Basics of instrument and tissue handling.pptx

Basics of instrument and tissue handling 1. Principles of superficial and subcutaneous tissues incision and closure 2.Safe use of surgical diathermy

1. Basics of instrument and tissue handling 1. Principles of superficial and subcutaneous tissues incision and closure 2.Safe use of surgical diathermy Dr. RUTAYISIRE François Xavier PGY1 Basic Surgical Skills Course University of Rwanda

2. Introduction Surgical instrument A s pecially designed tool or device for performing specific actions of carrying out desired effects during a surgery 1. M odifying biological tissue 2. P rovide access for viewing

3. Nomenclature 1. Action it performs • scalpel, hemostat 2. Inventor(s) name • Kocher forceps 3. Compound scientific name related to type of surgery • Osteotome - tool used to perform osteotomy

4. Actions: Hemostatic Forceps e.g : C lamps, artery forceps, hemostats • Purpose - to achieve hemostasis • Available in different lengths, curved and straight, serrated jaws or toothed ends • Examples - Mosquito, Kelly, Kocher

5. Parts of Hemostats

6. Actions: Soft Tissue Forceps Similar to hemostats • Purpose – holding and retracting soft tissue for longer periods • Characteristics include fine teeth or ridges on the jaws to provide a more delicate grip without trauma to tissue • Examples –Allis Intestinal, Babcock Intestinal, Kocher Artery, Right Angle, Forester sponge forceps

7. Actions: Thumb Forceps Do not have box locks or ring handles but rather have spring handles • Held closed by the thumb and finger pressure FORCEPS IS HOLD LIKE A PEN

8. Thumb Forceps Toothed Forceps Toothed forceps are useful for atraumatic tissue handling. USUALLY FOR HANDLING SKIN. NOT SUITABLE FOR GRIPPING NEEDLES. Only a small area of tissue is held in the jaws Tissue must be handled very gently to avoid unwanted damage Non-toothed forceps THEY HAVE SERRATIONS TO HELP GRIP NEEDLES, SUTURE MATERIALS AND ALIKE. Non-toothed forceps spread the force of the grip over a larger area They are used when handling delicate tissue such as bowel or vessels

9. Actions: Needle Holders Similar to hemostats but with smaller, shorter and thicker jaws • Available in a variety of lengths and styles and may be curved or straight • Needle holders have inserts in the jaw to prevent excessive wear of the instrument tungsten carbide granules in a cobalt or other metallic paste Needle holders with tungsten carbide inserts have gold plated handles • The inserts can be replaced which prolongs the life of the needle holder and reduce the replacement

10. Instrument handling After opening the suture pack, the needle is presented ready for mounting in the needle holder. Grasp the needle with the tip of the needle holder, two thirds along the shaft from the needle tip. When removing the suture from the pack, it is often useful to use your little finger to take up the slack in the suture.

11. Instrument Handling It is important that the needle is grasped at the tip of the jaws of the needle holder The needle can either be held two thirds away from the tip and perpendicular to the needle holder or, when using a half curved needle, it can be held half way along the shaft at a slight angle. Use forceps to manipulate the needle in the holder

12. Instrument Handling When grasping the needle, only one click is required on the ratchet. Putting too much force on the handles will damage the hinged area of the needle holder.

13. Instrument Handling I t is important that the needle is not handled at the tip or the swaged area.

14. Actions:Scissors Curved scissors – used to cut and dissect tissue • Straight scissors - used for cutting sutures and any tissue when a smooth, straight cut is desired, such as a damaged nerve or blood vessel • Scissors can be used for probing, dissecting, and spreading tissue • Should never be used to cut paper or tubing - bandage scissors may be utilized for this purpose Scissors may also have tungsten carbide cutting edges which provide finer cutting with longer lasting wear • Scissors with tungsten carbide inserts are identified by gold plated ring handles • Examples - Mayo scissors, Metzenbaum (Metz) scissors, Iris (dissecting) scissors

