PRINCIPLES OF SURGERY

In this book, you will find some very basic information concerning general surgery. It is divided into three parts and you also can learn something more from a video CD with video instructions about e.g. knot tying techniques. The three chapters you will deal with are:

Surgical Instruments
This section consists of a photo gallery and key points about the instruments of surgery. It also includes information on proper instrument handling.

Preparing the equipment for surgery

This section introduces the methods of equipment of sterilization. It includes basic information about how to prepare equipment for sterilization and how to ensure that proper sterilization is achieved.

Sutures and suture handling

This section includes instructional videos to help you learn the suture patterns and knot tying presented in the laboratory. Both right handed and left handed knot tying are included.

I. SURGICAL INSTRUMENTS
Surgical instruments exist in vast numbers and varieties. The following are examples of the basic instruments that should learned by every begining surgeon.

SCISSORS
Classification by type of points All types of scissors can have blunt or sharp blades (A: Sharp:Sharp, B: Blunt:Blunt).

All types can have either straight or curved blades.

Mayo and Metzenbaum Mayo scissors (B) are used for cutting heavy fascia and sutures. Metzenbaum scissors (A) are more delicate than Mayo scissors. Metzenbaum scissors are used to cut delicate tissues. Metzenbaum scissors have a longer handle to blade ratio.

FORCEPS

Forceps: consist of two tines held together at one end with a spring device that holds the tines open. Forceps can be either tissue or dressing forceps. Dressing forceps have smooth or smoothly serrated tips. Tissue forceps have teeth to grip tissue. Many forceps bear the name of the originator of the design, such as Adson tissue forceps. Rat Tooth: A Tissue Forceps Interdigitating teeth hold tissue without slipping. Used to hold skin/dense tissue.

Adson Tissue Forceps Small serrated teeth on edge of tips. The Adsons tissue forceps has delicate serrated tips designed for light, careful handling of tissue.

Allis: Intestinal Tissue Forceps: Hinged (locking) forceps used for grasping and holding tissue. Interdigitating short teeth to grasp and hold bowel or tissue. Slightly traumatic, use to hold intestine, fascia and skin. Babcock: An Intestinal Tissue Forceps More delicate that Allis, less directly traumatic. Broad, flared ends with smooth tips. Used to atraumatically hold viscera (bowel and bladder).

Sponge Forceps

Sponge forceps can be straight or curved. Sponge forceps can have smooth or serrated jaws. Used to atraumatically

Hemostatic forceps: Hinged (locking) Forceps. Many hemostatic forceps bear the name of the designer (Kelly, Holstead, Crile). They are used to clamp and hold blood vessels. Classification by size and shape and size of tips Hemostatic forceps and hemostats may be curved or straight.

Kelly Hemostatic Forceps and Mosquito Hemostats Both are transversely serrated. Mosquito hemostats (A) are more delicate than Kelly hemostatic forceps (B).

Comparison of Kelly and Mosquito tips Mosquito hemostats (A) have a smaller, finer tip.

Carmalt Heavier than Kelly. Preferred for clamping of ovarian pedicals during an ovariohysterectomy surgery because the serrations run longitudinally. 5

Intestinal Forceps

Doyen Intestinal Forceps Doyen intestinal forceps are noncrushing intestinal occluding forceps with longitudinal serrations. Used to temporarily occlude lumen of bowel.

Payr Pylorus Clamps Payr pylorus clamp is a crushing intestinal instrument. Used to occlude the end of bowel to be resected.

NEEDLE HOLDER
Needle holder: Hinged (locking) instrument used to hold the needle while suturing tissue. These may be straight or angled. The latter are useful when working at a depth or where there is a space constraint. The size of the needle holder must correspond to the size of needle it must grasp. Needles are held at the junction of their upper third and lower two thirds, at right angles to the needle holder, proximal to the tip and at the first ratchet.Good quality is ensured with tungsten carbide inserts at the tip of the needle holder. Mayo-Hegar Heavy, with mildly tapered jaws. No cutting blades.

Olsen-Hegar Includes both needle holding jaw and scissors blades. The disadvantage to having blades within the needle holder is the suture material may be accidentally cut.

Classification of needles
TYPE PROFILE Round Cutting Reverse cutting Blunt Diamond Precision point Multipurpose Roto grip SHAPE Straight Curved (3/8, 5/8,1/2 circle) JShaped

Atraumatic Eyed

RETRACTORES
Senn Blades at each end. Blades can be blunt (delicate) or sharp (more traumatic, used for fascia).

