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Flashcards in Principles of operative technique Deck (76):

List Halstead's principles

Gentle tissue handling
accurate haemostasis
preservation of vascularity
surgical asepsis
no tension on tissues
approximation of tissues
obliteration of dead space


What 4 basic techniques do all surgeries require?

incision and excision of tissue
maintenance of haemostasis
handling and care of exposed tissues
use of sutures, knots and other materials for closure and support


What instruments can be used to incise or excise tissue? 4

scalpel, scissors, electrosurgery, lasers


How can a steel scalpel be handled?

PENCIL GRIP - short, precise incisions
FINGERTIP GRIP - commonly used, larger incisions
PALM GRIP - when greater pressure must be applied


What sizes do scalpel handles come in?

3 (small), 4 (large) and size 7 (fine)


What scalpel blades are commonly used for the different sized scalpel blades?

For handle size 3/7, use blade 10 (curved), 11 (pointed) and 15 (small curve)

For handle size 4, use 20,21,22 and 23 (all curved)


What is press-cutting?

Use of s scalpel where you hold it in the pencil grip and apply pressure in the direction of the movement of the blade and is used to create incisions in hollow organs or cavities.


What is slide cutting?

A method for using the scalpel. Most commonly used and safest method of cutting and uses the pencil or fingertip grip.


What is sawing?

uses the pencil grip and allows a small incision to be deepend without removing the blade form the wound, but this method is traumatic and is more difficult to control depth.


What is craping?

analaogous to shaving hair or whiskers and may be used to develop pouches below the skin or fascia, to elevate muscles sub-peritoneally and to separate body cavity adhesions


After scalpels, what is the second commonest method to cut tissue?



What are some different types of scissors and what are their uses?

Mayo = heavy scissors, for dense collagen rich tissue
Metzenbaum = fine scissors, for blunt dissection and sharp dissection of delicate tissues
Heavy suture scissors = use for large guage sutures to prevent dulling the blades of surgical scissors
Ligature cutting scissors = should be used for fine guage suture


When are scissors best suited? What about straight and curved scissors?

For cutting flaccid tissues not under tension and stabilise the tissues as they cut while allowing good control of depth. Straight scissors provide a much better mechanical advantage for cutting whereas curved scissors provide increased mobility and motility.


What are the 4 different scissor grips?

wide-based tripod grip
thenar eminence third finger grip
backhand grip thumb and third finger
backhand thumb-first finger


Which scissor grip describe using hte tips of the thumb and third finger int he ringers with the index finger on the shank for support?

wide-based tripod


When do you use a thenar eminence third-finger grip?

more useful for needle holders than scissors


What grip do you use to cut toward the surgeon's dominant side?

backhand grip thumb and third finger


Which scissor grip do you use when making a cut towards the surgeon?

backhand thumb-first finger


What is 'scissor cutting'?

uses the blades and is applicable to short incisions


What is 'push cutting'?

suitable for long insicions in sheets of tissue. scissor blades are partially closed and then pushed through the tissue in one motion (tailor's cut)


What is 'blunt dissection'?

inserting closed scissor blades into tissue plance to be separated and then opening them. the scirssors are then withdrawn before closing the blades and repeating the manoeuvre. This is used for dissecting structing (vessels, nerves, muscle bellies) separated by more delicate tissue (fat, loose areolar fascia)


How does electrosurgery and lasers work? Benefits? Negatives?

transmit energy directly to tissues, resulting in vaporising of the tissue along the incision. there is greater collateral damage via thermal necrosis, but haemostasis may be provided


Advantages of electrosurgery

reduced blood loss (improved haemostasis)
decreased need for ligatures
reduced operating time


Disadvantages of electrosurgery

delayed wound healing and reduced resistance to infection
risk of fires and burns and the expense of the equipment


What does a continuous undamped sine wave provide?

maximum cutting with minimum coagulation and lateral thermal necrosis


What do interrupted, damped sine waves do?

maximise coagulation and minimise cutting


What are the different types of surgical haemorrhage?

primary - bleeding immediate
delayed intermediate - bleeding within 24 hours of surgery (e.g. slipped ligature)
delayed secondary - bleeding more than 24 hours after surgery (e.g. necrosis of ligated vessel)


