14. Principles and Techniques of Surgery
Surgical Principles § Many factors that affect the healing process can be controlled by the surgical team before, during, and after operations. Prevent Infection § Maintain a sterile and aseptic technique § Organisms from patientʼs body § Surgical scrub, perioperative antibiotics, debridement § Organisms from medical personnel § Surgical scrub, mask, gloves, gown § Organisms from fomites and the environment § Patient draping § Sterility of surgical instruments and materials Incision Planning § Planning necessary before ANY incision or excision § “Decision before Incision” § Considerations § Optimal exposure § Optimal scarring § Relaxed Skin Tension Lines Relaxed Skin Tension Lines § RSTLʼs are lines of minimal tension of the skin § Incisions placed on or parallel to these lines § Least possible tension while healing § Good scar lies along the lines (axis) of the RSTLʼs
Aesthetic Units of the Face In the face incisions parallel to RSTLʼs, along aesthetic unit boundaries, and in the midline heal with less perceptible scarring
Dissection Technique § § § §
Clean incision should be made through the skin with one stroke of evenly applied scalpel pressure Incision should be perpendicular to skin surface § Avoid beveled (slanted) incision edge Sharp dissection should be used to cut through remaining tissues. Preserve the integrity of as many of the underlying nerves, blood vessels, and muscles as possible.
Tissue Handling § § § § § §
Be gentle to tissues! Less tissue trauma promotes faster healing. Handle all tissues delicately and minimally Retractors should be placed with care to avoid excessive pressure Preserve vital structures (nerves, vessels, skin, etc) Crushing and tension cause serious complications: § Impaired blood and lymph flow § Tissue ischemia and inflammation § Predisposition to microbial colonization
Hemostasis § §
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Hemostasis is the process of stopping bleeding. Provides surgeon with a clear field for greater accuracy. § Bloodless (“dry”) field is essential for proper visualization § Blood stained tissues less clear Prevents postoperative hematomas. § Hematomas cause wound breakdown and infection Specific and direct hemostasis to avoid excessive tissue damage and injury to adjacent structures.
Hemostatic Methods: § Mechanical: Pressure; Suture ligature § Thermal: Electrocautery § Chemical (Topical): Thrombin; Fibrin; Surgicel; Gelfoam
Free Vessel Ligature
Figure-of-8 Suture
Electroautery § Used to coagulate (cauterize) and cut tissues § Electrical current which coagulates blood vessels to arrest bleeding § Avoid near skin where may cause damage and devitalize § Monopolar cautery § Patient must be grounded § Blue-coagulate § Yellow-cut Maintaining Moisture in Tissues § Prevent tissue desiccation during procedures § Periodic irrigation with warm physiologic saline § Cover exposed surfaces with saline-moistened sponges Debridement of all devitalized and necrotic tissue Removal of foreign materials Undermining: “Tension-free closure” § Undermining (relaxing or loosening) of skin and soft tissues prior to wound closure decreases tension at wound edges.
Wound Closure Choice of Closure Materials Maximize the opportunity for healing and minimize the likelihood of infection. Proper closure material allows approximation of tissue with as little trauma as possible, and with enough precision to eliminate dead space. § Surgeon preference § Location of the wound § Arrangement of tissue fibers § Patient factors Cellular Response to Closure Materials § § §
Sutures (and knots) implanted in tissue causes a tissue reaction verus the foreign body Post operative cellular responses to surgery cause edema of the skin and subcutaneous tissues. Place adequate number of sutures to close and support wound, without overdoing it.
Closing Tension: “Approximate but do not Strangulate” § Enough tension must be applied to approximate tissue and eliminate dead space § Sutures must be loose enough to prevent exaggerated patient discomfort, ischemia, and tissue necrosis during healing. § Post operative cellular responses to surgery cause edema of skin and subcutaneous tissues. Elimination of Dead Space § Dead spaces are areas in the wound that have not been adequately closed § Facilitate complications § Wound separation § Seroma or hematoma § Bacterial overgrowth Layered Wound Closure § Wounds are closed in anatomic layers (Fascia, superficial fascia, dermis, epidermis)
Surgical Instruments
General Tips § Choose the shortest instrument that will comfortably reach the operative site § If cutting suture or other non-tissue material, avoid using fine scissors § Choose instruments in good repair § Forceps that cross at the tip, scissors that do not cut easily and needle drivers that do not grip the needle securely can be frustrating and dangerous. Handling Instruments § Use three-point control § With “open-close” instruments, extend your index finger along the instrument to provide extra control and stability § Place only the tips of your fingers and thumb through the handles on instruments that open and close. § Rotation of the instrument can come from your wrist and forearm and provide a greater arc of control. Scalpel § Composed of a blade and a handle. § Load or unload the blade to the handle with hemostat grasping base of the blade
Scalpel blades com in various shapes and sizes. § #10 blade: Large incisions § #11 blade : Stab incisions § #12 blade: Hook blade § #15 blade : Fine precision work The way in which the scalpel is held depends on its size and the procedure being performed #10 blade: § Hold the knife parallel to the surface between the thumb and middle finger § The index finger guides the blade provides three-point control, and determines the degree of pressure applied. #15 blade: § Hold the instrument like a pen with your thumb, third finger and index finger holding the knife and your index finger controlling the dissection. Forceps § Used to grasp, retract, or stabilize tissue § Hold between thumb and middle finger while index finger used for stabilization § When operating on skin, us forceps to grasp dermis rather than epidermis to minimize tissue trauma at wound edge
Tissue Scissors § Used to separate (dissect) tissue § Curved vs straight tips § Point curved tips up when dissecting to avoid cutting deeper structures § Appropriate tension and counter tension on tissues when dissecting
Retractor § Blunt instrument for pulling tissues for exposure and tension/counter tension
Skin Hooks § Used for retracting tissue for § Exposure and tension § Sharp prongs hook dermis § Grasp b/t thumb and index finger § Middle finger to stabilize hook or provide counter traction on tissue beyond hook Needle Holder (Needle Driver) § Instrument for placing sutures § Holds needle and pushes (drives) needle with attached suture through tissues § Held in palm with thumb and tip of fourth finger in rings (holes) § § § §
Second finger stabilizes end of needle holder Needle with attached suture grasped in the jaws of the needle holder *1/2 to 2/3 from the pointed tip. Needle loaded in tips of holder jaws Needle holder also used to tie and knot sutures
Hemostat § Clamp designed to grasp blood vessels § Held like a needle holder Vessel Ligature
Suction § Removes fluids and blood from surgical field
Suture Scissors § Larger blades § Used to cut sutures § Deep (buried) sutures § Left in body § Cut on knot § Skin sutures § Surface, generally removed § Cut to leave 4-5mm tail
Towel Clip § Used to hold towels and surgical drapes together § Held like a hemostat
Suggested Reading: Thorne, C. (2007) Techniques and principles in Plastic Surgery. In: Thorne C, et al: Grabb and Smithʼs Plastic Surgery, 6th ed (pp. 3-14). Philadelphia: Lippincott Williams & Wilkins. Ethicon Wound Closure Manuel (2004)