Hohman Levers tissue away from bone during orthopedic procedures

SCALPELS
Handles #3 Handle #4 Handle

Handles and Blades Blades #10, 11, 12, 15 fit the #3 handle. Blades #22, #23 fit the #4 handle and are commonly used for large animals.

Disposable Scalpel

TOWEL CLAMPS
Towel clamps secure drapes to a patient's skin. They may also be used to hold tissue. Backhaus Towel Clamp Locking forceps with curved, pointed tips.

PORPER INSRTUMENTS HANDLING

Scissors and Hemostats:

The thumb and ring finger are inserted into the rings of the scissors while the index and middle finger are used to guide the instrument.

Thumb Forceps:

Thumb forceps are held like a pencil.

Scalpels: The scalpel is held with thumb, middle and ring finger while the index finger is placed on the upper edge to help guide the scalpel.

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II. PREPARING THE EQUIPMENT FOR SURGERY

A) STERILIZATION TECHNIQUES
In this section we mention some mainly used techniques of sterilization. 1. STEAM STERILIZATION IN AUROCLAVE An autoclave is a self locking machine that sterilizes with steam under pressure. Sterilization is achieved by the high temperature that steam under pressure can reach. The high pressure also ensures saturation of wrapped surgical packs. Autoclave Settings General Wrapped Items Bottled Solutions 'Flashing' Temperature (F) 250 250 270 Pressure (PSI) 20 20 30 Time (min) 30 30 4-7

2. ETHYLENE OXIDE 3. COLD - COLD (CHEMICAL) STERILIZATION Instruments must be dry before immersion. Glutaraldehyde (Cidex) is the most common disinfectant. 3 hours exposure time is needed to destroy spores. Glutaraldehyde is bactericidal, fungicidal, viricidal, and sporicidal. 4. RADIATION AND FILTER - RADIATION STERILIZATION: High energy ionizing radiation destroys microorganisms and is used to sterilize prepacked surgical equipment. Used for instruments that can't be sterilized by heat or chemicals. Radiation sterilization is being promoted as an alternative to ETO sterilization. Care needs to be taken because not all materials can be irradiated successfully. Currently used by manufacturers, but not used in veterinary hospitals. Common sources of radiation include electron beam and Cobalt-60.

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B) STERILIZATION METHODS HANDOUT

A. Methods of Sterilization 1. Physical Methods a. Steam Thermal - Autoclave i. Definition -- a self-locking apparatus for the sterilization of material by means of steam under pressure. ii. Settings for general wrapped items: Temp. - 250oF Pressure - 20 PSI Time -- 30 min Setting -- Fast Exhaust & Dry iii. Settings for bottled solutions: Always vent bottles to avoid bursting! Temp. - 250oF Pressure - 20 PSI Time -- 30 min Setting -- Slow Exhaust iv. Setting for "Flashing" an unwrapped instrument: Temp. - 270oF Pressure - 30 PSI Time -- 4-7 Min Setting -- Fast Exhaust v. Notes -- The above are general steam autoclave settings. Different models may operate with varying settings. Always refer to the appliance literature before operating a new piece of equipment. b. Radiation i. Use on materials that cannot be sterilized by heat or chemicals ii. Radiant energy destroys microorganisms c. Filtration -- is a method utilizing filters capable of screening out microorganisms 2. Chemical Methods a. Ethylene Oxide Gas i. Colorless gas at room temperature ii. Odor similar to ether iii. Very toxic and irritating to skin and mucous membranes iv. Microorganism destruction is caused by a chemical reaction v. Materials sterilized need to be aerated in well ventilated room or placed in an aerator. Length of time required depends on items sterilized. vi. Effective sterilization is dependent on concentration of gas, exposure time, temperature, and relative humidity vii. Hazardous chemical, use great care

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b. Cold Sterilization i. Instruments should be completely dry before soaking to prevent dilution ii. Instrument soaking solution - 10-20 minute emersion only disinfects iii. Incomplete destruction of spores, unless soak is for 10 hours iv. Examples: Instrument Germicide (Phenol and Ethyl alcohol), CidexTM (Glutaraldehyde) v. Most require thorough rinsing before using instrument vi. Contact time required varies with product used B. Sterilization Shelf Life of Packaged Supplies 1. The following wrapped items, if carefully maintained, are sterile for up to one (1) month: a. Double cloth wrapped instruments b. Double paper wrapped instruments c. Inexpensive peel pouches for gauze sponges d. NalgeneR saline bottles 2. Two (2) packaging methods are sterile for up to six (6) months: a. MonarchR Instrument Canisters -- Special box system with single use filters for use in steam autoclaves b. Sterility Maintenance Covers -- Sealable plastic covers to place over freshly autoclaved and cooled packs to extend shelf life by diminishing air penetration 3. Heat sealed packages commercially prepared in tube or peel pouch form may be considered sterile for up to one (1) year. C. Sterility Check List Before assuming a pack is sterile, always evaluate the following before opening the pack: 1. Expiration or sterilization date 2. Indicator color change 3. General condition of wrapper and how it had been stored 4. Always check for holes or moisture damage

