Surgical Operations PDF

Surgical Operations 1 General Principles of Surgical Operations Types of suture materials I- Absorbable sutures: A. Natural: 1. Plain catgut: From the submucosal collagen of the sheep's intestine....

Surgical Operations 1 General Principles of Surgical Operations Types of suture materials I- Absorbable sutures: A. Natural: 1. Plain catgut: From the submucosal collagen of the sheep's intestine. Time of absorption: one week. (absorbed by phagocytosis) Uses: Its use is limited now because of severe reactions. 2. Chromic catgut: Like plain catgut, but it is modified by chromium salt solution to make it less irritant and to increase time of absorption to 3 weeks. B. Synthetic: 1. Dexon (polyglycolic acid): Multifilamentous with good tensile strength, Time of absorption: 4 months. 2. PDS (Polydioxanone synthetic smooth suture): It is monofilamentous,so it is useful in suturing infected or contaminated wounds Time of absorption: 6 months. 3. Vicryl (polyglactin): It is multifilamentous. Time of absorption: after 4 months. Used now: for gastrointestinal anastmosis. 4. Monocryl polyglecapron 25: Monofilament with high tensile strength. Time of absorption: 3-4 months. II- Non absorbable sutures: A. Natural: Surgical silk: It is multifilamentous. Rich in protein material so it causes marked tissue reaction. If infection occurs, we remove sutures to allow improvement. B. Synthetic: 1. Nylon (Ethilon): It is polyamide. Mono-or multifilamentous with good tensile strength. 2. Prolene (Polypropylene): Monofilamentous with good tensile strength But: it has difficult knotting. 3. Polytetrafluroethylen e (PTFE): Minimal tissue response with good handling. 4. Recently Stapler. Adhesive tapes. , Stainless steel  Surgical Operations 2 NB: 1. monofila ments sutures: Made up of single strand, less harbourin g of organisms , well suite for vascular surgery 2. multifilam ent sutures: made up of several filaments as strand , greater tensile strength 3. tensile strengh: Is the strength, which is required to hold the tissues in proper Apposition TYPES OF STITCH ES (Refer to CD videos). ,;,i~; ~\i;f:/l~ c. i~f \:r : ·f.:. \. ~\:. A. lo~~.rr.YP.t.~(I_; 1. Simple. 2. Mattress: a. Vertical mattress. b. Transvers e (Horizonta l) mattress. 3. Lembert' suture: It is the 2 nd row of sutures: CD a- The 1st is all through b- The 2nd is the inverting sutures = _o___ =v ~: 4. Tension suture. B..G9.0.t.i.O.Y9.Y.$_; 1. Simple overhead. 2. Blanket suture. 3. Quitted suture. 4. Lembert's suture. 5. Connell's suture. (loop on mucosa). When ► It should be removed within 1-2 weeks depending on anatomica l location 1. Face ➔ 5-7 days 2. Scalp ➔ 10 days 3. Trunk & upper extremitie s ➔ 10-14 days 4. Lower extremitie s ➔ 14-21 days Surgical Operations 3 ► Prompt removal reduce the risk of suture marks infection tissue reaction How Skin should be cleaned & sterilized Suture is gently elevated with forceps one side is cut then grasping by the knot then pulled towards the suture line 1. Steri- Strips 2. Staplers 3. Tissue adhesive 4. Barbed sutures es of Sutur e Needles A. A,q:;9,r_(tj_i:,g_t9.J'1g_$h~.Pg_9.f._th~.. J:IJ~g~_I_~,:. (1) Straigh t: it is used in superficial structure s e.g. skin. (2) Curved: either 3/8, 1/2, 5/8 of a circle. n n r,::....... _,.,,,,,,, --- B. Aq::;9,r_(t tog.t9..t.'1g. ~r9.~$. J,~.~t.i.9.i:i..9.f. th.~. n~-~~-' ~- ( 1 J Rounde d needle: Its cross section is circular //J Used for organs, mucosa and intes tines.~- (2) Cutting needle: i Its cross section is triangula r (Sharp borders). Used for sutures in the skin. C. -~-q:;9,r_(tj_i:,g_t9..t.'1gJbx.~~-dj_i:,g; ( 1) Eyeless : The thread is incorporated within the needle So the needle can not be threaded. Used in plastic, vascular, neuro-su rgery, intestine and organs. (2) Eyed needle: There is a small opening ( eye) in the needle, So, it can be threaded and reused. Its use is limited. Surgical Operations 127 General anesthesia ➔ Lithotomy ➔ cruciate incision, trimming of the edge. Submucou s abscess ➔ procotoscop e & diathermy knife. 