Basic Surgical Skills & Anastomoses.pptt

Basic Surgical Skills & Anastomoses.ppt

1. Basic Surgical Skills &
Anastomoses
Skin Incision

2. Incision of skin
•Usually made using scalpels with
disposable blades
The blade shape & size is chosen for the
task in hand
Blades used for skin incision usually
have curved margin & to make holes for a
drain or for arteriotomies have a sharp tip
When incising skin, the knife should
be pressed down firmly at right angles to
the skin

3. Incision Conti…
•At the same time, tension should be
applied across the line of the incision so
that the skin springs apart cleanly
Diathermy & laser blades have started to
replace scalpels when opening deeper
tissues
Advantage is it reduce blood loss,
save operating time & appear to reduce
postop pain

4. Suture of skin
•1.Wounds should be closed with minimum
tension
2.The edges should be left slightly gaping
to allow for swelling in the wound edges
3.The needle is inserted at right angles to
the skin for simple suture
4.The entry & exit points should be the
same distance from the wound edge as
the thickness of the skin being closed

5. Suture of skin Conti…
•5.If the edge of the wound is everted with
toothed forceps while the needle is
inserted, it is possible to ensure that a
wider bite of the deep tissues is taken than
the skin
The same can be done as the needle
exits from the other side of the wound
The result is that the suture takes a
deep oval course

6. Suture of skin Conti…
•6.When the suture is tightened, the wound
edges will evert slightly which gives good
healing
If the suture enters & exits from the skin
at an acute angle, then the wound will be
inverted & poor healing will result
7.The knot should be to one side
8.Knots must be tight, ends long enough to
grasp when removing the suture

7. Suture of the skin Conti…
9.Stitches should be separated by a gap
that is twice the thickness of the skin
If a wound is difficult to close- place
stitches alternately at each end towards
the center
If the wound has curves or zigzag-
stay sutures at the tip of each corner will
make sure that the edges come together
in the correct orientation & avoid dog-ears

8. Suture of the skin Conti…
•If a skin lesion is excised the wound length
should be around 3 times the maximum
width of the skin excised
10.When removing stitches- cut below the
knot & remove by holding the knot

9. Types of Skin Closure
•Can be interrupted or continuous
May be simple, mattress or
subcuticular Interrupted sutures has the
advantage that they can be removed
individually if hematoma or infection forms
locally but time taking than continuous
Mattress sutures appose skin
edges tidily & close the dead space but
slower to insert than simple sutures but
also avoid the fat stitch before closing skin

10. Skin Closure Conti…
•Subcuticular sutures look very nice to the
pt. but are difficult to put in if the wound is
curved
They also have the disadvantage that any
dead space need closure separately
The cosmetic result in the long term is not
apparently any better than conventional
closure

11. Skin closure Conti…
•All skin closures removed as soon as the
wound is secure to avoid scarring, infection &
irritation As a general
rule non absorbable sutures should be removed
from the :- Face- in 2-3
days, Scalp- 5 days
Upper limb &
groin- 7 days Abdomen- 10
days Dorsum & lower
trunk- 10-14 days

12. No-Touch Technique
•Whenever possible should be applied
This is not possible when doing closure
subcuticularly using a straight needle
Needle holders should be appropriate
Short handed holders used for skin, long
handed holders for deep sutures
The needle held in the tip of the holder &
grasped ~2/3 of the way back from its tip
where there is flattened part

13. No Touch Conti…
•If the needle is held too far back, the
swage will be crushed & the needle break
If the needle is grasped by its tip it will
bend or break
Needles can be placed in the holders to be
used forehand or backhand

14. Suture Materials
•Suture materials can be natural or
synthetic, monofilament or braided, can be
coated
Diameter vary from 0.002-0.8mm which
corresponds to 0.2-8 on the metric system
& 10/0 to5 on the British Pharmacopoeia
Choose the finest suture that will hold
the wound secure & the actual amount
used kept to a minimum