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C) SELECTING AND PACKAGING GOWNS

Disposable Paper Gown ADVANTAGES: Paper gowns are resistant to wetting so they are less permeable to bacteria. They are preferred for wet bloody surgery (equine abdominal surgery). Donning a new gown for each surgery and disposing of it at the end ensures sterility. DISADVANTAGES: Paper is less ecologically sound because it is not reusable.

Linen (cloth) Gowns ADVANTAGES: Linen gowns are both comfortable and reusable. Previously worn gowns can be autoclaved to regain sterility. DISADVANTAGES: Linen is a woven material so that when it becomes wet, bacteria can permeate through its interstices. Linen is not the gown material of choice for wet, bloody surgical procedures.

Plastic Gowns ADVANTAGES: Plastic is superior in its resistance to wetting and bacterial penetration. Plastic can be used to reinforce paper gowns during wet surgery (plastic sleeves for abdominal surgery). DISADVANTAGES: Plastic is extremely uncomfortable to wear because of the inability to shed heat and perspiration.

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III. SUTURES AND SUTURE HANDLING

There are several types of knots used in surgery. You can distinguish simple knots and ties, which form sutures. You can see 13 videos of basic knots and suture patterns. Video list is on the last page.

Tying Ligatures and Sutures

Basic knots and ties include: Square Knot, Surgeon's Knot, Deep Tie, Ligation Around a Hemostatic Clamp, Instrument Tie

Suture Patterns can be continuous or interrupted:

Interrupted Patterns: Simple Interrupted Pattern,Burying The Knot, Horizontal Mattress Pattern , Vertical Mattress Pattern Continuous Patterns: Simple Continuous Pattern, Ford Interlocking Pattern, Lembert Pattern, Connell Pattern, Cushing Pattern, Subcuticular Pattern, Subcutaneous Pattern, Continuous Everting Mattress Pattern

Insert needle through the skin at right angles including enough subcutaneous tissue to aid in everting the skin edges Exit through skin of the opposite edge at the same angle including a comparable volume of subcutaneous tissue.

Used mainly to aid in everting skin edges in areas with a tendency to invert. Insert needle as in [1], at least 1cm away from the edge and exit through the opposite edge at the same width and depth Using a backhand grip reinsert needle through the skin close to the edges in the reverse fashion.

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Connells suture for tendons:

Match correct tendon ends using the position of the tendons & the corresponding shapes of the cut ends. Fix tendon with a needle and steady one end with a needle. Do not grasp tendons with any instrument as this will promote adhesions.

Suture materials:
can be absorbable or non-absorbable. Both of them have some dis-and advantages:

Absorbable sutures Name Plain Catgut Chromic Catgut Poliglecaprone 25 Polyglactin 910 Polyglycolic acid Polydioxanone Brand Name Tissue Reactivity Knot Security Handling ----Monocryl Vicryl Dexon PDS II severe moderate minimal minimal minimal minimal poor good good fair fair good fair good good good good good

Non-absorbable sutures Name Silk Braided Polyester Stainless Steel Wire Polypropylene Polyethylene Brand Name ----Prolene, Fluorofil --Tissue Reactivity severe practically none minimal minimal Knot Security Handling good poor excellent good poor excellent good poor fair fair

Ethibond, Tevdek moderate (if coating sheds)

Suture size is based on strength and diameter as decided by the United States Pharmacopeia (U.S.P.) This system uses "0" as the baseline, average size suture. As suture diameter decreases, "0's" are added or numbers followed by a "0" (for example, 000 and 3-0 are the same size). As suture diameter increases above "0", numbers are assigned to the suture material. 16

On the pictures below you can see some examples of suture materials and suture scale and usage, respectively.

VIDEO LIST
About 50 MB of video sequences are available. Using Quick Time Player, you can see and try to imitate: 1.mov square knot, two-handed technique, right handed 2.mov square knot, two-handed technique left handed 3.mov surgeons knot, rigt handed 4.mov deep tie, right handed 5.mov ligation around a hemeostatic clamp 6.mov instrument tie 7.mov simple interrupted suture pattern 8.mov horizontal mattress suture pattern 9.mov vertical mattress suture pattern 10.mov simple continuous pattern 11.mov Connell pattern (for tendons) 12.mov subcuticular suture 13.mov subcutaneous suture

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