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CPS > Surgery 2 > Flashcards

Surgery 2 Flashcards

1
Q

Where should sutures be placed when closing intestinal surgery sites and why?

A
  • Submucosal layer
  • Will not tear
  • Over time, other layers will close and restore near to normal bowel function
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2
Q

What suture patterns can be used for the closure of GIT or bladder surgery?

A
  • Continuous

- Interrupted

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3
Q

What suture material should be used in the luminal side of the GIT and why?

A
  • Monofilament
  • Reduce drag on tissue
  • Absorbable
  • e.g. PDS (polydiaxonone)
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4
Q

How many layers should be included in the closure of GIT or bladder surgery?

A
  • Can be single or 2 layer closure

- Layers tend to divide selves into mucosal +submucosal layer and muscular+serosal layer

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5
Q

Describe the closure of the small intestine following biopsy (suture pattern, thickness, suture material, additional steps)

A
  • Continuous inverting pattern e.g. Cushing pattern
  • Bring serosal layers together on both sides to form air and water tight seal
  • Commonly full thickness suture
  • Absorbable monofilament
  • Omentalise the site by draping omentum over the top
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6
Q

What is the purpose of omentalising a surgery site?

A
  • Keeps contamination in local area
  • Supplies blood
  • Supplies lymphatic drainage
  • Seals off site and aids healing
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7
Q

Describe enterectomy closure (technique, suture pattern, additional steps)

A
  • End to end anastomoses
  • Multiple interrupted sutures or continuous pattern
  • Drape omentalise (may or may not need to secure omentum)
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8
Q

Why are synthetic monofilament suture materials commonly used in GIT surgery?

A
  • Synthetics have less risk of reaction

- Monofilaments reduce bacteria wicking

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9
Q

Name the suture materials commonly used in GIT closure and the sizes used

A
  • Polydioxanone (PDS)
  • Polyglyconate (Maxon)
  • Glycomer 631 (Biosyn)
  • Polyglecaprone 25 (monocryl)
  • 3/0 or 4/0
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10
Q

What needles are used for GIT surgery?

A
  • Atruamatic round bodied needle
  • Or tapercut point needle
  • Ideally swaged on material as eyes are traumatic
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11
Q

How can you check for leaks in the bowel following closure?

A
  • Syringe with saline on 23G needle
  • Insert into lumen, use finger to prevent saline moving past site
  • Observe for leaks
  • However leaks are common and will contaminate the surgical site, so forcing leakage is not recommended
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12
Q

What is serosal patching?

A
  • Used instead of omental draping where no omentum is available
  • Use neighbouring intestine to act as patch
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13
Q

Describe cystotomy closure (thickness, suture pattern, suture material, additional steps)

A
  • Full thickness, generally single layer, simple continuous or interrupted can be used
  • Classically use 2 layer closure in very inflamed bladder
  • Absorbable sutures
  • PDS, monocryl, vicryl, 3-0 to 5-0, swaged on taper-point needle
  • Omentalise
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14
Q

What suture pattern may be used if concerned about leakage in a thin walled bladder?

A

Single layer continuous appositional closure +/- second layer of inverting suture

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15
Q

What are some key considerations when closing a cystotomy?

A
  • Non-absorbable material leads to nidus formation (foreign point where crystals aggregate)
  • Is weak tissue *but regains ~100% strength within 14-21 days)
  • More rapid loss of suture strength in contact with urine, especially infected urine (PDS best)
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16
Q

Outline the key steps to take before abdominal closure

A
  • Check integrity of repair
  • Check for bleeding
  • Lavage and suction if required
  • Count swabs
  • Change gloves and instruments (contaminated by bowel and would cause skin infection)
  • Plan reconstructino of the original anatomy
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17
Q

What layer is critical in abdominal closure?

A
  • External rectus sheath

- Easier to locate cranial to the umbilicus vs caudally

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18
Q

Describe the closure of the linea alba (suture pattern, tension, suture material, additional)

A
  • Continuous suture patterns preferable
  • 6 throws at each end
  • Absorbable monofilament e.g. PDS, 3-3.5 metric max (dogs)
  • Long acting as takes time to regain strength
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19
Q

Why are continuous suture patterns preferable in the closure of the linea alba?

