Flashcards in Marius and Stine doc Deck (103):
1
periods of surgery and milestones
1) primeival times until 1846
only removed injured parts
2) 1846 - 1960s
discovered narcosis
removal and reconstruction of injured parts
Milestones
- initiation and application of asepsis and antisepsis, discovery of blood groups
development of intensive therapy
3) 1960s - today
the development of instruments,
natural science research,
and technical development allowing huge modern advances in surgical approaches and interventions
In 1962 the first kidney transplant occured in Szeged
In 1967 the first heart transplant occured in South Africa.
2
When was Ether day and who did what
Dr William Morton
Anesthetized a patient with Ethyl Ether
October 16 1846
3
When and whom invented chlorinated lime hand washing? His findings
Ignaz Semmelweis 1847
It could drastically reduce the rates of peurpural fever after giving birth.
4
Who invented antiseptic theory
Joseph Lister
He used phenol to clean surgical tools.
1867
5
Who introduced the antiseptic theory in hungarian surgery
Ignaz Semmelweis
6
Name 4 surgical instruments refer to doctors in the development of surgery
Kocher clamp
Lumnitzer clamp
Pean clamp
Hegar needle holder
7
What does NOTES mean?
Natural
Orifice
Transluminal
Endoscopic
Surgery
8
Synonyms for NOTES technique
Endoscopic
Transgastric
Transvaginal
Transcolonic
Transvesical
9
List bloodless and bloody procedures
Endoscopy
Laparoscopy
Reducing a broken bone
Organ transplantation
C-section
Appendectomy
10
Definition of surgical intervention
Any diagnostic or therapeutic procedure, when we disrupt the body integrity or reconstruct tissues is a surgical intervention.
Specifically, a procedure performed on a living body with instruments for the repair of damage or restoration of health, especially on involving incision, excision, or suturing.
11
What do the septic and aseptic operating theatres stand for
In septic operating rooms infected body parts are operated.
In aseptic operating rooms, the operation is not on an infected body part, and the danger of bacterial infection does not usually exist
They can share a common corridor
12
How shall the staff and patient enter the operating room?
Before entering the room the staff should change clothes in the locker room and put on the surgical cap and face mask, then enter.
The patients are brought in after passing through a separate locker room.
13
Describe the structure of the operating room.
50-70 m2 without windows
lighted
walls covered with light colored tiles
Artifical ventilation and air conditioning
Must be separate from the wards and ICU, but should be close to the ICU.
Operating room complex consists of
Locker rooms
Scrub in area
Preparing rooms
Operating theatres
No gaps in the walls or floor, and easily cleaned
Automatic doors
Central and portable vacuum system
Pipes for gases
Main layout:
Operating lamp, Operating table, Sonnenburgs table, Supplementary instrument stand, Kick bucket, Suction apparatus
Diathermy
Microwave oven
Anesthesia machine and anesthesia instruments
Waste bin
14
List 8 equipments/instruments in the operating room
Operating lamp,
Operating table, Sonnenburgs table, Supplementary instrument stand,
Kick bucket,
Suction apparatus
Diathermy
Microwave oven
Anesthesia machine and anesthesia instruments
Portable X ray
Waste bin
15
Explain the rules of behaviour in the operating room!
Only those whose presence is necessary should be in the Operating room
Activity causing increased air flow should be avoided (laughter, talking, movements)
Entry into the OR is allowed only in operating room outfit and shoes worn exclusively in the OR, a complete change of clothes is required for all staff and patients coming into the OR.
Leaving the OR in a surgical outfit is forbidden
Door of the OR must remain closed
Movement into the OR out of the holding area/locker room is only allowed in a cap and mask that covers the hair, mouth, and nose.
16
Describe the general rules of the aseptic operating room!