Why is haemostasis important in surgery?

obscures surgical field
increases likelihood of infection
extravasated blood irritates tissues, delays wound healing and increases infection
preventive haemostasis avoids surgical panic which often causes more trauma
hypovolaemia and death possible


What is preventive haemostasis?

minimises primary haemorrhage (i.e. direct BV trauma)


How is preventive haemostasis done?

choosing a surgical approach that avoids major BVs
avoiding or retracting BVs
identifying BVs and provide haemostasis before cutting
gentle dissection


What surgical methods augment physiological haemostasis?

pressure with a swab
temporary packing
wound closure
haemostatic forceps
cautery and diathermy
vascular clips and staples
topical agents
Tourniquet (Rumel)


What are the principles for the correct use of a swab? 7

use woven cotton swabs not pressed felt swabs
use swabs with radioopaque marker
use singly to encurage gentle use
use singly to reduce likelihood of leavingone behind
open swab out if performing a delicate manouevre
use large laparotomy swabs in body cavities
blot tissue, don't wipe


What factors do you need to consider when deciding which haemostatic measure to use? 5

least traumatic
least foreign material
least necrotic tissue
depends on tissue


How do haemostatic forceps work?

they crush the tissue or vessel at the point of contact and have a ratchet so that they may be left inplace


What are different examples of haemostats? 4

Halstead mosquito (small)
Kelly (medium)
Carmal (Large)
Kocher (large with rat-toothed tip)


How do you achieve haemostasis in small vessels?

crushing or crushing with torsion before the haemostat is removed may be sufficient


How do you achieve haemostasis in larger vessels?

electrosurgery or ligation may be used after haemostats are applied


What points are important to consider when using haemostats?

the smallest forceps capable of accomplishing haemostasis should be used, the tips of the forceps are used to grasp the vessel and curved forceps are preferred since they place the tip in the line of sight.


What is another name for electrosurgery?



How does diathermy work?

it passes an electric current through the tissue, producing heat as a result of tissue resistance. Other methods of cautery, such as hot irons and chemical styptics (silver nitrate) are not commonly used in surgery.


2 advantages of electrosurgery?

decreased operative time and reduced blood loss


What is monopolar diathermy? Advantages?

current flows between the handpiece (active electrode) to ground plate (indifferent electrode).

Advantages: ability to cut tissues as well as coagulation and the ability to apply current to instruments in contact with patient (conductive diathermy)


What happens in bipolar diathermy? Advantages?

the current passes between the two tips of the bipolar forceps.

The advantages include a lower current since a smaller distance is travelled, reduced local tissue trauma, reduced incidence of distant tissue trauma and burns are unlikely and it can be used effectively in a wet surgical field.


What knots should surgeons be aware of?

Simple knot - 1 single throw
Square (reef) knot - 1 single throw then another in opposite direction
Surgoen's knot - 1 double then, then a single throw in opposite direction (to manage tension)
Half-hitch - 1 single throw, then another (square knot), but tightended by sliding (to manage tension)
Granny knot - 1 single knot, followed by another in same oreintation (AVOID - will loosen)


What ligatures can be used for vessels?

Simple, encircling ligature
Double ligation ( 2 encircling ligatures or 1 encircling and 1 transfixing ligature)
Halsted's transfixing ligature
Modified transfixing ligature
Tissue ligature (mattress suture)
Stick ties (= tacking suture)


Define ligature

a piece of thread (suture) tied around an anatomical structure, usually a BV or other hollow structure to shut it off.


What is a vascular pedicle?

the tissues containing arteries and veins of an organ


What ligatures should be used for vascular pedicles?

Triple clamp technique (ligature tied into crushed area left by proximal clamp)
Modified Miller's knot
Transfixing ligature
Division of pedicle ('divide and conquer')


What is a transfixing ligature?

Ligature passes through the tissue pedicle and round it


What is a modified miller's knot?

end of ligature passes under loop of ligature - not commonly used


What happens in the divison of a pedicle?

the large vascular pedicle ligated as separate smaller pedicles


What is the triple clamp technique (ligature)?

ligature tied into crushed area left by proximal clamp


What are the 4 different types of haemostatic agent?