15. Instrument Handling The tips of the scissors should be used for dissection and division of structures.

16. Instrument Handling When using instruments with finger loop handles, it is important to use the correct grip

17. Actions: Retractors Purpose - used for holding the incision open to provide exposure to the surgical site • The use of specific retractors depend on the type of surgical procedure being performed • Smaller types - held by fingers or hand retract skin and subcutaneous tissue in shallow surgical areas • Larger, heavier types - retract muscle tissue and organs in deeper surgical sites Some retractors are held in place by an assistant • Self-retaining retractors require no assistant - held open by their own action and may be used in conjunction with the hand held retractors

18. Actions: Others Suction tubes • Biopsy needles • Knife handles

19. Scalpel instrument handling The scalpel pack should be opened carefully The needle holder must always be used to pick up the blade, never the fingers.

20. Instrument handling The blade must be slid carefully into place, lining up the central opening with the notch on the handle. The blade is removed by gently lifting the proximal end and then withdrawing the scalpel handle (note that in this manoeuvre the blunt handle is moved but the sharp blade remains still). Blades are placed in sharps bins for disposal.

21. Instrument handling

22. Instrument handling Scalpel should be held with the handle in the anatomical snuffbox (like holding a pen) • Allows short, fine, precise incisions Skin is stabilized by exerting tension with the opposite hand • Thumb is placed on one side of the cut with the other fingers placed on the opposite side

23. Instrument handling Wrong way. The grip is unstable.

24. Instrument handling Handle with great care as blades are very sharp • Practise attaching and detaching the blade using a haemostat - Never handle the blade directly! • Always pass the scalpel in a kidney dish - Never pass the scalpel point first across the table

25. Suturing Sutures An ideal suture should exhibit the following characteristics:  easy to tie/secure ;  elicits very little tissue reaction ;  maintains its tensile strength for the period required for it to hold the tissue together while it heals. Most suture material is now synthetic. Sutures can be absorbable or non-absorbable, and may be braided or monofilament in construction. Each type has its own properties, which are largely concerned with memory and with tensile strength.

26. Suture properties Memory T he extent to which the suture tries to stay in its original shape. Memory can lead to difficulty tying a knot as the suture may unravel as it tries to return to its original shape (e.g. when it was stored in the suture packet). This is more of a problem with larger monofilament sutures. Tensile Strength T he amount of force required to snap a suture is related to its tensile strength, which diminishes with time. The length of time over which this occurs is dependent upon the type of suture. The measurement of tensile strength is expressed as the time taken for the suture to lose half of its original strength. For example, the 50% tensile strength of Polydiaxone (e.g. PDS ) is 28 days, whereas that of Polyglactin ( e.g. Vicryl ) is 18 days.

27. Comparison of sutures Advantages of Braided Sutures Tie more securely Retain less memory than monofilament sutures Less risk of the suture “fracturing” when handled with forceps Advantages of Monofilament Sutures Less tissue reaction Less incidence of micro-abscess formation in the tissue

28. Comparison of sutures Advantages of Absorbable Sutures Not being required to be removed Are not present after wound healing has been achieved Advantages of Non-Absorbable Sutures Offer long-term support Less tissue reaction

29. Different suture types are suitable for different situations. Eg : most surgeons will close the skin layer by using either a subcuticular absorbable suture, or an interrupted monofilament suture. For a continuous suture, most prefer a monofilament suture, which slides through the tissues more easily, and reduces the chances of the tissue “bunching”. For areas where wound healing takes longer, it is important to use a suture that has a longer 50% tensile strength and absorption rate – e.g. polydiaxone may be used to close the linea alba.