Only sterile instruments can be used for a sterile operation
Sterile personnel can only handle sterile equipment, and sterile equipment can only be handled by sterile personnel
Sterile instruments only stay sterile if handled by a sterile person
Instruments located below the waist are no longer sterile
If a sterile instrument contacts one of doubtful sterility, it is no longer sterile
Edges of boxes and pots are not sterile
A surgical area can never be considered sterile, however the applications of aseptic rules are mandatory
17
Explain the definition of asepsis!
All of the procedures, actions designed to keep microorganisms away from patient’s body and the surgical wound. The purpose of asepsis is to prevent contamination.
In a wider sense, the asepsis means such an ideal state when the instruments, the skin, and the surgical territory do not contain microorganisms.
18
Explain the definition of antisepsis!
Includes all those procedures and techniques designed to eliminate microbial contamination present on objects and skin by means of sterilization and disinfection. The purpose of antisepsis is to eliminate or remove contamination that is present.
Because skin surfaces and so the operating field and the surgeon’s hands can not be considered sterile, in these
cases we can not talk about the superficial sterilization. In a wider sense, antisepsis includes all those prophylactic procedures designed to ensure surgical asepsis.
19
How to prevent the evolution of postoperative wound infections
before the surgery?
Careful scrubbing and preparation of the operation site.
Only wearing sterile clothes in the OR
Knowledge and control of risk factors, normalizing serum glucose for diabetic patients.
Perioperative antibiotic prophylaxis in septic or high risk patients.
20
How to prevent the evolution of postoperative wound infections
during the surgery?
1. Appropriate surgical techniques must be applied
2. Change of gloves and rescrub if necessary.
3. Normal body temperature must be maintained. Narcosis may worsen the thermoregulation.
Hypothermia and general anesthesia both induce vasodilatation, and thus the core temperature
will decrease.
4. The oxygen tension must be maintained at a proper level.
21
How to prevent the evolution of postoperative wound infections
after the surgery?
1. Wound infection generally evolves shortly (within 2 hours) after contamination.
Hand washing
and
the use of sterile gloves while handling wound
dressings and changing bandages during the postoperative period.
22
What is the definition of sterilization!
The removal of viable microorganisms (including latent and resting forms such asspores) which can be achieved by different physical and chemical means and methods.
Important methods that are used frequently:
autoclaves,
gas sterilization by ethylene oxide,
cold
sterilization,
irradiation
plasma sterilization
23
What is the definition of disinfection!
The reduction of the number of viable microorganisms by destroying or inactivating them.
Generally used methods:
low-temperature steam,
chemical disinfectants
phenols,
chloride derivatives,
alcohols,
quaternary ammonium compounds
Iodine solutions
24
Explain the steps of the two-phase surgical hand scrub!
Mechanical cleansing followed by rubbing with disinfectant
Mechanical cleansing:
Wash hands and forearms thoroughly with soap and warm water.
No time limit on this phase, just until we are satisfied.
Wash the soap off completely, there can be no foam on your hands in phase 2.
Use paper towels to dry the hands and forearms completely
Disinfecting phase
Rubdisinfectant hand scrub 5 times for one minute each time.
1st time: all the way to the elbow
2nd: 2/3 of forearm
3rd: 1/2
4th: 1/3
5th: only the hands and wrists.
25
What is the purpose of isolation? How do we do it?
After skin preparation the operating area must be isolated from non-disinfected skin and body parts by covering it with sterile linen or sterile water proof paper drapes.
To prevent contamination from the patients skin
4 pieces:
1) Scrub nurse and assistant use a specially folded sheet to isolate the patients legs
2) Horizontal sheet isolates the head and is fixed to the guard
3) Two horizontal sheets on the sides are then placed
4) The isolated area is always smaller than the scrubbed area
5) Backhaus towel clips fix the isolation sheets to the skin
Schaedel towel clips fix the isolating sheets to eachother.
26
List the basic surgical instrument groups!
Cutting and dissecting instruments
Grasping, clamping, and occluding
Hemostatic
Refracting and exposing
Wound-closing instruments and materials
Special instruments
27
What is the function of the dissecting instruments? List some of these dissecting instruments!
