Name these forceps

A

Babcock forceps

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26
Q

Name these forceps

A

Doyen Forceps

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27
Q

What are the purpose of retractors?

A

Expose the surgical field with as little trauma as possible

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28
Q

What retractor is this and what are they used for?

A

Finger held retractors- used for thin or delicate tissue planes

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29
Q

What are hand held retractors used for?

A

Used for retraction thicker or more robust tissue planes

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30
Q

What is the name of this retractor and what is it used for?

A

Balfour retractors

Used for abdominal wall retraction, especially in larger animals and for working in the cranial abdomen- central blade can be used to lift the xiphoid process and improve exposure

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31
Q

What is the name of of these retractors?

A

Gossett retractor- used for abdominal retraction

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32
Q

What is the name and functions of these retractors?

A

Finochietto rib retractors

Used to seperate the ribs for intercostal thoractomy or the divided halves of the sternum for median sternotomy

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33
Q

What is the name and function of these retractors?

A

Gelpi retractors

Used to seperate tissues in various locations, the tips are quite sharp so use with caution around delicate structures

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34
Q

Why is suction useful during surgery?

A

It is the most effective way of removing large volumes of fluid from the wound.

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35
Q

What are the names and function of these suction tips?

A

Top- Frazier-ferguson

Good for fine work and removint haemorrhage during dissection

Middle- Yankauer

Good for removing large volumes of fluid from body cavities

Bottom- Poole

Good for removing fluid from body cavities and doesn’t block easily

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36
Q

What are the complications of improper tissue handling?

A
  • Tissue ischaemia with subsequent delayed healing or necrosis leading to wound dishiscence, incisional hernias etc
  • Dead space leading to seroma and abscess formation
  • Wound contamination leading to infection
  • Increased postoperative pain
  • Poorer cosmetic results
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37
Q

What is suture material selected based upon?

A
  • Tensile strength
  • Structure of the suture
  • Chemical composition of the suture
  • Local wound conditions
  • Wound healing rate
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38
Q

What is tensile strength and how do you decide what tensile strength to use?

A

This is proportional to the diameter of the suture

Use suture with a tensile strength equal to the strength of the tissue

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39
Q

How is metric and USP suture diameter calculated?

A

Metric- diameter of a suture to tenths of a mm

USP- suture size in arbituary units based on diameter of suture in thousands of an inch

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40
Q

What is the ideal structure of suture material?

A

Easy to handle

low tissue drag

resistance to contamination

good knot security

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41
Q

What is the difference between monofilament and multifilament sutures?

A

Monofilament is a single strand of material

Multifilament is multiple strands of suture braided or twisted together

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42
Q

What are the advantages and disadvantages of monofilament sutures?

A

Advantages

  • Little tissue drag
  • Withstand contaminatino

Disadvantages

  • Prone to damage from handling equipment- breakage
  • High degree of memory- gives worse knot security
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43
Q

What are the advantages and disadvantages of multifilament suture?

A

Advantages

  • Easier to handle from less memory
  • Better knot security

Disadvantages

  • Increased tissue drag
  • Increased chance of contamination
  • Capillary action
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44
Q

What is the differecne between absorbable and non-absorbable sutures and when would both be used?

A

Absorbable

  • Lose tensile strentgh within 60 days

Non-absorbable

  • Retain their strength for more then 60 days
  • Used for skin, some hernias, ligament and tendon repairs
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45
Q

What are synthetic and natural absorbable sutures?

A

Synthetic are made from synthetic polymers and are broken down by hydrolysis

Natural is made from animal or plant material and are broken down by enzymatic degradation causing inflammation and more tissue reaction

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46
Q

What suture should be used in contaminated/infected wounds and why?

A

Least amount possible of synthetic monofilament

Multifilament may habour bacteria and synthetic gives the least amount of tissue reaction

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47
Q

What suture material should be used for visceral wounds and connective tissues/fascia and why?

A

Visceral wounds- absorbable as gain tensile strength to support itself after 14-21 days

Connective tissues/facsia- non-absorbable or slowly absorbable as ther heal more slowly

48
Q

What are the generic features of all needles and what differences affect choice?

A

Most stainless steel- strong, withstands corrosion and doesn’t harbour bacteria

Needle choice-

long enough to reach both sides

Appropriate diameter for suture

49
Q

What are the two ways needles are attached to suture?

