Soft Tissue Surgery Flashcards
Name the 7 Halstead’s Principles 1913?
- Gentle tissue handling
- Haemostasis
- Strict asepsis
- Preservation of blood supply
- No tension on tissues
- Good approximation of tissues
- Obliteration of dead space
Name 8 common abdominal procedures?
- neutering
- cesarean
- exploratory laparotomy
- cystotomy
- splenectomy
- Gastrointestinal surgery
- Hernia repair
- Hepatobilliary surgery
What does ‘otomy’ mean?
Making a hole into something
what does ‘ostomy’ mean?
Making the hole permanent
What does ‘ectomy’ mean?
Removing something
What are the 6 laparotomy approaches?
- ventral midline
- flank
- inguinal
- parapenile
- sublumbar
- paracostal (behind the last costal rib)
what is the difference between laparotomy and celiotomy?
Nothing, they are the same thing.
When would you use an inguinal incision?
Cryptorchid dog
When would you use sublumbar incision?
Large animals
Why would use a parapenile approach?
In the male dog where the penile sheath gets in the way of a ventral midline incision. Underly the sheath and locate the linea alba.
What is a big problem with cotton drapes?
Strike through where the blood comes into contact with the drape and unclipped hair - this is bad contamination.
Which external sheath is the critical layer?
Rectus abdominis
When suturing the abdomen, which layer do we put sutures through?
Linea alba
What two methods do we use to dissect through the linea alba?
Lift and Nick
Push and cut
What does the push and cut cause?
May expose the falciform fat.
Where does the falciform fat sit in the dog?
Cranial to the umbilicus
What do we have to make sure we do with surgical swabs?
Count them in and count them out
What feature makes swabs visible on radiographs?
radiopaque markers.
How should we remove the blood using swabs?
dab, don’t wipe.
Name three steps to examining the abdomen?
- Need good expsure e.g. make sure the incision is long enough.
- use retractors e.g. Bafours and Gosset
- Be methodical, especially with the GIT.
How many points of contact have Balfour retractors?
3
How many points of contact have gosset retractors?
2
Where can the pancreas be found?
Right limb of the pancreas is alongside the duodenum. The left limb is along the greater curvature of the stomach.
What does the duodenal manouvre expose?
The right urogenital structures.
The vena cava and portal systems.
What does the colonic manouvre expose?
The left side of the abdomen.
Which muscle layer is on the outside of the bowel?
Longitudinal with circular inside.
What are the 4 layers of the bowel from the inside out?
- mucosal layer
- Submucosal layer
- Smooth muscle (circle, longitudinal)
- serosa
Which layer of the bowel holds the sutures?
Sub-mucosal layer
What are the 7 rules of GI surgery?
- Incorporate the submucosa into the sutures
- Gentle tissue handling
- maintain a good blood supply
- Prevent tension across the suture line
- avoid spillage of contents - laparotomy swabs
- Lavage and suction
- peri-operative antibiotics - this is a contaminated surgery
What is the bacterial threat from the stomach?
Low bacterial count - acid scald is much more of a problem
What is the bacterial load of the small intestine?
high load
What is the bacterial load of the colon?
Even higher load - higher than the small intestine
What does suture pattern depend on?
Incision location and the reason for surgery.
For luminal structures, why would you use a narrow filament?
Not as much drag.
What is Intussusception?
This is when the oral end of the bowl folds in on the aborral end. Folds like a teloscope.
When does the bowel intussuscept?
When it is disorientated.
What has to happen if the bowel has been intussuscepted for a while?
Remove that part of the bowel.
What kind of clamps are best to use on the bowel?
Use non-crushing clamps therefore fingers are often the best.
What is an enterotomy?
Biopsy taken from the bowel.
What filament should be used for enterotomy?
Mono-filament, absorbable.
What is a beneficial thing to do following enterotomy?
Omentalise the wound e.g. place the omentum around it and protect the wound - blood supply and lymphatic drainage and will heal quicker.
What suture pattern would you use to close an enterotomy?
Simple continuous
Give an example of atruamatic clamps?
Doyen (non-crushing) clamps
How can you keep the omentum in place over the top of the wound site?
Cat tack the omentum in place.
What is PDS?
Polydioxanone
What is Maxon?
Polyglyconate
What is Biosyn?