Their function is to cut or dissect the tissue and remove unnecessary tissues during surgery.
Scalpel
Scissors
Hemostats
Dissector
Diathermy knife
Ultrasonic cutting device
CUSA cavitron ultrasonic surgical aspirator
LASER
Amputating knifes, saws raspatories, bone rasps.
28
Explain the use of electric/diathermy knife! What kind of diathermy knifes do you know?
Dissects tissue with help of heat generated by electrical current.
It can also be used to coagulate blood from vessels.
Allows cutting and hemostasis simultaneously.
types:
Monopolar: electric current passing between the diathermy knife and an indifferent electrode placed beneath the back or a limb of the patient.
ex. electrocauter or electrocautery knife.
Bipolar: electric current is passing between two parts of the instrument.
ex. bipolar forceps
29
Is it accepted to use electric knife on patients with pacemaker?
Patients with old pacemakers the electric current may cause arrythmia, so it must be adjusted prior to surgery.
Modern pacemakers do not have this problem.
30
What do you know about the ultrasonic cutting device?
An ultracision uses ultrasound to cut and coagulate tissues
Works similarly to the diathermy but does not cause thermic injury
It makes it possible to have more precise movements during surgery.
31
Name the non-locking grasping instruments! Explain their functions!
Non-locking grasping instruments are the
Thumb Forceps
Forceps are used to hold the tissues during cutting and suturing,
to retract tissues for
exposure,
to grasp vessels for electrocautery,
to pack sponges and gauze strips in the case of
bleeding to soak up the blood,
and to extract foreign bodies.
Can be different sizes
Tips can be Blunt/smooth, sharp/slinter, or ring
Used to hold tissue during cutting and suturing
smooth forceps also called anatomical foceps
toothed forceps also called surgical forceps
Splinter forceps also called opthalmic foceps.
For holding skin and subcutaneous tissue, toothed forceps
For holding sponges, bandages, anatomical foceps
For holding vessels and hollow organs, anatomical forceps
Not suitable for long continuous grasping. Use tissue graspers for this.
32
List organ clamps!
For delicate grasping and holding of organs
Klammer intestinal clamp
Gallbladder clamp
Babcock forceps, also intestine gall bladder, wide flat grasping surface
Allis lung clamp
33
List the hemostatic instruments! Explain their functions!
Act mechanically or thermally to stop bleeding at incision or surgical site
Can clamp a vessel to halt bleeding or clamp a vessel prior to cutting to prevent bleeding
Vascular clamps, Pean, abdominal Pean, mosquito, bulldog, Kocher, Lumnitzer, Satinsky
Electrocautery knife
Ligation needles, Deschamp ligation needle,
Directing probes, Payr probe
Argon beam coagulator
34
List the retracting instruments! Explain their functions!
Retractors are used to hold tissues and organs aside in order to improve the exposure, visibility and accessibility of the surgical field.
Hand held retractors held by an assistant: skin hooks, rakes, visceral and abdominal wall retractors, Roux and Langenbeck retractors
Self retaining retractors
35
What do you know about the CT and MRI examination of patient carrying metallic clips?
In CT: the clip distorts the picture in the area around the clip, it is can be done.
MR: It is impossible to perform MR with met`al clips.
The magnetic field will move them and they can wander in the body.
Non-magnetic clips like titanium, platinum, and absorbable clips can be used with MR.
36
Explain the application area of metallic clips
The michel clips can be used with a michel clip applicator or remover
Used to close a skin wound or any luminal structure
Other uses:
In the wound stapler, for atruamatic and fast wound closure.
In hemostasis to occlude a lumen.
As a marker to be seen on X-ray.
37
What is the Steri-Strip? When to use it?
Made from fibrin, collagen or thrombin,
induces blood coagulation producing a fine fibrin mesh.
Used to induce hemostases on operations in solid organs
To close sites of air leakage in lung surgeries
For wound closure
Disadvantage: Can increase the degree of infection in infected wounds, and lead to abscess formation
38
List special instruments!
