Surgical technique Flashcards
Scenarios that result in secondary intention wound healing
Extensive loss of epithelium
Extensive contamination
Extensive tissue damage
Extensive oedema
Wound reopening
Third intention wound healing
Wound is closed several days after formation
Might be after infection is under control or oedema is reduced
Delayed primary closure
Stages in wound healing and cell types involved
Inflammatory
Plts- immediate
Neuts- 0-1
Macro 1-2s
Proliferative - epithelial- proluferate- closure in 48hrs
Fibroblasts- 2-4 synthesise ECM
Endothelial- 3-5d
Maturation
Modify collagen cross linking
When do abdominal incisions regain their strength
3-4m
Hence why slowly absorbable PDS is used
Ideal theatre designs
Close to surgical wards
ICU
Sterile supplies
A+E
CT
20 degree
Clean filtered air
Suture used in bowel, vascular anastomosis and ligation and abdominal, subcutaneous and closure
Bowel- vicryl as heals quickly
Vascular anastomosis- prolene- monofilament good for running stitches
Ligation- PDS
Abdo- PDS
Subcut- absorbable
Closure- non absorbable
Principals of vascular anastomosis
Prolene - non absorb mono
Evert edges
Principals of duct anastomosis
Invert edges
Mono absorbable - PDS
Performed over a stent- removed later e.g T tube CBD
What size of wound will you require grafting or local flap
1cm^3
Split vs full thickness
Full- better cosmesis
Face
Primary contracture- elastin in dermis
Split- larger
No primary contracture
When is delayed primary closure used
If the wound is dirty
Closure of scalp wound
Staples
What is used for third degree burn on abdo
Split thickness graft
If patient has nose bitten off by dog what reconstruction
Debridement, antibiotics, tetanus and rabies
For upper two-thirds defects, thin skin from the preauricular region or neck works well. For lower third defects, the thick skin of the forehead provides the best match.
What can you do to a split thickenss to make it spread more
Make it mesh
Blue line around mesh, how quickly does it spread
Re- epitheliarization
1mm/day
What is required for a great to stick
If there is granulation tissue forming
Closure after drained of foul/painful smelling sebaceous cyst
Delayed primary closure
Best Ix fro osteomyelitis
MRI
Closure of diabetic foot ulcer
VAC assisted closure- encourage granulation tissue
When is VAC assisted closure CI
Malignancy
Osteomyeltiis
Necrotic tissue with eschar
Risk of fistulation
Closure of wound dehiscence on abdo
Healthy- suture
Wound manager- some granulation tissue where there is a high
output bowel fistula present in the dehisced wound.
Bogota bag- Temporary measure to be adopted when the wound cannot be closed
VAC- ONLY if the correct layer is interposed between the suction device and the bowel.
* Failure to adhere to this absolute rule will almost invariably result in the development of multiple bowel fistulae and create an extremely difficult management problem.
Zadik procedure anaesthesia
1% lignocaine in ring block
For toenail removal
What is used in Piere block and antidote
Pierre block- Prilocaine
Less cardiotoxic
Methylene Blue
What drugs increase lidocaine toxicity
BB
Cipro
Local doses
Agent Dose plain Dose with adrenaline
Lignocaine 3mg/Kg 7mg/Kg
Bupivicane 2mg/Kg 2mg/Kg
Prilocaine 6mg/Kg 9mg/Kg
What is CI with diathermy
Alcohol based skin prep
Use cholrhexidine or iodine
When to give Abx in surgery
If giving prosthetic or implant/valve
Tourniquet - give early
Dirty or clean contaminated
Which electrical device should you use in ERCP sphincterotomy
Monopolar
Modes of electrocautery
Cutting - uses a continuous waveform with a low voltage- giving high power
* Precise cutting without thermal damage
Causes vaporisation
Coagulation - pulsed waveform with a high voltage.
Causes thermal damage
Causes evaporation
Blending- alternating of both
Desiccation - Active electrode in direct contact with tissue
* Low current and high voltage system
* Results in loss of cellular water but no protein damage (unlike coagulation)
used for treating nodules under the skin where minimal damage to the skin surface is desired.