A

Swaged on- attached during manufacture- less traumatic (new and sharp)

Eyed needles- re-usable, cheap, need to thread a needle

50
Q

What are the two shapes of needles?

A

Straight- used near the body surface or skin held in fingers

Curved needles- used for most suturing and are especially useful for narrow and deep wounds

51
Q

What is the difference between round bodied and cutting needles?

A

Round have sharp point that pierces and spreads tissue without cutting. Used for suturing easly penetrated tissue

Cutting needles have two or three sharp cutting edges designes for use in difficult to penetrate tissues

52
Q

Name these three types of cutting needles based on the followign descriptions:

  • Cutting edge along inner (concave) side of the needle. This may cause the suture material to cut out towards edges of incision
  • Have cutting edge alonf outer (convex) side making the needle stronger and suture less likely to cut out
  • Combination- used for dense/tough fibrous tissue (tendon) and for some cardiovascular procedures
A

1- Conventional cutting needles

2- Reverse cutting needle

3- Taper cut needle

53
Q

What are the differences between the three types of needle holders?

A

Mayo-hagar

  • No scissor blade with ratchet

Olsen-hegar

  • Scissor blade with ratches

Gillies

  • No ratchet arms are different lengths
54
Q

How short should ends of suture be cut?

A

Cut the ends of the suture as short as possible without compromising the knot

3mm synthetic sutures

6mm surgical gut

1cm at skin to facilitate removal

55
Q

How many throws are required for a safe knot?

A
56
Q

What are the three suture patterns and what effect do they have on tissue alignment?

A

Appositional- brindh the wound edges into direct contact and are the most widley used type of suture

Inverting- turn the wound edges inwards

Everting- turns wound edges outwards

57
Q

What are the advantages and disadvantages of interupted sutures?

A

Adv-
Easily placed and removed
allow adjustment of tension across a wound
More fail tolerany than continuous

Disadvantages-
Less economic on suture material

58
Q

What is a vertical matress suture useful for?

A

It can help to relieve minor tension and is usually alternated with simple interupted, vertical removed 3-4 days post op.

59
Q

What are the advantages of continuous horizontal?

A

No sutures to remove in fractious pets

No sutures passing through the skin to cause irritation or track infection into the wound

Minimal scar formation

60
Q

What difference is there between simple continuous and ford interlocking?

A

Each loop through the skin is partially locked allowing greater security if the suture breaks- can be fiddly to remove

61
Q

What suture pattern is commonly used for subcutaneous tissue and why?

A

Simple continuous or continuous horizontal mattress pattern

Decrease tension across the wound before skin sutures are replaced- reduce dead space and approximate skin edges

62
Q

What suture pattern is used to close the skin?

A

Simple interupted, cruciate matress or continuous.

Spacing depends on direction of the skin tension lines and thickness of skin but generally 5-10mm appart

63
Q

How can staples be more or less expensive then using suture?

A

Can be more expensive as they cost more then suture material

But if closing larger wounds it can be cost effective

64
Q

When are staples not suitable?

A

Wounds that are under tension

Wounds with complicated geometry/uneven edges

Less then 4-6mm depth of tissue seperating them from bone or viscera

65
Q

When are circular and linear stapling devices mainly used?

A

Most commonly for hepatic and pulmonary lobectomies and closure of stomach of bowel

66
Q

How long does it take for cyanoacrylate adhesives to polymerise?

A

In the presence of moisture- less than 60 seconds (often less then 15)

67
Q

When are cyanoacrylates useful?

A

Useful for repairing small skin wounds

Useful if suture removal will be difficult

68
Q

What are the disadvantages of tissue adhesives?

A

Low strength

Adhere poorly to moist surfaces

Not suitable for use on mucous membranes, larger wounds or wounds under tension

69
Q

Why should tissue adhesives not enter wounds?

A

Cyanoacrylates may cause chronic inflammation and wound infection or granuloma formation

70
Q

What do these terms mean?:

  • tomy
  • ectomy
  • centesis
  • pexy
A

-tomy
to incise into

-ectomy
to remove or excercise

-centesis
introduction of needle into cavity to aspirate fluir or gas for diagnostic or therapeutic purposes

-pexy
surgical fixation

71
Q

What do these terms mean?:

  • rraphy
  • stomy
  • desis
  • plasty
A

-rraphy
act of suturing

-stomy
Surgically creating an openning

-desis
secure fixation by surgical methods

-plasty
surgical shaping or moulding of a structure

72
Q

What are the 6 phases of wound healing?