A
  • Even distribution of tension along the length of the closure
  • More rapid closure
  • Less suture material = less foreign body material and so less change of reaction
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20
Q

Describe the closure of the abdominal wall subcutaneous layer (suture pattern, material, additional considerations)

A
  • Simple continuous
  • PDS or monocryl
  • Need to eliminate dead space, use tacking sutures if necessary
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21
Q

Outline the closure of the abdominal wall intradermal layer (suture pattern and material)

A
  • Simple continuous

- PDS or monocryl

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22
Q

Outline the closure of the abdominal skin (pattern, material, additional considerations)

A
  • Interrupted or continuous pattern
  • Non-absorbable
  • Usually nylon
  • Do not pull sutures too tight as need to allow for some swelling
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23
Q

What are the layers that must be closed in abdominal wall closure?

A
  • External rectus sheath
  • Linea alba
  • Subcutaneous layer
  • Intradermal layer
  • Skin
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24
Q

What is ileus?

A

Lack of movement in the bowel

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25
Q

How can ileus be prevented?

A
  • Feed after surgery
  • Starving leads to villous atrophy, ulcerations, breakdown in gut barrier
  • Oral route best but other routes may be needed
  • Early enteral nutrition is indicated in most circumstances
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26
Q

Describe post-operative care for intestinal/urinary/abdominal surgery

A
  • Early enteral nutrition
  • Cover wound before leaving theatre
  • Analgesia
  • Antibiotics when required (contaminated surgery)
  • Check wound every 24 hours
  • Verbal and written discharge instructions for the owner
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27
Q

What are the clinical signs of wound infection/peritonitis/uroabdomen?

A
  • Vomiting
  • Pyrexia
  • Dull
  • Lethargic
  • Inappetant
  • Pendulus abdomen
  • Palor
  • In shock
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28
Q

How can you differentiate between wound infection, peritonitis and uroabdomen?

A

Paracentesis to look at fluids and identify process and therefore treatment required

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29
Q

What management may be required following post-operative complications in intestinal, urinary or abdominal surgery?

A
  • May require revision surgery
  • Copious lavage and drainage
  • Peritoneal drainage
  • Proactive especially if suspect peritonitis
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30
Q

What is the purpose of patient prep before surgery?

A

Reduce contamination of surgical wounds

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31
Q

Outline patient prep

A
  • Clipping, scrubbing, draping
  • Prep should be carried out in separate room as clipping and scrubbing generate environmental contamination
  • Final prep in theatre and should not be clipped once there
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32
Q

Describe the key points regarding scrubs

A
  • Are clean but not sterile, reduce shedding of skin debris
  • Shirt tucked into trousers
  • Do not wear outside theatre (cover)
  • Do not wear for examining cases, visiting wards, changing bandages etc
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33
Q

Describe the key points regarding surgery sews

A
  • Prevent gross floor contamination
  • E.g. Clogs, sandals or overshoes
  • Ensure shoes are clean
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34
Q

Describe the key points regarding surgical hats

A
  • Reduce bacteria shedding from hair
  • Should always be worn in theatre
  • Ideally disposable
  • Hoods better than hats
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35
Q

Describe the key points regarding surgical masks

A
  • Protect wound from saliva and microorganisms
  • More bacteria expelled when talking
  • Are not 100% effective , nearer to 80% for up to 8 hours
  • Do not tie by crossing over head
  • Do not wear untied
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36
Q

What is the purpose of surgical hand scrubbing?

A

Kills transient bacteria and produces prolonged depressant effect on resident bacteria

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37
Q

Describe the traditional scrub protocol (SHS)

A
  • Pre-wash hands to remove gross debris
  • Rinse with scrub solution
  • Pay attention to nails, thumbs and ulnar surfaces
  • Ensure all surfaces of hands and forearms are exposed to scrub for at least 2 mins
  • Always keep hands above elbows
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38
Q

Describe the surgical hand rub

A
  • Sterilium
  • Kills >99.9% of pathogens within 15 seconds
  • Kills bacteria, yeasts, TB, mycobacteria, viruses (including HIV)
  • Non-irritating/moisturinsing
  • Must wash hands and clean nails before, must not have organic debris on hands
  • Apply to dry hands
  • Rub fo 1.5 mins
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39
Q

Compare the SHR and SHS

A
  • SHR = surgical hand rub (sterilium)
  • SHS = surgical hand scrub (chlorhexidine or PI)
  • SHR and SHS have similar efficacy
  • SHR has more lasting effect
  • SHR is cost and time saving
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40
Q

Describe the towel drying protocol following the hand scrub

A
  • Open towel and keep at arms length
  • Consider towel in quarters
  • Dry hands in top quadrants then dry arms on lower quadrants
  • Ensure do not go back to hands after arms
  • Ensure wipe down arms and do not go back up
  • Prevent towel touching front of scrubs
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41
Q

What are the 2 basic types of gowns and drapes?