Volkmann curette
Instruments for bone surgery
-Mallet
-Chisels
Round ended probe
Payr clamp
Suction set
-with re-sterilisable suction tip
X-raying set
Implants, prosthetics
- metal screws, pins, joint prosthetics
-hernial meshes
-vascular grafts
-silicon implants
39
Describe the conventional (close-eye, French-eyed) needles!
Needs to be threaded
Needle and two arms of thread goes through the tissue and it can cause trauma to the tissue
Disadvantages:
Needs to be threaded
Danger of untying
Re-sterilization
Need to care for the needle tip
Danger of corrosion and untying
40
Describe the atraumatic needles!
Less thickness than conventional needles due to no arms of the thread sticking out.
Causes less tissue trauma
The diameter of the needle-thread combination is less than that of the thread.
Good for vascular surgeries where the thread is larger than the hole made by the needle, preventing leakage.
Advantages: no threading time, no need for resterilization, no need to care for needle tip, and no danger for corrosion or untying.
Disadvantages: the thread can become separated from the needle with strong pulling.
41
What are the main groups of the circular needles?
3 main groups:
Taper-point
Taper-cutting
Blunt taper
The diameter of the needle is smaller than the thread
Taper-point needle. Both the tip and body of the needle are circular. Separates tissue fibers without cutting them.
Used in easily penetrable tissues - peritoneum, abdominal organs, myocardium, subcutaneous tissues.
Taper-cutting needle. 3 cutting edges, that gradually flatten and become obliterated at the body of the needle.
For the sclerotic, scarry, or calcified tissues.
Blunt taper have circular body and a blunt end.
To prevent the danger of accidental needle stick in patients with HIV or hepatitis.
Also for bile and urinary ducts.
Pushes tissue aside and no cutting of their structure is caused.
42
Explain the difference between conventional and reverse cutting needles!
Conventional cutting needles. The edge is facing the internal part of the curving body
Reverse cutting needle, the third edge is facing the external part of the curving body.
43
What are the main characteristics of the surgical suture materials?
Physical:
Caliber
Tensile strength
Elasticity
Capillarity
Structure
Water absorbent capacity
Sterilizability
Application properties:
Flexibility
Capability to slip in tissue
Knotting properties and Knot security
Biological properties:
Absorbent capacity
44
What are the advantages and disadvantages of natural and synthetic suture materials?
Natural materials:
Advantages
-Good handling
-Easy knotting
Disadvantages
-Tissue retraction
-Unpredictable enzymatic absorption
-Contain proteins that can be immunogenic and damaging
-Purchase, screening, controlling
Synthetic materials:
Advantages
-economic
-predictable absorption by hydrolysis
-minimal immune/tissue reaction
-Strength
Disadvantages
-Difficult handling and knotting
Synthetic threads are considered the modern standard.
45
What does the term “thread memory” stand for?
The capacity of the suture thread to return to its former, packaged shape.
46
What are the advantages of monofilament threads?
Smooth surface
less friction
less resistance
no serrating phenomenon
less tissue injury
no spreading of bacteria
no capillarity
no transporting tumor cells.
47
What are the disadvantages of multifilament (twisted or braided) threads?
Stretching
Tissue drag
Serrating
Tissue trauma
Capillarity
Transporting bacteria
Transporting tumor cells
48
Which one is better: monofilament or multifilament thread?
Monofilaments
Smooth surface
less friction
less resistance
no serrating phenomenon
less tissue injury
no spreading of bacteria
no capillarity
no transporting tumor cells.
49
List the advantages and disadvantages of natural suture materials!
Natural materials:
Advantages
-Good handling
-Easy knotting
Disadvantages
-Tissue retraction
-Unpredictable enzymatic absorption
-Contain proteins that can be immunogenic and damaging
-Purchase, screening, controlling
50
List the advantages and disadvantages of synthetic suture materials!
Synthetic materials:
Advantages
-economic
-predictable absorption by hydrolysis
-minimal immune/tissue reaction
-Strength
Disadvantages
-Difficult handling and knotting
51
Describe the enzymatic and hydrolytic absorption processes of suturing materials!