15. Metal Sutures & Clips
•Are quick & accurate
Disposable units are more expensive
All clips are easy to remove &
cosmetically acceptable scars

16. Tissue Glues
•1.Cyanoacrylates-used for skin closure but
need perfect hemostasis if they are to
work well
They are as expensive as disposable
metal stapling units but quick to use & do
not delay wound healing
2.Fibrin tissue glues-work by conversion
of fibrinogen to fibrin by thrombin with
cross-linking by F- 13

17. Fibrin glue Conti…
•The network has good adhesive properties
Used in hemostasis in the liver & spleen
Also in neurosurgery for dural tears, in
ENT & ophthalmic surgery
In general surgery, for the prevention of
postop adhesion in the pericardium & the
peritoneum, To control GI hemorrhage at
endoscope when bleeding is not brisk
More effective when combined with
collagen

18. Anastomosis
•On the bowel was not undertaken
successfully until the 19
th
century
Before that, experience was limited to
exteriorization or closure of simple
lacerations
Lambert(1826) described seromuscular
suture technique
Senn advocated a two layer technique
Halsted favored a one layer closure that
does not incorporate the mucosa

19. Anastomosis Conti…
•Connell used a single layer of interrupted
sutures incorporating all layers of the
bowel
Kocher”s method, then became the
standard, a two layer anastomosis, first a
continuous all layer suture using catgut
then an inverting continuous or interrupted
seromuscular layer suture using silk

20. Anastomosis Conti…
•Inversion is the safest in bowel (least likely
to leak), paradoxically end-to-end staples
give an everted anastomosis with no cxn
Matheson of Aberdeen is currently popular
is single layer extra mucosal anastomosis
b/c the least tissue necrosing or luminal
narrowing

21. Anastomosis Conti…
•Anastomosis of vessel -Pioneered by
Carrel-an everting anastomosis with
accurate opposition to provide an intact
endothelium that prevented platelet &
thrombus
Involves three stay sutures to make an
equilateral triangle

22. Bowel anastomosis
•Can be open or closed
With good bowel preparation clamps are
not necessary
At the corners, one or two Connell loop-
on-the-mucosa sutures help to invert the
mucosa in the all layer continuous inner
suture
Finally, anastomosis inverted using a
seromuscular continuous Lembert suture

23. Conti…
•To make an end-to-end anastomosis
bowel ends of equal diameter selected
Parachuting or purse-stringing a proximal
dilated lumen into narrower bowel risks
leakage
In such a case the options are:
Side-to-side
End-to-side or
The Cheatle split

24. End-to-end one layer & end-to-side
•Useful in :-
When access is not so easy Ex-
Transabdominal esophago-gastric
anastomosis, low anterior resection
When there is disparity in the bowel
lumen When the serosa is lacking

25. Essentials for safe bowel
anastomosis
•1.Local
Good blood supply (no tension)
Inverting anastomosis with appropriate
suture
Accurate apposition & suture technique
(or stapling)
Avoidance of tissue damage by
clamps

26. 2.Systemic
•Bowel preparation (& avoidance of spillage)

Antibiotic profilaxis
Maintenance of good perfusion & tissue
oxygenation during anesthesia (correction
of shock)
Adequate nutrition
Adequate resectional margins & avoidance
chemotherapy/radiotherapy

27. Local & systemic adverse factors
•1.Local
Persisting disease process
Distal obstruction
Poor blood supply eg-rectum,
esophagus Poor technique: hematoma,
dead space, poor perfusion
Presence of foreign body
Gross
contamination/infection

28. Local & systemic Conti…
•2.Systemic
Shock of any cause
Metabolic diseases:DM, uraemia,
jaundice Immunosuppression: cancer,
steroids, AIDS
Malnutrition

29. Complications after anastomosis
•1.Leakage
2.Bleeding
3.Stenosis in
Bowel which may be due to
a. fibrosis following a leak
b. inexpert technique
c. recurrent tumor in a suture
line Arteries :a. technical b.
atherosclerosis c. intimal hyperplasia