A
  • Reusable woven fabrics

- Disposable non-woven fabrics

42
Q

Describe the reusable woven fabric gowns/drapes

A
  • Ineffective when wet
  • Tighter weave = more effective barrier
  • 30-50% culture positive at the end of surgery
  • Prone to bacterial penetration at seams and cuffs so require careful inspection at each laundering for organic material
  • Lint production
43
Q

Describe disposable non-woven drapes/gowns

A
  • Polyesters, wood pulp, synthetic polymers etc
  • Randomly orientated fibres prevent penetration of fluid and bacteria
  • Lower numbers of positive cultures at end of surgery and lower particle counts vs woven fabrics
  • More expensive
44
Q

Describe the key points regarding surgical gloves

A
  • Are not an absolute barrier
  • Commonly get hole (more common in orthopaedic surgery)
  • Change gloves as soon as notice rip
  • Closed gloving better
45
Q

Explain what is meant by the sterile field in surgery

A
  • Surgical site, instrument trolley and surgeon
  • On surgeon, is chest to level of the surgical field, sleeves from cuff to 5cm above elbow
  • Nothing below height of table/instrument trolley is considered sterile
  • Cannot lean over surgical field if are not sterile
46
Q

What are potential sources of contamination in theatre?

A
  • The patient
  • The surgical team
  • Equipment
  • Operating room environment
  • Talking
  • Moving in and out
47
Q

What are the ideal characteristics of an antiseptic agent?

A
  • Rapid action
  • persistent effect
  • Residual action
  • Active in organic matter
  • Non-irritant/toxic
  • Easy to use, cost effective and economical
  • Bacteriocidal broad spectrum activity
48
Q

What are the common antiseptic agents used in surgical prep. solutions?

A
  • Povidone iodine
  • Chlorhexidine gluconate
  • ## Alcohol tinctures
49
Q

What is the mechanism of action of povidone iodine?

A

Damages cell wall and inhibits protein synthesis

50
Q

What is an iodophor?

A

Iodine complexed with a high molecular weight carrier to reduce staining and local tissue toxicity, is the active form that acts as the disinfectant agent in povidone iodine solutions

51
Q

Explain the effect of dilution on bacteriocidal activity of povidone iodine

A
  • Greater dilution leads to paradoxical increase in bacteriocidal activity
  • Is due to increase in free iodine
52
Q

Describe the activity of povidone iodine

A
  • Rapid action
  • Bacteriocidal, broad spectrum
  • Active against fungi, most viruses, protozoa, yeasts, mycobacteria
  • Poor against spores unless prolonged contact (15mins-2hours)
  • Effective at reducing bacteria for 1 hour, some persistent activity for 4-6 hour, minimal residual activity
  • Activity decrease in organic material
53
Q

Describe the effects of povidone iodine solutions on the patient and staff

A
  • High incidence of skin reactions (up to 50%)
  • Acute contact dermatitis
  • Sensitivity in people
  • Systemic toxicity if used on open wounds, mucus membranes and peritoneal surfaces
54
Q

What is the mechanisms of action of chlorhexidine gluconate?

A

Bisbiguanide compound that alters cell wall permeability and causes protein precipitation

55
Q

Describe the activity of chlorhexidine gluconate

A
  • Rapid action
  • Bactericidal, broad spectrum (better for Gram +ve than -ve)
  • Effective against some resistant bacteria incl, MRSA
  • Good against most yeasts
  • Variable against fungi and some viruses
  • Minimal effect against spores
  • No effect against Mycobacteria
  • Active in organic matter
  • Excellent persistent and residual activity (binds to stratum corneum so repeated applications have cumulative effect)
56
Q

Describe the effects of chlorhexdine gluconate on the patient

A
  • No staining issues as seen with povidone
  • Skin reactions uncommon (sporadic with prolonged use e.g. photosensitivyt, contact dermatitis, hypersensitivity)
  • Minimal skin absorption so ok for neonates
  • Ototoxic, cannot be used in middle or inner ear (deafness)
  • Neurotoxic: cannot be used on brain or meninges
  • Concentrations >0.05% are toxic to cornea and conjunctiva
57
Q

What is the role of alcohol tinctures in surgical prep?