Fulguration- Electrode probe is held away from tissue
* Produces spray effect with local, superficial tissue destruction
* Low amplitude and high voltage system
- superficial skin charring - over a wider area than when operating in contact with the probe, and this technique is therefore used for very superficial or protrusive lesions such as skin tags
What devices are used in brain tumours
Ultrasound based devices
- These include CUSA and Harmonic scalpel.
- They generate high frequency oscillations that seal and coagulate tissues.
Disinfection vs sterilisation
Disinfection- eliminating or reducing harmful microorganisms
Sterilization -killing all microorganisms
Methods of sterilisation
Autoclave- reusable surgical equipment- like metal - air removed pressurised steam at a temperature of 134 degrees for 3 mins
For TB
Endoscopy/laparoscope- 2% glutaraldehyde solution
Ethylene oxide- used in industry - Cannula/sutures
Gamma rays- thermal stable
Plastic syringes, transfusion, needles
Flap vs graft
Graft takes fast
Covers larger area
Requires granulation tissue to take
Flap- used for bone, tendon, or joint
Non graftable
Reconstruction of skin from where tumour of face removed
Unsure on boundaries
<2cm can leave
>2cm- graft
Certain of boundaries- local flap
Level of evidence
1- systemic review, meta analysis
2- randomised controlled trial
3- pseudo randomised or historical controls
4- case reports
5- panel opinion
Chemo has extravasated mx?
When an extravasation reaction is suspected, the infusion should be stopped and the infusing device aspirated. The extremity should be elevated.
As a general rule cold compresses have been shown to reduce the incidence of subsequent ulceration with doxorubicin.
Warm compresses have been found to be beneficial in extravasation of vinca alkaloids. - vincristine
TPN/contrast extravasated mx
Withdraw infusion
Hyaluronidase into infusion site
Suture to close abdo
Polydiocanaone Mono
Suture for skin closure
Poliglecaprone mono (monocryl)
Pre tibial 3-7cm flavour, necrotic and haematoma, bone fine
Debride and split thickness
Simple finger laceration closure
Interrupted 5/0 Ethilon
Removal after 14d
Forehead laceration closure
Interrupted Prolene 5/0
Removal after 4-5d
Sterries in children
Excision of sebaceous cyst or lipoma closure
Interrupted 2/0 Vicryl to fat
3/0 monocryl to skin
Inguinal hernia closure
Prolene 3/0 mesh
vicryl 2/0 fasciae, fat
Monocryl 3/0 skin
Laparoscopic appendectomy/chole closure
PDS all ports >5mm
Mono 3/0 or glue to skin
Silk to drains
Midline lap closure
1 PDS to midline fasciae
2/0 vicryl to fat
3/0 mono to skin
3/0 Vicryl Rapide for new stomas
Pfannestiel closure
1 PDS to rectus
2/0 vicryl to fat
3/0 monocryl to skin
Femoral embolectomy closure
5/0 prolene ot arterotomy
2/0 vricyl to fascia and fat
3/0 monocryl to skin
Use of prolene
Vascular anastomosis
Cardiac surgery
Ethilon use
Skin incision or traumatic wounds
Removed after 4-14d
Steel wire use
Close sternum after median stenotomy
Ethibond use
Prostehtic heart valves
Tendon repair
Ribs
PDS sue
Closing linea alba
Hernia defects
Intestinal or ureteric anastomosis
Monocryl use
Skin closure
Vicryl use
Skin and soft tissue closure
Ligation of vessels
Cutting vs reverse cutting vs round bodied needle
Cutting- sharp on concave edge
For tough tissue such as skin and fascia
Can weaken tissue
Reverse- sharp on convex edge
Used when risk in cutting suture out and causing damage- thin skin, tendon, ligaments, eye
Round taper point- needle point round
Blunt- liver or spleen
Taperpoint- leaky tissue- bowel, vessel, myocardium
What anticoagulant does blood bank store donated blood in
Citrate - binds to Ca preventing coag
Tourniquet types
Single cuff pneumatic- knee arthroscopy
Different pressure
Double cuff- regional block
Non pneumatic- venopuncture
