Surgery - principles Flashcards
Halsted’s principles (8)
Aseptic technique Anatomical/technical knowledge Gentle tissue handling Control haemorrhage Preserve blood supply Accurate tissue apposition Minimise tension Eliminate dead space
Principles of tissue dissection & handling
Dissect along tissue planes Blunt + sharp dissection Lighting, retraction & suction Tension at right angles to dissection plane Keep tissues moist - lavage + sponges
What are the consequences of blood in the operative field?
Obscures structures Irritant to tissues Prevents tissue apposition Delays healing Potentiates infection
Types of haemorrhage
Primary = at the time of Sx Delayed = post-op (e.g. dehiscence)
What are the clinical signs of haemorrhage?
Tachycardia Hypotension Peripheral vasoconstriction/hypoperfusion/cold extremities Weak pulse Pale MM Long CRT Mental depression Delayed recovery from Ax
Methods of haemostasis
Careful surgery/dissection Haemostats Electrocautery Topical haemostatic agents (AgNO3) Vessel sealant devices Tamponade (30s --> 2-3mins) Ligation (3 forceps, transfixing ligatures)
Indications for exploratory laparotomy
GI disorders - FB, rupture, torsion UGT disorders Penetrating trauma Acute abdomen - GDV Peritonitis PSS Splenic disorders - haemangiosarcoma Unknown origin abdo disorders
What equipment is required for ExLap?
General sx kit Balfour self-retaining abdominal retractors Suction Sponges Sample tubes Suture material
What are the 4 approaches for ExLap?
Ventral midline
Paracostal (extension to expose liver)
Flank = OVH, grid gastropexy
Retroperitoneal = adrenals, kidneys
4 layers of the abdominal wall
Transversus abdominus
Rectus abdominus
Internal abdominal oblique
External abdominal oblique
External landmarks for ExLap
Xiphoid process
Pubis
Umbilicus
Internal landmarks for ExLap
Falciform ligament Duodenocolic lig (at caudal duodenal flexure) Mesenteric root Omentum + omental bursa Kidneys BVs - aorta, CdVC, portal v. Ileum w anti-mesenteric vessels
What 4 quadrants are explored in an ExLap?
Cranial/Cr L quadrant
Cranial R quadrant
Caudal L quadrant
Caudal R quadrant
What organs are assessed in the Cranial/Cr L quadrant?
Diaphragm
Liver
Stomach
Gastro-oesophageal sphincter
What organs are assessed in the Cranial R quadrant?
Duodenum Pancreas Portal v. CdVC R kidney/adrenal
What organs are assessed in the Caudal R quadrant?
Urinary bladder/uterus
Uterus + ovaries
Prostate
Open omental bursa to visualise L limb of pancrease
What organs are assessed in the Caudal L quadrant?
Spleen Rectum, colon, caecum --> follow prox to duodenocolic lig Mesenteric root + LNs Ileum Jejunum Duodenum at duodenocolic lig L kidney/adrenal Aorta
What types of samples should be taken during ExLap?
Swabs = C&S
Fluid samples = peritoneal fluid, bile, urine
Tissue Bx
What biopsy technique is used for the liver, pancreas, GIT, & adrenal?
Liver = guillotine or punch Bx Pancreas = guillotine suture Bx GIT = skin punch Bx (full thickness) Adrenal = FNA
Steps involved in closure of the abdominal cavity
Lavage until clear (0.9% NaCl) + no bleeding
Linea alba closure (Cd > Cr) (simple continuous w absorbable monofilament PDS)
SQ closure
Intradermal/skin closure (non-abs monofilament)
Complications of laparotomy
Hypothermia (intra-/post-op) Seroma Dehiscence/evisceration FBs left in abdomen Adhesions Peritonitis Infection Self-trauma (dt tight suture knots) Skin irritation
What type of suture should be used in skin sutures & why?
Monofilament = no wicking of bacteria into wound
Non-absorbable = good knot security
- absorbable may be used but will not be absorbed as no contact w body fluids/enzymes
What type of suture should be used in SQ sutures & why?
Absorbable = cannot remove
