Basic principles of surgery

1. PRINCIPLES OF
SURGERY
MALIHA MALIK
ROLL NO. 1007

2. CONTENTS
DEVELOPING A SURGICAL DIAGNOSIS
BASIC NECESSITIES FOR SURGERY
ASEPTIC TECHNIQUE
INCISIONS
FLAP DESIGN
•Prevention of flap necrosis
•Prevention of flap dehiscence
•Prevention of flap tearing
TISSUE HANDLING
HEMOSTASIS
•Means of promoting wound hemostasis
•Dead space management
DECONTAMINATION AND DEBRIDEMENT
EDEMA CONTROL
PATIENT GENERAL HEALTH AND NUTRITION

3. PRINCIPLES OF SURGERY
Human tissues ,due to their innate properties
,react to injury fairly predictably. So ,with
experience certain set principles are evolved
for optimal healing.These are called as BASIC
PRINCIPLES OF SURGERY.

4. DEVELOPING A SURGICAL
DIAGNOSIS
Important decisions regarding
surgery are made from :
Identifying signs and
symptoms by
1. Complete and thorough
history
2. Physical examination
Radiographic findings
Laboratory investigations
Record keeping/data in an
organized form
Differential diagnosis

5. BASIC NECESSITIES FOR
SURGERY
1. Adequate visibility is based on
Adequate access- mouth opening,
surgical exposure, retraction
Adequate light
Surgical field free of excess
blood and other fluids.
2. Assistance

6. ASEPTIC TECHNIQUE
It includes minimizing wound contamination by
pathogenic microbes through:
Medical asepsis
Surgical asepsis

7. ASEPTIC TECHNIQUE(CONTD..)
Universal precautions are applied to prevent
sepsis and efforts fall under the following
headings.
1.Instrument sterilization.
2.Operatory disinfection.
3.Surgical staff preparation.
 Hand and arm preparation.
Clean technique.
Sterile technique.

8. INCISIONS
Incisions are necessary for many
OMFS procedures. The following
principles apply.
Use a sharp blade of proper size .
Use firm continuous strokes.
Avoid cutting vital structures.
Incise perpendicular to the
epithelial surface.
Intraoral incisions should be
properly placed.

9. FLAP DESIGN
Principles of flap design help to prevent:
1.Flap necrosis.
2.Flap dehiscence
3.Flap tearing.

10. 1.Preventing flap necrosis
1.The tip should never be wider than the base unless a
major artery is present at the base.
2.The length of a flap should be no more than twice the
width. In the oral cavity, the length should never
exceed the width.
3.When possible, include an axial blood supply in the
base.
4.The base should not be twisted, stretched or grabbed
with instruments that can interrupt or destroy the blood
supply feeding and draining the flap.

12. 2.Preventing flap dehiscence
Dehiscence (separation) is avoided by
approximate the edges over healthy bone,
handling the edges gently and minimizing
tension.
Dehiscence exposes underlying bone leading
to pain,bone loss, infection and scarring.

13. 3.Preventing flap tearing
Make incisions long enough to give adequate
access.
Make more than one releasing incision if more
access is needed.

15. TISSUE HANDLING
Apart from careful flap design and incision
technique, the careful handling of the tissues is also
necessary for optimal and uncomplicated healing.
Excessive crushing, pulling, extremes of
temperature, desiccation and harsh chemicals
damage tissues and these should be avoided.
Toothed forceps and skin hooks are preferred to
forceps that crush the wound edges.

16. TISSUE HANDLING(CONTD..)
Avoid excessive pulling forces to retract tissue.
Use copious irrigation when drilling or cutting bone to
decrease bone damage from heat.
Protect soft tissue when drilling from frictional heat and direct
trauma.
Wounds should never be allowed to desicate.
Only physiologic substances should come in contact with the
living tissue.

17. HEMOSTASIS
Prevention of excessive blood loss is important
for :
Preserving patient’s oxygen-carrying capacity
Increased visibility
To prevent formation of hematomas

18. HEMOSTASIS(CONTD..)

MEANS OF PROMOTING WOUND
. HEMOSTASIS
1.Assist natural clotting processes by
applying pressure on a bleeding vessel
or a hemostat.
2.Use of heat(thermal coagulation).
3.Suture ligation.
4.Use of vasoconstrictive
substances(epinephrine)
5.By applying
procoagulants(commercial thrombin &
collagen)

19. HEMOSTASIS(CONTD..)

DEAD SPACE MANAGEMENT
 Dead space is an area that remains devoid
of tissue after wound closure.
 It is created by removing tissue in the
depths of the wound or by not reapproximating
all tissue planes during closure.
 These are usually filled with blood
(hematoma) which delays healing and
predisposes to infection.

20. HEMOSTASIS(CONTD..)

DEAD SPACE MANAGEMENT
Can be managed in 4 ways:
1.Suture all tissue planes.
2.Pressure dressing.
3.Packing(with an antibacterial medication).
4.Use of drains.

21. DECONTAMINATION AND
DEBRIDEMENT

22. DECONTAMINATION AND
DEBRIDEMENT(CONTD..)
Debridement with copious irrigation
of wound with sterile saline during
surgery and after closure.(large
volumes of fluid under pressure)
 To remove debris .
 To reduce the bacteria count and
minimizes the likelihood of infection.
To remove necrotic, foreign and
devitalized tissue .

23. EDEMA CONTROL
Results from the collection of serum(fluid)in the
interstitial spaces due to the transudation from
damaged vessels and lymphatics obstruction by fibrin.
Variables help determining the degree of postsurgical
edema:
1.Tissue injury
2.Loose connective tissue

24. EDEMA CONTROL(CONTD..)
•Post-surgical edema is minimized by:
1.Careful and gentle tissue handling
2.Short term steroids(prior to surgery)
3.Use of ice packs(controversial)
4.Head kept elevated above the rest of the body for few
postoperative days

25. PATIENT GENERAL HEALTH AND
NUTRITION

PROPER
WOUND
HEALING

26. PATIENT GENERAL HEALTH AND
NUTRITION(CONTD..)
1.Diseases inducing catabolic
metabolic state
•Poorly controlled IDDM
•End-stage renal or hepatic disease
•Malignant diseases
2. Conditions interfering with delivery
of oxygen and nutrients to wounded
tissue
•Severe COPD
•Poorly compensated congestive
heart failure
•Drug addictions (ethanolism)
3. Drugs or physical agents that
interfere with immunologic or wound
healing cells
•Autoimmune diseases (long-term
corticosteroid therapy)
•Malignancies (cytotoxic agents &
radiation therapy)
•Medical conditions impairing patient’s ability to
resist infection and wound healing :

27. PATIENT GENERAL HEALTH AND
NUTRITION(CONTD..)
SURGEON’S ROLE :
Increased chances of normal
healing of an elective surgical
wound by evaluating and
optimizing the patient’s general
health status before surgery.
For malnourished patients,
improving nutritional status so
that the patient is in a positive
nitrogen balance and an anabolic
metabolic state.

28. Thank you for the PATIENT
LISTENING