Surgical Principles

Question 1

Halsted’s Principles

Answer 1

Strict aseptic technique
Meticulous hemostasis
Preservation of blood supply
Gentle tissue handling
Minimal tissue tension
Accurate tissue apposition
Obliteration of dead space

Question 2

Causes of Surgical Hemorrhage

Answer 2

Iatrogenic/technical

Genetic (von willebrand)

Acquired: trauma, hemodilution, academia, hypothermia

Question 3

Preventive Hemostasis techniques

Answer 3

Good surgical planning and knowledge of related anatomy
Ligation or coagulation of vessels prior to transecting
Accurate dissection and knowledge of local vessels
“Don’t cut vessels with names”

Question 4

Delayed Hemorrhage is primarily due to…

Answer 4

**Incomplete treatment of primary hemorrhage

Happens significantly post-op ~24 hours or more
Poor ligation technique
Intra-op hypotension
Dysphoric recovery

Question 5

Steps of Controlling Hemorrhage

Answer 5

Direct pressure
Hemostat
Ligation
Electrocautery/energy sealing devices
Hemostatic material, “Gelfoam”

Question 6

Direct pressure to control hemorrhage

Answer 6

Use finger first
Allows time for assessing the situation and planning more permanent hemostasis
May be used in combination with sponge
30s for platelet aggregation
2-3min for fibrin clot
Blot, DO NOT WIPE

Hemostats
Crush tissue at point of application
Damage vessel wall & activate clotting cascade
Small, low-pressure vessels = definitive
Large vessels = temporary
Types of hemostats
Use smallest forceps possible
Curved hemostats preferred (visibility)

Question 7

On small superficial vessels that are hemorrhaging, hemostats should be applied…

Answer 7

Tip toward vessel
Concave surface down

Grasp with tip to decrease surrounding tissue damage

Question 8

On large vasculature (pedicles or larger single vessels) that are hemorrhaging, hemostats should be applied…

Answer 8

Perpendicular to vessel
Concave surface toward line of transection
“Tips up”
Grasp with jaw for increased security

Should then be ligated using the smallest suture with adequate strength

Question 9

Larger Isolated Vessels should be _______ _________ (especially arteries) before transection

Answer 9

Double ligated

Question 10

Estimating Hemorrhage volumes

Answer 10

4x4 fully saturated= 5ml

Lap sponge entire surface covered = 75ml

Lap sponge soaked and dripping= 100ml

“Puppy pad” fully soaked= 500ml

Question 11

Blood loss and appropriate response

Answer 11

90ml/kg total blood volume

20% loss, respond with crystalloids
40% loss, respond with colloids
> 50% loss, fatal