Surgery Lecture 2. September 15

Question 1

Surgical wound. Healing

Answer 1

• primary apposition
• primary wound healing
• defining factors (see later)

Question 2

Defining factors of surgical wound healing

Answer 2

Local:
- tissue perfusion
- dead space
- technical errors
- infection

General:
- kachexia
- hypoalbuminaemia
- inflammation
- immunosupression
- chemo-/radiotherapy

Question 3

Complication of the surgical wound

Answer 3

1. Aseptic (NO BACTERIA, e.g. suture insufficiency, haematoma, seroma)
2. Septic

Question 4

Types of the septic surgical wounds

Answer 4

1. Incisional superficial
2. Incisional deep
3. Organ/cavity

Question 5

Incisional superficial septic surgical wound

Answer 5

Time of onset after surgery: within 30 days
Localisation: only skin or subcutis
Clinical signs:
- superficially purulent
- positive bacteriology
- at least one of the followings: pain, swelling, erythema, warmth

Question 6

Incisional deep surgical septic wound

Answer 6

Time of onset after the surgery: without implants: within 30 days; with implant: within 1 year
Localisation: deeper layers (e.g. fascia, muscle)
Clinical signs:
- deeply purulent
- wound insufficiency of opened abscess
- fever and local pain (except for negative bacteriology)
- deep abscees

Question 7

Organ/cavity septic surgical wound

Answer 7

Time of onset after surgery: without implants: within 30 days, with implant: within 1 year
Localisation: any tissue affected by surgery except for skin, subcutis and muscle
Clinical signs:
- pus accumulation in organ or cavity
- positive bacteriology

Question 8

Clean <-> clean/contaminated <-> contaminated <-> septic

Question 9

“Clean” surgery category of the wound

Question 10

“Clean/contaminated” surgery category of the wound

Question 11

“Contaminated” surgery category of the wound

Question 12

“Septic” surgery category of the wound

Question 13

Perioperative bleeding. Causes

Answer 13

Surgical technical anomaly
- direct iatrogenic trauma,
- invasive tissue dissection
- incomplete ligature

Coagulopathy
- congenital (von Willebrandt, haemophilia A,B)
- acquired (trauma-shock, immuno-mediated thrombocytopenia, DIC, SIRS, splenic torsion, hepatopathy, uremia, etc)

Question 14

Coagulation tests used for prevention of perioperative bleeding

Answer 14

Primary haemostasis: platelet count, bleeding time
Secondary haemostasis: APTT (intrinsic), PTT (extrinsic)

Question 15

Intraoperative surgical haemostasis

Answer 15

Physical compression: swab/gauze, vessel forceps, ligature

Coagulation:
- electrocautery
- gelatine-sponge: Spongostan
- oxidated cellulose mesh: Surgicel
- electronic tissue sealing device
- argon spray
- laser
Etc

Question 16

Basic instrument set

Answer 16

• drape
• towel clamps
• sharp instruments (scalpel, scissors)
• needle holders
• tissue forceps, vessel forceps
• sponges, laparotomy pads

Question 17

Answer 17

Scissors

Question 18

Answer 18

Needle holders

Question 19

Answer 19

Tissue forceps

Question 20

Answer 20

Vessel forceps

Question 21

Answer 21

Towel clamps

Question 22

Answer 22

Towel clamps

Question 23

Answer 23

Towel clamps

Question 24

Answer 24

Retractor

Question 25

Answer 25

Curette spoon

Question 26

Answer 26

Suction device

Question 27

Gastrointestinal set

Answer 27

Retractors + bowel clamps + “staplers”

Question 28

Thoracic set

Answer 28

Finochietto retractor + a traumatic instruments + “staplers”

Question 29

Microsurgery set (e.g. vascular, ophthalmologic)

Answer 29

A traumatic “de Bakey” instruments + operating microscope

Question 30

Suture materials. Size

Answer 30

Metric scale: diameter (mm) x 10 USP (US Pharmacopoeia) 14/0 -> 7

Question 31

Suture materials. Structure

Answer 31

- monofilament - multifilament

Question 32

Suture materials. Crucial properties

Answer 32

- material (absorbable <-> nonabsorbable) - structure (monofilament <-> polyfilament) - tensile strength - time of losing the majority of tensile strength - type of absorption - time of complete absorption - knot security - tissue reactivity - drainage property - tolerance against contamination

Question 33

Types of absorbable suture materials

Answer 33

Natural: - catgut (plain, chromic) - collagen Synthetic: - polyglycolic acud (Dexon, Maxon) - polyglactin (Vycryl, Monacryl) - polydioxanone (PDS)

Question 34

Types of nonabsorbable suture materials

Answer 34

Natural: - silk (Mersilk) - cotton Synthetic: - polyamide (Nylon, Supramid, Suturamid, Ethilon) - polyester (Dagrofil, Ethibond, Ti-Cron, Mersilene - polyolefins (polipropilen, polietilen) Stainless steel

Question 35

Types of surgical needles

Answer 35

Question 36

Classification of suture patterns

Answer 36

According to: 1. Knot - interrupted - continuous 2. Tissue layer - skin, intracutaneous, subcutaneous, fascial, abdominal, intestinal, etc - appositional/ inverting/ tension sutures - penetrating (Albert)/ seromucular (Lembert) 3. Other categories:] - tension sutures - plastic sutures (intracutaneous) - “crushing”/ “non-crushing”

Question 37

Simple interrupted suture

Answer 37

- skin - fascia - GI tract

Question 38

Cruciate (X-) suture

Answer 38

Skin

Question 39

Interlocking continuous suture

Answer 39

- skin - diaphragm

Question 40

Lembert suture (seromuscular)

Question 41

What are appositional sutures