A

Lag or inflammatory phase

Repair phase-
Connective tissue repair
Wound contraction
Epithelilisation

Remodelling phase

73
Q

How long does the lag/inflammatory phase last and what happens?

A

Lasts 1-5 days

Immediate response to injury is haemostasis

Neutrophils- attracted to wound by chemotaxis- degrade necrotic tissue and control infection by destroying bacteria

Monocytes enter differentiate into macrophages- remove degenerate neutrophils, necrotic tissue and debris by phagocytosis and secrete growth factors

Heat, pain, redness and swelling

74
Q

How long does the repair phase last and what are the three overlapping parts?

A

Lasts 6-16 days

Connective Tissue Repair

Wound contraction

Epithelialisation

75
Q

What happens during the connective tissue repair phase?

A
  • Mesenchymal cells in the wound edges differentiate into fibroblasts
  • Inflammatory cells remove necrotis tissue and debris
  • New fibroblasts move into wound and create collagenous ECM
  • Angiogenesis (capillary ingrowth)
  • 7-14d after injury the collagen stabilises- fibroblasts undergo apoptosis and some new capillaries
  • Results in granulation tissue- scar
76
Q

What happens during the wound contraction of the repair phase?

A
  • Begins 5-9 days post injury
  • Exact mechanism unclear
  • Specialised myofibroblasts containing actin-containing microfilaments appear to proliferate
  • Attach to wound matrix and each other and contract
  • Contraction continues till wound edges meet or equal tension or rest of skin
77
Q

What happens during epitheliazation phase of repair phase?

A
  • Partial thickness wounds occurs straight away
  • Full thickness requires adequate granulation tissue so 4-5 days late
  • Epithelial cells from wound edges and any remaining hair follicles migrate across the wound until they form a monolayer
  • Proliferation begins 1-2 days later
  • Epithelial layer becomes firmly attached to underlying dermis and stratifies
78
Q

What happens during the remodelling phase and when does it occur?

A

Starts 14-16 days post-wounding and lasts 2 weeks to months

  • Collagen content and strength of wound increase rapidly first 14-16 days then remodelling begins
  • Cellular content of granulation tissue reduces and the collagen bundle reorganizes by thickening, cross linking and reorientating along the lines of tension
  • Scar will never be as strong as original tissue- 20% in first 3 weeks, reach 70-80%
79
Q

What local factors affect wound healing?

A

Wound perfusion- dividing cells within the healing wound require O2, shock/hypotension/arterial occlusion due to pain slow the healing

Tissue viability- devitialised/necrotic tissue prolong inflammatory phase and delay

Wound fluid accumulation- haematomas or seromas slow healing by physically seperating the tissues and put pressure reducing perfusion

Infection- prolongs inflammatory phase, reduces chemotaxis, increases tissue damage

Mechanical factors- tension, motion and pressure

80
Q

What happens in skeletal muscle is sarcolemma is grossly disrupted or significant muscle mass lost?

A

Repair occurs by fibrous union between the ends of the muscle strands

81
Q

What systemic factors affect wound healing?

A

Immunosupression

Neoplasia

82
Q

What is required for successfull healing of intestinal wounds?

A

Avoiding infection, preservation of blood supply and avoiding tension are critical to healing

Collagenase activity in the wound causes a reduction in wound strength

83
Q

What happens when a nerve is severed?

A

The severed ends retract
Cell body swells
Nucleus becomes eccentrically-placed and distal portion of axon undergoes wallerian degeneration

Within 48 hours sprouts from proximal axon attempt to grow down the distal endoneural tube- can be blocked so may split to supply 2 endoneural tubes

84
Q

What differs about epithelium, endothelium and mesothelium wound regeneration?

A

Similar mechanisms- rate of healing differs

85
Q

What is special about liver regeneration?

A

Can regenerate 70-80% of volume in 6 weeks by proliferation and hypertrophy

86
Q

What is the 6-8 hour golden period?