Absorption is enzymatic or by hyrdolysis
Natural materials, enzymatic, inflammatory/immunogenic
Hydrolysis is passive and without participation by cellular elements, synthetic.
Chemical and physical bonds between thread fibers disintegrate and the thread is excreted.
52
What do you know about the size classification of the suturing materials?
The USP, US pharmacopoeia is used to determine diameter of threads
Thinnest 11/0 = 0.01 mm.
10/0 - 0.02mm
9/0 - 0.03
down to 2/0
then 0
then 1,2,3,4,5,6, 7
7 is the thickest = 1.0-1.09 mm
OR, metric units can be used, measured in 0.1 mm increments. This is more acceptable in Europe and Hungary, but still in Hungary the USP is the standard measurement.
53
What do you know about the vertical mattress suture?
It is a 2 row skin suture. aka Donati suture.
A deep suture through the skin and subcutaneous layer, 1.5cm from the incision, through both sides,
then a superficial back stitch placed into the wound edge, 1-2mm. Then knotted on the same side as the first puncture.
The two stitches are in a vertical plane perpendicular to the wound line.
For wide, deep superficial wound closure.
54
Where do we use the simple continuous suture line?
Can be applied to suture tissues without tension.
Wall of internal organs.
Stomach, Intestines, Mucosa.
Knot is only tied at the beginning and the end.
It is fast, but not very strong.
55
What do you know about the simple interrupted suture?
For skin, fascia and muscles.
A knot is tied after each stitch.
Stitches must have equal tension
Advantage: Wound remains closed if one suture breaks.
Disadvantage: Time consuming because of tying all the knots.
56
Where do we use the purse-sting suture?
On the openings of the GI tract.
ex. in appendectomy
Used to close a circular opening.
An atraumatic needle and thread are used, and the wound edges are inverted into the opening, then the threads are pulled and knotted.
57
When it is suggested to remove the stitches? What are the influencing factors?
Usually 3-14 days, and after careful disinfeciton of the wound.
Influencing factors:
-The location of the sutures
face, 3-5 days, skin of head and abdominal wall 7-10 days. Trunk and joints 10-14 days. Hand and arm 10 days. Leg and foot, 8-14 days.
-The tension on the field, and the amount of movement/use of the area
-The blood supply, better circulation heals faster,
-General condition of the patient.
The thread should be cut as close to the skin as possible, so no skin that was outside the skin is pulled through the wound, to avoid infection.
58
What is a wound?
Any circumscribed injury due to an external force. Can involve any tissue or organ.
Can be mild, severe, lethal.
59
What areas are injured in case of a simple wound?
Skin, mucous membranes, subcutaneous tissue, superficial fascia, and partially the muscle.
60
What areas are injured in case of a compound wound?
The tissues of a simple wound, plus some of the following:
muscles,
tendons
vessels
nerves
bones
61
What kind of wounds do you know based on their origin?
Mechanical
-punctured = punctum
-incised = scissum
-cut = caesum
-shot = scopleratium
-torn = lacerum
-bite = morsum
-crushed = contusum
Irradiation
Thermal
Chemical
-acid
-base
-toxin
Surgical
62
List the wounds of mechanical origin!
Mechanical
-punctured
-incised
-cut
-shot
-torn
-crushed
-bite
63
What do you know about the incised wound?
Caused by a sharp object, has sharp edges all the way to the base of the wound and the angles of the wound are narrow.
All surgical wounds are this type.
Has the best healing of all wounds
64
What do you know about the shot wound?
Has an aperture, a slot tunnel, and possibly exit wound.
Close range shot will also cause burn injury at the aperture.
Causes penetration of foreign materials, bullet, fabric, dirt, that may remain in the patient. Opportunity for infection.
Various characteristics depending on what tissue/organ was in the course of the bullet.