4- Others: ► Neck: transverse parallel to skin crease. ► Axilla: vertical (gap on adduction). ► Fore hand: transverse (crease). ► Cheek: semilunar. ► Cubital & pop. Fossa: transverse. ► Gluteal abscess: With direction of gluteus maxims fibers i.e. downwards forwards & laterally. NB. Abscess where we do not wait for fluctuation : in important areas a. Parotid. b. Breast. c. Pulp. d. Peri-anal. B. Cold abscess: ► Anti-T.B drugs. ► The rule is aspiration (not drainage). a- Aspiration : Independen t site. Healthy skin area. Enter zigzag way. Complete aspiration. Inject streptomyc in. Repeat it. b- Drainage: In 2 conditions: 2ry pyogenic infection. Impending rupture. Open in independen t area ➔ wall is curetted well ➔ dust with streptomyc in ➔ close without drain. Surgica l Drai Drains: Classificatio n: o Open. o Closed. o Active. o Passive. Uses: o Withdrawal of fluids. o Apposition of tissues to remove potential space by suction. Types: o Corrugated drain: Safety pin on skin. Shorten everyday. Doesn't get lost. o Open passive drain: Simple pack "gauze dressing" Abscess.  Surgical Operations 128 o Closed passive: Robertson's. Similar to T-tube o Closed Active J-Vac (mastectom y) (e.g. thyroidecto my) Closed suction system [Tube + bag + suction] o Open active Suction in peritoneum Pump Drains are inserted to: o Evacuate establish collections of pus, blood or other fluids o Drain potential collections Advantage s: o Drainage of fluid removes potential sources of infection o Drains guard against further fluid collections o allow the early detection of anastomoti c leaks or haemorrha ge o Leave a tract for potential collections to drain following removal Disadvant age: o Presence of a drain increases the risk of infection o Damage may be caused by mechanical pressure or suction o Drains may induce an anastomoti c leak o Most abdominal drains became infective within 24 hours Tubes and Drains NG tube: Decompres sion: o Remove gas at top of stomach Long term feeding: o 1 week/1 month o Silicon narrower and softer o Complex carbs/prote ins/polypep tides Used for acute poisoning Made of PVC or Latex (note - fibrosis in latex) 45 cm long (Esophagus ➔ 25 cm long) Indications : o Decompres s stomach o. Prevent aspiration o Long term feeding · o Poisoning Contra-indi cations: basal skull fracture Complicatio ns: o Pressure necrosis ➔ anosmia o Aspiration pneumonia /atelectasis o Sinusitis o Minor upper GIT bleed o Epistaxis o Pharyngeal irritation How to insert one: o Explain procedure to the patient o Measure from tip of nose around the ear lobes to xiphoid o Prepare equipment - sterile, lubricant gel etc o Ask patient to swallow as passing tube down (ice chips/wate r) o Gentle and firm continuous pressure o Confirm placement by Aspiration of contents Surgical Operations 129 Inject air and listen for sound with stethoscope Low chest x-ray Orogastric tube: Poisoning Massive upper GI bleed Basal skull fracture Foley Catheter: Uses: o Drain bladder in acute retention o Monitor output o Bladder surgery o Pelvic surgery e.g. C-section o Empty bladder before surgery Self-retaining 2 channels or 3 channels Balloon Side arm and valve mechanism ensures balloon stays inflated 3-way is wider and harder o Can't be left in too long o Used for continuous irrigation of bladder in hematuria Materials: o Latex: change in 3 weeks o Silicone: 3 months o PVC: intermittent self catheterization Complications: o UTI's Prevented by Continuous drainage Avoiding stasis Drink a lot of fluids Change regularly o Strictures o Stone formation o Reduced sphincter tone o Paraphimosis o Blockage o By-passing Endotracheal tube: Clear/transpare nt Cuffed/uncuffed o Cuffed Aspiration protection. Adults o Uncuffed ➔ children. Size ➔ internal/outer. Graded. Radio-opaque line. One use only. Other types: o Double lumen. o Reinforced. o Laser. Cuffed endotracheal tube