A

Wounds can be closed with minimal intervention because bacteria introduced would take 6 hours to adhere to tissues

Now considered less important- many factors affect the speed (number, tissue, trauma)

87
Q

What are the 2 main ways wounds are categorised?

A

Degree of contamination- based on number of bacteria present in the wound

Aeitiology- cause of a wound determined the likely amount of tissue trauma and contamination

88
Q

What are the different classes of degree of contamination?

A

Clean- elective surgical wounds not entering the respiratory, urogenital or GI tract with no breaks in asepsis

Clean-contaminated- surgical wounds involving resp, urogenital, gastrointestinal without minor significant contamination

Contaminated- fresh traumatic wounds less then 4-6 hours old, surgical wounds of resp, uro, GI with significant contamination, surgery with inflammation, major break in asepsis

Dirty- traumatic wounds oler then 4-6 hours, contaminated with foreign material, perforation of a hollow viscus, surgery in presence of abscessation

89
Q

What are the 7 classes of aetiology classed wounds?

A

Abrasion- partial thickness wound with loss of epidermis and part of dermis

Avulsion- tearing of tissue from its attachments

Degloving- low-velocity avulsion of skin due to rotational forces

Incision- sharp trauma resulting in a smooth-edged wound with minimal tissue trauma

Laceration- sharp trauma resulting in an irregular wound with tearing of tissue and trauma of underlying tissue

Puncture wound- penetratoin of sharp object, often minimal superficial damage with substantial damage to deeper structures, can carry risk to organ systems

Burns

90
Q

What is the basic treatment plan of wounds?

A

Convert a wound into a clean or clean-contaminated wound if possible and then close

If this cannot be achieved the wound is managed as an open wound

91
Q

How should the wound be prepared?

A
  • Take swabs for bacteriology before cleaning the wound
  • Prevent further contamination by covering with sterile, water soluble ointment or swabs soaked in saline
  • Clip a large area around the wound- start at edges and work away
  • Prepare skin around the wound with surgical scrub- do not allow contact to wound
92
Q

What is hydrodynamic debridment often called and how is it done?

A

Lavage

Aims

  • Decrease bacteria​
  • Remove debris
  • Prevent further contamination
  • Prevent transformation of acute clean or contaminated wounds into infected
  • Convert contaminated or clean-contaminated wounds to suitable for primary closure
  • In grossly contaminated wounds, copious lavage with tap water
  • Otherwise perform pressure irrigation with large volumes of isotonic solution- 8psi optimum
  • Antiseptics can be added to final not detergents
93
Q
A
94
Q

What does hydromechanical debridment use and what does it do?

A

Amorphus hydrogel dressings- intrasite gel

Promotes hydration
Autolysis of necrotic tissue
Absorb sloughing tissue
Promote a moist wound site
Prevent eschar formation
Bacteriostatic

95
Q

What should be done for hydromechanical debridment for wounds containing necrotic tissue?

What sould be done for wounds with lots of exudate?

A

Cover the hydrogel with a non-adherent semi-occlusive primary dressing layer or an adherent primary layer

This will absorb the hydrogel and act similar to a wet-dry dretting

Lots of exudate:

Cover with hydrocellular foam dressing that will not absorb gel, remove the gel when changing the dressing with lavage, change 1-3 days depending on exudate amount, infected change daily

96
Q

When is surgical debridment used?

A

Wounds with extensive tissue trauma or large amount of debris

97
Q

How is surgical debridment done?

A

Evaluate viability of tissues based on colour, puls and bleeding
If it can’t due to oedema wait 48-72 hours
Remove all devitalised tissues and foreign material
Preserve muscles, tendons, nerves and blood
Lavage again

98
Q

What are the treatment plans for the following after debridment:

  • Clean/clean contamination
  • Contaminated
  • Contaminated to dirty
  • Unsuitable for closure
A
  • Clean/clean contaminates- primary closure- immediate suture closure without tension
  • Contaminated- delayed primary closure- closure 1-5 days after wounding, before granulation bed formation, lavage wile open
  • Contaminated to dirty- secondary closure- closure >5 days after injury, exise wound, granulation tissue margin and epitheliliased edges then close
  • Wounds unsuitable- second intention healing- no closure- healing by granulation, epithelialisation and contraction
99
Q

What is the primary larer of open wound managment?