65
Classify the wounds according to bacterial contamination
Clean wounds
Clean-contaminated wounds
Contaminated wounds
Dirty wounds, Heavily contaminated.
66
What does the primary wound managements stand for?
Temporary, first aid. Aim is to prevent secondary infection.
-Cleaning of the wound
-Hemostasis
-Covering
Final primary wound management.
Surgical closure can be performed a maximum of 12 hours after the time of injury
-cleaning
-anesthesia
-excision
-suturing.
Primary wound closure is always performed for injuries of the:
Thoracic cavity
Abdominal wall
Dura mater
It is contraindicated when:
-there are signs of inflammation
-strong contamination
-foreign bodies are not removed
-shattered wounds with blind spaces
-bite, shot, and deep punture wounds
-injuries of people with special jobs, surgeons, butchers, veterinarians, pathologists
Because the wound needs to be cleaned 3-8 days after primary wound closure.
67
What does the term „primary delayed suture” stand for?
Clean, wash, and cover, and then if no signs of infection occur within 4–6 days.
Cleaning, anesthesia, excision, suturing.
68
What is the „early secondary wound closure”?
After first management of the wound, the excised wound becomes necrotic/inflamed and starts to proliferate, then there is a need to refresh the wound edges.
2 weeks after the injury:
anesthesia,
excision,
suturing,
and draining.
69
What is the „late secondary wound closure”?
The proliferating parts and scars of the former wound should be excised. With greater defects, plastic
surgery solutions should also be considered.
4–6 weeks after the injury: anesthesia, excision of
the secondarily healing scar, suturing, and draining.
70
What holding positions of the scalpel do you know?
Fiddle-bow grip. Used for long, straight incisions
The pencil grip, used for short, fine incisions.
71
Describe the phases of wound healing!
0-2 days
Hemostasis-inflammation
- vasoconstriction
- wound fills with blood clot, platelet aggregates, fibrin
clot develops
- signs of inflammation are present
- blood flow increases, immune cells release pro-
inflammatory cytokines and growth factors.
- cytokines promote:
angiogenesis
fibroblast, B and T cell activation
Keratinocyte activation
Wound contraction
Removal of bacterial components.
3-7 days
Granulation-Proliferation
8 day onward, for months
Remodelling.
72
What is happening in the granulation-proliferation phase of wound healing?
Formations of granulation tissue and fibroblasts. Fibroblast migration and proliferation, ECM deposition.
Collagen and elastic fibers protect against infection and provide medium for re-epithelialization.
Granulation tissue formation
Angiogenesis
Epithelialization
Contraction
73
What is happening in the remodeling phase of wound healing?
ECM remodelling, collagen deposition and degeneration/reorganization.
Vascularity is reduced, capillaries regress.
Myofibroblasts contract the wound and ECM.
ECM is looser and weakened.
Remodelling continues indefinitely.
Final strength is about 80% of normal tissue.
74
Describe the types of wound healing!
Healing by primary intention. Sanatio per primum intentionem
-wound edges are approximated.
-minimizes scarring
-most surgical wounds heal by primary intention healing
Healing by secondary intention: Sanatio per secundum intentionem
-the wound is allowed to granulate, resulting in a broader scar
-wound may be packed with gauze or drained.
-wound is filled with granulation tissue/connective tissue which transforms into scar tissue.
-larger clot
-more inflammation
-larger scar
-more contraction
example: tooth extraction sockets
Tertiary intention: (don't mention this unless they ask)
- wound is initially cleaned and observed, and purposefully left open. for 4-5 days before closure.
ex. healing tissue grafts.
75
List the influencing/delaying factors of wound repair!
Local factors:
Ischemia
Infection
Foreign bodies
Edema, increased tissue pressure
Systemic factors:
Age and gender (faster in men)
Sex hormones
Stress
Ischemia
Disease/chronic debilitating conditions
Obesity
Medication
Alcoholism
Smoking
Immunocompromised states
Nutrition.
76
What early complications of wound healing do you know?