30. Electro-Surgery (Diathermy)
•The term electro- cautery
involves the application of
direct current (e) flowing in one direction
In surgical diathermy (electro-
surgery) a high frequency alternating
current is passed through the body tissue
& the concentration of current producing
an area of high current density liberates
heat

31. Diathermy Conti…
•Temperature may rise >1000c
Current frequencies in the range of
400KHz-10MHz are used & in this range
there is minimal muscular response

32. Electro-Surgical tissue effects
•1. Cutting- divides tissue with electric
sparks
Intense heat focus at the surgical
site Tissue is vaporized
Achieved with a constant
wave form of low voltage

33. Electro-surgical Conti…
•2. Fulguration
Tissue is coagulated & charred over a
wide area
Achieved by an intermittent
waveform of high voltage producing
less heat 3. Desiccation
This occurs when the
electrode is in direct contact with
tissue

34. The circuits
•1. Monopolar-The active electrode is the
surgical site
The Pts return electrode is elsewhere
on the Pts body (the plate)
The current passes through the Pt as it
completes the circuit from
the active to the Pt return
electrode

35. The circuits Conti…
•2. Bipolar- The function of active & return
electrodes are performed at
the surgical site
The two blades of the forceps perform
these two functions
Thus, only the tissue grasped is
included in the electrical circuit
No Pt return electrode is needed

36. Variables affecting the tissue effect
waveform
•Includes:-
Power setting
Size of electrode
Time

Tissue type
Manipulation of electrodes

37. Safety measures
•a. diathermy generator & accessories
serviced regularly & a full record kept
b. plugs, leads & sockets checked
c. foot pedals checked to ensure that they
are completely sealed & sensitive to light
pressure
d. alarm system working
e. pt is protected from metal, & that the skin
is checked after removal of the plate

38. Safety measures Conti…
•f. appropriate mode of diathermy
(mono/bipolar) selected & the correct
setting to be used checked
when monopolar is used ensure that the
coagulation & cutting levels are set
(cutting & fulguration need higher current
than coagulation) which is not applicable
to bipolar

39. Safety measures Conti…
•g. make sure that the indifferent electrode
in the monopolar system uses a flat
surface that is dry, & that there is no thick
hair present which interfere conduction
h. should never be used in the presence
of ether & kept at least 50cm from
anesthetic machine
i. alcoholic disinfectants
dried before diathermy is used

40. Safety measures Conti…
•If diathermy is ineffective, before
increasing the current, look for
faulty connection
faulty active
electrode
poor contact of plate
a disconnected or faulty cable

41. Commonest causes of diathermy
injury
•A. incorrect application of the pt plate
B. pt touching earth, metal
C. careless technique

42. Pts with a pacemaker
•The radiofrequency of the electric current
used in electro-surgical procedures may
affect the pacemaker
Early pacemakers were sensitive to
high to high frequency signals & led to
occasional fibrillation
These are no longer inserted

43. Pts with pacemaker Conti…
•Modern pacemakers are still sensitive but
have an in-built safeguard so that any
interference is inhibitory rather than
stimulatory
It is always safer to use a bipolar circuit

44. Metallic prostheses
•With a monopolar circuit, the pt return
electrode should be sited well away from
the prosthesis

45. Electro-Surgical safety
•Direct coupling- occurs when the surgeon
activates the generator while the active
electrode is in contact with or near another
metallic instrument
Insulation failure- the high voltage
waveform of coagulation as opposed to a
cutting current may escape through
defects in the insulation, causing
significant injury

46. Electro-Surgical Safety Conti…
•Metal cannulae-A capacitor may created
b/n the active surgical instrument
electrode & the metal cannulae & the
resulting electrostatic field b/n these
conductors allows a current to be induced
in the second conductor (metal cannulae)
It is reduced but not eliminated by the use
of plastic cannula

47. Advisory Tips
•Inspect insulation regularly & thoroughly
Use a low power setting
Use a low voltage waveform when
possible
Use intermittent activation rather than
continuous
Do not activate when the electrode is
in contact with other metallic
instruments