A
  • Part of 2 step procedure

- Increases effictiveness of chlorhexidine and iodophores (povidone)

58
Q

Describe the activity of alcohol tinctures

A
  • Broad spectrum bactericidal
  • Good activity against bacteria and fungi, variable for viruses, poor against spores
  • Rapid kill, max activity requires 2 mins contact
  • Best is 60-70% concentration
  • Efficacy decreased in presence of organic matter
59
Q

Describe the effect of alcohol tinctures on the patient

A
  • Relatively non-toxic except in newborns
  • Avoid open wounds
  • Skin drying and degree of hypothermia via evaporation
  • Risk of explosion/fire with electrocautory
60
Q

What surgical prep solutions have the highest and most rapid kill rates of bacteria?

A

Alcohol tinctures

61
Q

Outline why chlorhexidine may be superior to povidone iodine

A
  • Broader spectrum of antimicrobial activity
  • Longer persistent and residual activity
  • Minimal loss of activity in organic matter
  • Fewer skin reactions and toxicity
62
Q

Describe the surgical preparation of eyes

A
  • Povidone iodine
  • Gently flush 1:10 dilution around eyelids
  • 1:50 dilution on ocular surfaces and conjunctival sav
  • Remove residual solution with sterile saline or Hartmann’s
63
Q

Describe the surgical preparation of ears

A
  • Pinna and surrounding skin can be prepared routinely

- Ear canal use 1: dilution of povidone iodine to flush, no alcohol

64
Q

Describe the surgical preparation of open wounds

A
  • All antiseptics cause tissue damage in open wound
  • Use chlorhexidine at 0.05%
  • Pack wound with sterile KY jelly while clipping to prevent contamination of wound with hair
  • Clip routinely
  • Lavage copiously with several litres sterile warm Hartmann’s or saline
  • Pack with moist swabs into site while rest of area is prepared
65
Q

Define asepsis

A

Absence of pathogenic microbes or infection in living tissue

66
Q

Define disinfection

A

Destruction of pathogenic microbes e.g. use of germicidal substances on inanimate objects

67
Q

Define sterilisation

A

Desctruction of all microorganisms on inanimate objects

68
Q

Why is hair removal important in preparation of surgical sites?

A

Hair is a gross contaminant and significant reservoir for microbes and organic debris

69
Q

Describe the surgical site preparation in theatre

A
  • Patient positioned on operating table
  • Final stage of prep should always be “no-touch” technique with alcholic tincture
  • Allow alcohol solutions to dry completely
  • Wipe up any pools of fluid
  • If contaminated at any stage, start again
  • Do not extend clip in theatre
70
Q

Outline the different hair removal techniques for surgery prep

A
  • Clippers: best, must be clean and in good condition, wide clip around proposed surgical incision (10-15cm)
  • Depilatory creams: messy, expensive, irritant, not good on coarse hair, frequent skin reactions but may be good for rabbits
  • Razors should never be used, cause significant grazing and associated with 10x increase in surgical wound infection rate
71
Q

Describe the surgical preparation of legs and paws

A
  • Climb entire limb for orthopaedic procedures (handing limb prep
  • Consider if bones grafts required
  • Paws have lots of bacteria and difficult to deal with nail beds and pads
  • Ideally cover paw with impermeable material e.g. surgical glove
72
Q

Describe surgical skin preparation

A
  • Remove gross dirt, transient microbes, reduce resident microbial count to pathogenic levels with minimal tissue irritation, inhibit rapid growth of microbes
  • Skin is not made sterile, does not penetrate deeper layers of skin
  • “clean prep” using non-sterile supplies
  • Wear gloves, good quality scrubs, no brushes
  • Warm water, avoid wetting patient excessively
  • Gentle pressure, circular motion, from centre outwards, discard until swabs come back clean
  • Contact time important
73
Q

What is the purpose of surgical draping?

A

Prevents bacteria from contaminating the surgical wound and surgeon’s gloves

74
Q

Describe surgical draping

A
  • Must remain securely fastened and provide impermeable barrier when dry and wet
  • Quarter draping is standard
  • Do not move drape once positioned
  • Towel clamps break sterile barrier of drape so used towel clamps are contaminated
  • Never use tissue forceps to attach drapes
75
Q

What are the 3 parts of a needle?

A
  • Point
  • Body
  • Eye
76
Q

What needle radii are most commonly used?

A

3/8 or 1/2

77
Q

Outline the use of straight needles

A
  • Manually handled (curved manipulated with needle holders)

- Classically used for skin closure

78
Q

What are the different needle section shapes called?