A

Determinds the dressing’s functin- should be in contact with wound surface to prevent tissue maceration

100
Q

What are the types of primary laters and when are they indicated?

A

Adherent dressings- Adhere to wound because fibrinous material, granulation tissue or proteinaceous exudate penetrates and dries
Slow healing by removing surface cells and growth factors, often painful removal and can cause tissue maceration

Non-adherent dressings- indicated for most wounds

101
Q

What factors determind the type of non-adherent dressing to use?

A
  • What you want the dressing to do- a hydrogel for debriding necrotic tissue, no gel if you want to speed up granulation tissue formation
  • How much exudate the wound is producing- non-adherent allow drainage to intermediate layer but retain sufficicent moisture to prevent desication
  • Is the wound infected- change the dressing at least once a day as bacteria will multiply in moisture layer, remove and lavage
102
Q

Name 9 non-adherent dressings

A
  • Calcium alginate
  • Fenestrated polyester film dressings
  • Hydrocellular foam dressings
  • Hydrocolloid dressings
  • Polyethylene/polyurethane film dressings
  • Petrolatum-impregnated gause
  • Hyperosmolar agents
  • Maggots
  • Silver dressings
103
Q

What do caclium alginate dressings do?

A

Absorb exudate and water on contact with wound surface forming non-adherent gel.

Extremely absorbent, can be left for upto 7 days on non-infected wounds.

Enhance autolytic debridment

Indicated for full or partial thickness wounds at any stage of healing with moderate to heavy exudation

104
Q

What do fenestrated polyester film dressings do?

A

e.g melolin, telfa pads, release pads

Polyester film stops dressing adhering to tissues

Mainly used for protecting wounds with an intact epithelial surface e.g surgical wounds closed primarily

105
Q

What do hydrocellular foam dressings do?

A

e.g ellevyn

These are extremely absorbent but do not transmit liquids to the secondary layer

Widely used and available in a variety of forms

Especially good on ulcers

106
Q

What do hydrocolloid dressings do?

A

e.g Granuflex, tegasorb

Composed mainly of cellulose that absorbs moisture and exudate, becomes a gel, creates a barrier to bacteria

Promotes autolytic debridment

Can handle a wide ranfe of exudate volumes

107
Q

What do polyethene/polyurethane film dressings do?

A

e.g opsite flexigrid, tegaderm

Non-absorbent but some pass water vapour into secondary layer

Typically left on longer than more absorbent or permeable dressings

Indicated for protection of wounds with an intact epitithelial surface (sutured, cathether)

108
Q

What do petrolatum-impregnated gauze dressings do?

A

May slow epithelialisation so contraindicated for wounds in the later stages of repair

Non-absorbent and hydrophobic due to petrolatum gel

Mainly used for protecting wounds with an intact surface but fragile epidermis

109
Q

What do hyperosmolar agent dressings do?

A

Commercial manuka honey dressings and home-made sugar dressings are hyperosmolar and dehydrate bacteria, impairing their growth

Honey may contain inhibitory substances like hydrogen peroxide and inhibins and its low pH reduces bacterial growth

110
Q

What do maggots do in dressings?

A

Larvae of Lucilia sericata are sometimes used for wound debridment

Gettinf the containment dressing to stay in place can be difficult

Preventing patient interference can also be hard

May become more useful as antibacterial resitance increases

111
Q
A
112
Q

What do silver dressings do?

A

Release bactericidal silver ions into the wound

113
Q

What is the purpose of the secondary layer in open wound managment?

A

Draws away and absorbs excess fluid, keepinf the primary layer in contact with the wound

Obliterates dead space by providing pressure and protects the wound by padding, supporting and immobilizing it.

Splints may be included in this layer

Types include: cast padding, absorbent pads, cotton wool

If the intermediate layer is not thick enough it may become saturated and need replacing.

114
Q

What is the purpose of the tertiary layer in open wound managment?

A

Secures the rest of the dressing, provides some pressure and supports and keeps the other layers clean.

If dressing is too lose it may slip and cause maceration if the primary layer loses contact with the wound, if too tight may compromise circulation

115
Q

How is too greater pressure avoided from the teritary outer later?

A

Use a thick enough secondary layer

Even distribution of tension

Estimating pressure with a finger placed underneath the bandage

Monitoring the patient after the bandage has been applied

Year 3 MOD (42 decks)

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