30. Size of Sutures V ary in size, depending on the job for which they are required. They are sized using the USP (United States Pharmacopoeia) system. Some examples of sizes and diameters are shown below: 6/0 = 0.07 mm 4/0 = 0.15 mm 3/0 = 0.2 mm 2/0 = 0.3 mm 0 = 0.35 mm 1 = 0.4 mm 2 = 0.5 mm

31. T ensile strengths and absorption times G iving an indication as to what situation you may wish to use certain sutures 50% Tensile Strength Absorption Time Polyglactin ( vicryl ) 18 days 28 days Coated polyglactin (vicryl rapide) 6 days 10 days Polydiaxone (PDS) 28 days 180 days Polyglycolic acid (Dexon II) 16 days 60-90 days

32. Needles Needles may vary in size, and type. The shape of the needle is determined by the access to the tissue that requires to be sutured – normally the tighter the operative space is, the greater the curvature of the needle is that is required. The basic shapes used are: ¼, 3/8, ½, 5/8 Circle, J shape compound curved needle (used to close the sheath in laparoscopic ports) Previously a straight needle was available for closing skin in a subcuticular fashion, but this is no longer used as they are more prone to needle stick injuries

33. Safe use of surgical diathermy/electrosurgery

34. “Electrosurgery” is generally used to describe operations that utilize an alternating current to cut and coagulate tissue.

35. Introduction “Electrosurgery at least permits us today to remove certain brain tumors from situations and under circumstances which a year ago – indeed six months ago – I would not have thought possible.” Dr. Harvey Cushing, 1926. M ore recent quotes give a different impression: “Most hazardous device used on a daily basis” “Causes more patient injury than any other electro-medical device used in the operating theatre”

36. History Development of the first commercial electrosurgical device is credited to William T. Bovie , who developed the first electrosurgical device while employed at Harvard University. The first use of an electrosurgical generator in an operating room occurred on October 1, 1926 at Peter Bent Brigham Hospital in Boston, Massachusetts. The operation—removal of a mass from a patient’s head—was performed by Harvey Cushing.

37. What is an electrosurgical system? Electrosurgical system as the combination of components that enable a physician to perform electrosurgery. Six components of an electrosurgical system: the generator, the handpiece, the cables, the electrode, and the dispersive pad/return electrode, the foot pedal/control .

38. Electrosurgical devices are frequently used during surgical operations helping to prevent blood loss in hospital operating rooms or in outpatient procedures

39. Principle: Convert normal frequency alternating current (50 Hz) to high frequency alternating current (50 kHz) Ion Exchange is not possible at such a rapid rate of change of current no stimulation Modern electrosurgical units can produce currents in the range of 200–300 kHz. High frequency AC to a small area raised temperature & coagulation.

40. 45 Monopolar: Patient's body forms part of circuit Used for cutting and coagulating Bipolar: Current passes between tips of forceps, not through patient Used for fine coagulation Diathermy may be:

41. 46 The plate contact is crucial Current (  heat) is focused at the point of the instrument and dissipated over the area of the plate (10 000x larger) Monopolar Diathermy

42. 47 May earth if body comes into contact with metal or if plate is not in full contact Monopolar diathermy (cont.) X

43. 48 750 volts No return electrode Bipolar diathermy

44. Principle Whenever current is concentrated in a small area heat is generated. This heat can be used for coagulating and cutting tissue.

45. 50 Pacemaker malfunction Arcing to metal instruments and implants Burns if used with spirit-based skin preparations Burns from shorting or improper application of plate Risks when using diathermy:

46. Electrocautery Smoke contains: – Toluene, benzene, hydrogen cyanide, formaldhyde – Potential carcinogens – Avoid inhalation using Inline filters, effective evacuation systems, improved masks Avoid using diathermy inside bowel as it contains flammable gases: hydrogen, methane

47. 53 DIATHERMY = DANGER! It’s your responsibility!

48. Thanks

49. References Bailey &Love 25 th edition Foster, M.E. & Morris-Stiff, G. (2000) Basic Surgical Operations. Churchill Livingstone  Kirk, R.M. (2002) Basic Surgical Techniques 5th Ed. Elsevier Churchill Livingstone Okoshi K, Kobayashi K, Kinoshita K, Tomizawa Y, Hasegawa S, Sakai Y. Health risks associated with exposure to surgical smoke for surgeons and operation room personnel. Surg Today. 2015 Aug;45(8):957-65. doi : 10.1007/s00595-014-1085-z. Epub 2014 Nov 25. PMID: 25421864. National Association of Theatre Nurses (2004) Standards and Recommendations for Safe Perioperative Practice. NATN