A
  • Blunt (circular or elliptic)
  • Sharp (polygonal)
  • Compound (tapercut)
79
Q

Compare standard and reverse cutting needles

A
  • Standard: sharp point is on the top of the needle, on the wound side
  • Reverse: sharp point is on the underside of the needle, away from the wound
80
Q

Compare swaged and eyed needles

A
  • Swaged easier to use and have optimal penetration properties
  • But more expensive
  • Eyed can be fiddly, can blunt over time and lead to increased tissue trauma
81
Q

Describe the composition of needles

A
  • Made from stainless allows
  • Must be sufficiently rigid to resist forces applied but must also be flexible enough to bend before breaking
  • Bending property is called “ductility”
82
Q

Outline the use of taperpoint needles

A
  • Produce less tissue damage as there is little lateral damage
  • May blunt quickly
  • Poor for cartilaginous skin
83
Q

Outline the use of cutting needles

A
  • Good for subcuticular use
  • 3 cutting edges around shaft, wider than main body of needle so end up with a lot of collateral damage
  • Poor for bowel surgery as may lead to leakage
84
Q

Outline the use of tapercut point needles

A
  • Edges are no wider than body of needle so minimise lateral damage
  • But some cutting properties so can go through tough tissue
85
Q

What are the factors must be met when choosing a needle?

A
  • Must be long enough to pass through 2 wound edges in a single movement
  • Diameter must be as small and as near to that of the suture material as possible
  • Curved proportionally to the wound depth
  • Use blunt needles wherever possible, cutting needles only for very resistant tissues
86
Q

List the different properties that can vary between suture materials

A
  • Natural or synthetic
  • Mono or multi filament
  • Absorbable or non-absorbable (within 60 days)
  • Composition
  • Diameter
  • Length
  • Colour
  • Memory
  • Plasticity
  • Elasticity
  • Fluid absorption and capilarity
87
Q

What is plasticity?

A

Can be stretched but will not return to its original shape

88
Q

What is elasticity?

A

Can be stretched and will return back to its original shape

89
Q

What does the suture composition determine?

A
  • Tensile strength
  • Biologic behaviour
  • Handling
90
Q

List the natural suture materials

A
  • Catgut
  • Silk
  • Surgical steel
91
Q

What are the 2 categorisations of suture size?

A
  • USP (United States Pharmacopia)

- Metric

92
Q

Outline USP classification of suture diameter

A
  • Based on tensile strength rather than diameter

- Goes from 11-0 to 7 increasing in tensile stength

93
Q

Outline metric classification of suture diameter

A
  • Based on diameter in mm
  • 1/10mm of diameter suture i.e. 2=0.2mm
  • Ranges from 0.1-10
94
Q

List monofilament suture materials

A
  • Glycomer 631 (biosyn)
  • Polyglecaprone 25 (Monocryl)
  • Polydioxanone (PDS II)
  • Polyclyconate (MAxon)
95
Q

List multifilament suture materials

A

0 Polyglycolic acid (dexon)

  • Lactomer 9.1 (polysorb)
  • Polyglactin 910 (Vicryl)
  • Polygactin 910, irradiated (Vicryl Rapide)
96
Q

Compare the effective time and absorption time of suture materials

A
  • Absorbable means are absorbed within 60 days
  • Absorption time can be significant e.g. for PDS is up to 210 days
  • Effective time is more important than absorption time, as suture loses strength before it is fully absorbed
  • PDS has the longest effective time of 28 days
97
Q

What are the consequences of suture material implantation?

A
  • Foreign body reaction (dependent on absorption characteristics)
  • Is either phagocystosed (higher reaction, natural materials) or hydrolysed (less reaction, synthetic materials)
  • Increased reactivity where more material placed
  • Infection may occur (increased risk with multifilament material)
98
Q

What are the advantages of monofilament materials?

A
  • Smooth surface so less friction
  • Does not support bacterial growth
  • No capillary action
99
Q

What are the disadvantages of monofilament materials?

A
  • Some can have high memory

- Stiff ends can cause irritation if the knot is not buried

100
Q

What are the advantages of multifilament materials?

A
  • Easy to handle, less likely to have memory
  • Soft and pliable
  • Well tolerated by patients
101
Q

What are the disadvantages of multifilament materials?

A
  • Rough surface can cause tissue drag
  • Potential spaces between filaments can act as a nidus for infection
  • Capillary action/wicking

CPS (13 decks)

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