Glycomer 631
What is Monocryl?
Poligrecaprone 25
What is a good size suture material to use for soft tissue surgery?
3/0 or 4/0
Name 2 reasons why these suture materials are good to use for soft tissue surgery e.g. GIT?
> Good tensile strength 5-7 days
> resist absorption >21 days
What kind of suture would you use to close the lumen?
Simple interrupted 2-3mm apart and 2-3 mm from edge/
Why would you not use an eye needle during bowel surgery?
Because this is traumatic and would cause damage at the site of the eye.
What type of needle would you chose for bowel surgery?
4.30 has sharp-cutting edge.
Use swaged needle.
How do you test that the site is not going to leak?
Inject saline fluid into lumen and hold other end with finger and see if leaks
How tight should the sutures be?
Just so that the sutures are appositional
Name 3 three things that starvation after gastrointestinal surgery will cause?
- villus atrophy
- Ulceration
- Breakdown of the gut barrier
What happens in dogs and cats if we don’t feed them after surgery? More common in dogs and cats than horses.
We see ileus where the bowel stops moving and there is a blockage.
Name three things that the omentum supplies to the wound?
- vascular supply
- fibrosis
- Phagocytosis
What do you do if there is no omentum?
Attach neighbouring piece of intestine to the site.
What is it called when a piece of health bowel is attached to the site of the wound to aid healing?
Serosal patching
Name 3 reasons why you would carry out bladder surgery?
- calculi e.g.bladder stones
- Tumour
- Biopsy
With bladder surgery, why do we need to avoid rough handling?
To avoid oedema
Where do we place a stay suture in the bladder? and why?
In the apex - to secure the bladder and draw it back cranially so that we have good access.
What do we need to avoid incising in the bladder?
THE TRIGONE
How would we normally close the bladder?
Single layer, full thickness, simple continuous or interrupted.
Why do we want to avoid non-absorbable sutures in the bladder?
Site for nidus and urolith formation
Within how many days does the bladder regain 100% strength again?
14-21 days
Which type of suture material is best in the bladder?
PDS
What causes a more rapid breakdown in strenght of sutures holding the bladder?
in contact with urine.
What else can you do to aid bladder healing?
Omentalise!
Is it better to do single layer or two layer closure of the bladder?
Classically, two layer closure
generally, 1 layer closure.
Name 5 things that you should do before closing the abdomen?
- check the integrity of repair (gut and bladder)
- check for bleeding
- count swabs
- lavage and suction
- change gloves? change instruments?
- depends on contamination
Which is the critical layer when closing the bladder?
the External rectus sheath
Where is it easiest to locate the linea alba?
Cranial to the umbilicus
How do you want to close the linea alba?
> even distribution of tension along length of closure
more rapid closure
less bacterial load therefore less suture maaterial
6 throws at each end
Which absorbable monofilament suture material could be used to close the abdomen?
PDS (3-3.5)
Will the linea alba ever regain full strength?
No, will only ever regain about 80% strength.
How many layers are there to closing the abdomen and what are they?
- subcutaneous layer
- intradermal layer
- skin layer
What pattern and suture material should be used for the SC tissues?
Simple continuous pattern, PDS or monocryl
What pattern and suture material should be used for intradermal sutures?
Simple continuous and PDS, or monocryl
What pattern and suture material should be used for skin sutures?
Non-absorbable, maybe nylon?
Use simple continuous or simple interrupted
What do we do to allow some swelling in the sutures?
Don’t pull them too tight.
When are the most bacteria going to enter the wound?
Within the first 12-24 hours. Want to stop the risk of SSI.
Why do we ALWAYS want to cover the wound before leaving theatre?
Because fibrin seal takes several hours to form.
Do we give analgesia post-operatively?
ALWAYS
How often do we check the wound?
Check the wound every 24 hours - inspection and gentle palpation with gloves.
What are 5 signs of uroabdomen or peritonitis?
- Pyrexia
- lethargy
- Needs fluids
- might go into shock
- Looks pale
How could we determine if there is an infection or uroabdomen?
Clinical signs, peritoneal tap, radiology, abdominal ultrasound.
What 3 things might we need to do following complications?
- revision surgery
- copious lavage and drain
- peritoneal drainage
If you suspect peritonitis, what should you not do?
send the dog home - need to act QUICKLY!