Seroma
Hematoma
Wound disruption
Superficial wound infection
Deep wound infection
Mixed wound infection
77
What are the characteristics of the seroma?
The wound cavity is filled with serous fluid, lymph or blood.
Signs: fluctuation, swelling, redness, tenderness and subfebrility.
Treatment: Sterile puncture and compression, suction drain.
Common after breast operations.
78
What are the characteristics of the hematoma?
Signs: swelling, fluctuation, pain and redness.
Caused by:
inefficient control of bleeding,
a short drainage time
anti-coagulation therapy.
The risk of infection is high.
Treatment: Sterile puncture in early phase, surgical exploration later.
79
What are the characteristics of the wound disruption?
The major types are:
- partial
- superficial (dehiscence),
- complete separation (disruption).
The deeper layers are involved FIRST and lastly the skin.
Local causes:
a surgical error (e.g. suturing the fascia with a continuious suture),
increased intra-abdominal pressure and wound infection, edema.
80
What forms of superficial wound infection do you know?
Diffuse or Localized
Diffuse - superficial inflammation spreading beneath the skin.
ex. Erysipelas and Lymphangitis
Localized - circumscribed infection, abscesses.
81
List the local and general symptoms of wound infection!
Local:
Redness, swelling, heat, pain, functional loss.
General:
Increased ESR, leukocytosis, fever, shivering, depression.
82
What are the late complications of wound healing?
Hypertrophic scars
Keloid scars
Necrosis
Inflammatory infiltrate
Abscesses
Foreign body-containing abscesses.
83
What are the characteristics of hypertrophic scar?
Develop in areas of thick chorium (dermis).
Non-hyalinic collagen fibers and fibroblasts
Confined to the incision line
Regress spontaneously 3-6 months after surgery.
Fall back to the level of skin in 1-2 years.
84
What are the characteristics of keloids?
Unknown etiology, more common in African and Asian groups.
Well defined edges.
Over proliferation of collagen in the subcutaneous layer of skin.
Can itch or be painful.
Overgrow the incision line.
Treat with local corticosteroids and anesthetics.
Prevention with an atraumatic surgical technique.
85
What is hemostasis and what are the factors of it?
Hemostasis is the process that causes bleeding to stop
Factors
Platelet hemostasis
Vascular constriction
Blood clotting
86
What are the characteristics of diffuse bleeding?
Oozing from denuded or cut surfaces.
Capillary bleeding
Parenchymal bleeding
Can become serious if uncontrolled
87
What could be the direction of bleeding from clinical point of view?
External, resulting in visible bleeding
Internal:
Into a luminal organ: hematuria, hemoptoa, melena into the GI
Into a body cavity: Hemothorax, hemopericardium, hemascos
88
What methods of surgical haemostasis do you know?
Mechanical
Thermal
Chemical and Biological
89
List the mechanical methods of surgical haemostasis!
Digital pressure
Tourniquet
Ligation
Suturing
Preventive hemostasis
Clips
Bone wax
Expedients
Rubber bands
Esmarch bandage
Penrose drain
Vessel loops
Pneumatic tourniquets
Pressure dressings
Packings
Tambonades
Sand bag.
90
List haemostatic methods based on thermal effects!
Monopolar diathermy
Bipolar diathermy
Electrocauterization
Local electrosurgery
Laser surgery
Hypothermia
Cryosurgery
91
What are the mechanisms of haemostasis based on chemical and biological materials? List 3 materials!
Vasoconstrictive agents:
-epinephrine, oxytocin for bleeding from the uterus
Coagulation:
-microfibrillar collagen, thrombin
Hygroscopic effect"
-absorbable collagen, absorbable gelatin, oxidized cellulose
Novel agents:
HemCon
QuikClot
92
Give examples of vital, absolute, and relative indications!
Vital indications:
100% mortality without operation,
ex. rupture of an aortic aneurysm.
Absolute indications:
Disease can be exlusively treated with an operation, but the time can be chosen within narrow limits
ex. mechanical ileus.