Agents causing:
vasoconstriction - ice saline, phenylephrine, adrenaline
promoting clotting - fibrin, collagen, cellulose, gelatin, polysaccharide
physical barrier - bone wax, glue


When should you use haemostatic agents?

Avoid if possible but use for liver and nasal biopsy (maybe because lots of blood?). Only collagen and bone wax are commonly used.


Name 2 types of tourniquet



What are thumb forceps?
When to use them?
Why use them?

the instruments most often used to manipulate tissue
spring-like action (opens jaws when pressure released)

Skin/dense tissues = Adson or Adson-Brown forceps
More delicate tissues = DeBakey

stabilise tissue for incision or suturing
retract tissue for exposure or incisions
grasp vessels for electrocoagulation
Pass ligatures
extract needles
pack swabs
clear blood with swabs


What can tissue forceps be used for? 5

Stablising/retracting tissues = Allis (teeth), Babcock (no teeth)

Dissection of neurovascular strucutres from other tissue: Mixter, Lahey

Occlusion of hollow organs: Doyens (GIT), Rochester-Carmalt (uterus)

Occlusion of vessels and vascular pedicles: haemostats

Tangential occlusion of BVs after incision: Cooley, Satinsky


What are alternative methods of tissue manipulation that are less traumatic?

stay sutures
skin hooks
non-crushing forceps
assistant's fingers/hands
surgical swabs


What are the 2 groups of retractor?

hand held or self-retaining (ratchet or lockingmechanism)


What is the major disadvantage of retractors and what can be done to minimise this?

tissue trauma or ischaemia at point of contact

use a saline-soaked swab


What are alternatives to retractors?

packing organs off with sabs
exteriorising organs from body cavity
stay sutures


What are common hand-held retractors? 4

ribbon malleable retractors


What are common self-retaining retractors?

Gelpi and Weitlaner (general surgery)
Finochietto (thorax)
Gosset and Balfour (abdomen)


What are examples of towel clamps?

Backhaus or cross-action


How can draped squares be secured to the patient's skin? 3

towel clamps
Michel clips


What are the benefits of wound lavage?

removal of bacteria and FBs
toxin dilution
reduced wound infection
tissue hydration
improved visibility
warming the patient


What is the ideal lavage?

sterile, isotonic, non-toxic, normo-thermic (38-42 degrees) solution and Hartmann's solution or normal saline

ABs - no proven advantage
antiseptic - may be harmful

If lavage is used, the fluid must be completely removed, since bacterial opsonisation and phagocytosis is impaired in wound fluid.


How can fluid be removed from a wound?

suction tips such as Frazier (fine), Yankauer (wide bore) or Poole (multiple holes)

These are less traumatic than blotting with swabs and allows some estimation of blood loss


What can staples be used for?

close the skin, fascia and hollow viscera


What can be tissue adhesive be used for?

close the skin


What is suture closure usually performed with?

needle holder and thumb forceps


List some needle holders - 4

Mayo or Mayo-Hegar (ratchet)
Olsen-Hegar (ratchet and scissors)
Gillies (scissors)
fine Castroviejo (ratchet)


Why do some needle holders and scissors have tungsten-carbide inserts in jaws or blades?

to provide durability and hardness of edge


How can knots be tied?

One-hand tie: rapid, within cavity, tendency to form a half-hitch

Two-hand time: reliable, more economical use of material

Instrument: most economical, lack tactile feedback


What are the principles of a successful suture? 6

Knot security is inversely proportional to suture diameter

Tighten each throw separately with even tension on both hands to avoid loosening

use absorbable multi-filament suture for ligatures

place minimum number of throws to reduce knot bulk

cut the ends short (3mm) to minimise foreign material in wound (cat gut 6mm)

avoid including frayed or damaged suture in the loop


What are methods to manage tension at closure?

surgeon's knit
sliding half-hitch
stay sutures for temporary approximation
Galaban forceps
Always place 2-3 knots on top of a square or surgeon's knot

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