Relative indications:
Elective procedures, or for a disease that can be treated with or without surgery.
Time of surgery can be chosen.
example: hernia.
93
What are the components of surgical risk?
Risk of surgery itself
AND
the anesthesiological risk
94
What factors increase surgical risk?
• Acute surgery
• Duration > 2 hours
• > 65 years old
• Pregnancy
• Malignant diseases
• Malnutrition
• Alcohol
consumption
• Smoking
Opening of a body cavity
Operations over a hollow organ
Opening multiple hollow organs
Opening more than one body cavity at the same time has highest risk.
Acute disturbaces
• hypovolaemia
• dehydration
• shock
Acute inflammations
• respiratory
• urinary
• gastrointestinal
• sepsis
• Trombosis
Acute organ insufficiencies:
• Heart
• Lung
• Kidney
• Liver
Acute endocrine disorder
Organ insufficiencies
hear
lung
kidney
liver
Immunological disorders
Hemophilia
Organ alterations:
• Cardiorespiratory
• Hypertention
• Nervous system alterations
• Diabetes mellitus
• Chronic Uraemia
• Cirrhosis
• Susceptibility for infection
• Immunosuppresion
• Thromboembolic predisposition
• Chronic disorders:
• Hypovolaemia
• Anaemia
• Chronic inflammations
• Respiratory(bronchitis)
• Urinary
• Gastrointestinal (ulcer)
• Trombosis
• Allergia
Pregnancy as a surgical risk factor
- acute or chronic systemic risk factors next to the pregnancy + surgical diseases
- decreased maternal physiological reservoirs (respiration, circulation, metabolism)
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What kind of organ alterations increase surgical risk?
• Cardiorespiratory aka
Cardiovascular and
Pulmonary
• Hypertention
• Nervous system alterations
• Diabetes mellitus
• Chronic Uraemia
• Cirrhosis
• Susceptibility for infection
• Immunosuppresion
• Thromboembolic predisposition aka Hypercoagulable states
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What should be examined before the operation to estimate the surgical risk?
It means to examine the followings:
- cardiovascular state,
- respiratory system,
- renal function,
- liver function,
- endocrine balance,
- immune system.
- metabolic state,
- homeostasis,
Examinations
- physical examination
- laboratory examination
- radiological examinations (US, CT, MRI, isotop, DSA, and so on)
- instrumental examination (endoscopy, biopsy, cytological examinations)
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Heart and circulation:
- pulse, blood pressure
- ECG
- Echocardiography
- coronarography
- isotop
Increased cadiac risks:
- aortic stenosis, mitral stenosis
- dysrhythmia
- AMI: within 3 weeksmortality: 25%
- AMI: within 6 weeksmortality: 5%
97
Who invented the Vere's needle?
János Veres (1903-1979) was a pulmonologist in Kapuvár. In order to prevent injuries of the lung while getting through the thoracic wall, Veres used his own new, special, springloaded needle to create safely an artificial pneumothorax which was a technique for treatment of the tuberculosis at that time. Creates pneumoperitonuem during laparoscopy.
1938.
98
What are the characteristics of a mixed wound infection
1. Gangrene: necrotic tissues, putrid and anaerobic infection; a severe clinical picture. Treatment:
aggression surgical debridement and effective and specified (antibiotic) therapy.
2. Generalized reaction: bacteremia, pyaemia, and sepsis.
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What are the characteristics of deep wound infection
1. Diffuse infection (e.g. an anaerobic necrosis). Treatment: surgical exploration, open therapy,
rinsing the wound with H2O2, and antibiotics.
2. Localized infection (e.g. empyema), inside the tissues or body cavities (e.g. pleural and joint
cavities). Treatment: surgical exploration and drainage (Staphylococcus aureus!).
100
When is the horizontal mattress suture used?
On the skin, in the case of higher tension
101
Where is the simple running suture used?
GI tract, vessels, peritoneum, low tension skin.
102
Where is the running locked suture used?
Skin
'reduces wound tension'
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