03 Surgical Operations

03 Surgical Operations Principles of Surgery

2009 YONG YONGS NOTES - SURGERY 3-1

Surgical Operations

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Setting up the Operation Theatre

1. Location

a. Away from noisy / busy area

b. Easy access from A&E, ICU, ward

2. Number of Theatres

a. Workload

b. Staff

3. Nature of Theatres

a. Clean vs Dirty

b. Emergency vs Elective

c. Endoscopy room

d. Day Surgery

4. Zone

a. Sterile zone Operating room b. Clean zone Scrub room c. Dirty zone change room

5. Setup Facilities

a. Ventilation laminar flow, air condition, air flow, exhaust for

anesthetic gas

b. Lighting

c. Electrical

d. Gases

e. Monitor

6. Ancillary Facilities

a. Central sterile supply department

b. X-ray / image intensifier

c. Laboratories, frozen section

d. Blood bank

e. Storage

f. Teaching facilities

7. Others

a. Rest room

b. Changing room

c. Reception

d. Recovery

Principles of Sterilization and

Disinfection

Sterilization

1. Complete removal or inactivation of

viable microorganism (protozoa, fungi,

bacteria and viruses)

2. Type

a. Wet heat - 121C for 20min

b. Dry heat - 160C for 1 hour

c. Chemical - Formaldehyde,

glutaraldehyde, ethylene oxide

d. Irradiation

Disinfection

1. Significant reduction in the numbers of

organism present, particularly those that

might cause infection.

2. Antiseptics mild disinfectants that can be used on living tissues without causing

undue harm.

3. Example

a. Chlorhexidine 0.5%-4%

b. Povidone iodine 10%

c. Alcohol 70%

Hazards in the Operating Theatres

1. Staff

a. Wrong Identification - patient, side

operation, blood transfusion

b. Error transfer patient, retained swabs/instrument, tourniquet

duration

c. Position of patient brachial plexus injury

2. Environment

a. Poor Housekeeping water/wire on floor, poor lay-out

b. Thermal cold, thermal blankets c. Radiation pregnant staff X-ray d. Infection blood, Hep B, AIDS e. Chemical cleansing solution,

mistaken drug IV or regional

3. Equipment

a. Electrical diathermy, wire, plugs b. Laser hazards

c. Sharp instrument



Surgical Operations

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Daycare or Ambulatory Surgery

1. Definition

a. Any surgical procedure or

investigation performed on a

planned non-resident basis which

nevertheless need recovery facilities

2. Advantages

a. disruption to patients normal lives

b. morbidity - nosocomial infection

c. in-patient waiting list

d. cost, more cost efficient

e. Avoiding prolonged hospital stay

f. availability of in-patient bed

3. Disadvantages

a. rapport with patient

b. postop observation

c. Unexpected complication

4. Patient selection

a. Patient factors

i. Age < 70, > 6 months

ii. ASA Grade I or 2

iii. BMI < 30

b. Social factors

i. Live within 1 hour from hospital

ii. Access to telephone/ toilet

iii. Availability of a responsible adult

5. Operation selection

a. Short duration < 2 hours

b. Low incidence of complication

c. Not require blood transfusion

d. Not require major postop analgesia

6. Contraindication

a. ASA 3, 4, BMI >41

b. Operation > 2 hours

c. Poorly controlled DM, HPT, Asthma

d. Live > 1 hour from hospital

e. No telephone, toilet, guardian

7. Discharge criteria

a. Stable vital signs, alert, orientated

b. Comfortable, pain free

c. Able to walk, tolerate oral fluids

d. Discharge with follow up + contact

telephone number

Principles and Anatomy of Surgical

Access

1. Before Incision

a. Position patient

i. Lloyd-Davis - perineum

ii. Lateral - kidney

iii. Prone jack-knife - rectum/anus

iv. Trendelenburg - varicose

b. Prophylaxis antibiotic, DVT

c. Hair removal shortly before surgery

d. Sterile skin preparation

i. Povidone iodine 10%

ii. Alcohol 70%

iii. Chlorhexidine 0.5%

e. Sterile drap

i. Double thickness linen sheets

ii. Waterproof disposable fabric

Hepatitis / HIV

iii. Adhesive polyurethane film

Orthopedic / Vascular

f. Isolating stoma or infected areas

2. Principles of assess incision

a. Careful planning, adequate exposure

b. Single movement incision

c. Dont cross joint, follow Langers line d. Gentle tissue handling

e. Avoid old scar - adhesion below

f. Know tissue plane

g. Consider cosmetic aspect

h. Prevent faecal contamination

3. Closure

a. Avoid tension ischamic

b. Appose the tissue gapping

c. Repair each layer dead space

d. Control bleeding hematoma

e. Choose correct suture

f. Mass closure dehisce

i. 1cm from wound edge

ii. 1cm apart

iii. Suture 4 x length of incision

4. Type of incision

a. Midline - laparotomy

b. Paramedian - laparotomy

c. Kocher - cholecystectomy

d. Transverse - children

e. Lanz - appendicectomy

f. Pfannenstiel - caesarean Section



Surgical Operations

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Basic Surgical Techniques

Suture Materials

1. Natural

a. Absorbable

i. Plain Catgut

b. Non-absorbable

i. Silk, Linen

ii. Stainless steel wire

2. Synthetic

a. Absorbable

i. Vicryl - polyglactin

ii. Maxon - polyglyconate

iii. Dexon - polyglcolic acid

iv. PDS - Polydioxone

b. Non-absorbable

i. Nylon - Polyamide

ii. Prolene - Prolypropylene

iii. Polyester - Dacron

3. Type

a. Monofilament

i. Smooth - Easy fracture

b. Multifilament

i. Braided - Easy to handle

4. Needle

a. Conventional cutting

b. Reverse cutting

c. Round body taper point

d. Taper cutting

e. Blunt point

5. Diameter 6-O = 0.07mm 2-O = 0.30mm

5-O = 0.10mm O = 0.35mm

4-O = 0.15mm 1 = 0.40mm

3-O = 0.20mm 2 = 0.50mm

Dressing - Ideal surgical dressing

1. Absorbent, able to remove exudates

2. Maintain moist environment

3. Be leak-proof

4. Maintain temperature and gas exchange

5. Pain free, easy dressing

6. Be odourless

7. Be inexpensive

Plaster Casts

Hemostasis in Surgery

1. General Measures

a. Tamponade pressure dressings b. Correct coagulopathy

c. Transfusion of platelets, FFP, cryo

d. Specific treatment steroids, plasmapheresis

2. Surgical Hemostasis

a. Diathermy

b. Direct sutures

c. Hemostatic agents

d. Ligation of feeding vessels

e. Removal source of bleeding

f. Endoscopic hemostasis

The Use of Diathermy in Surgery

1. Principles

a. Use of high frequency (400kHz to

10MHz) alternating current (AC) to

produce heat (1000C)

b. Effect

i. Cutting - Continuous, sinus wave

ii. Coagulation - Pulse, square wave

c. Type

i. Monopolar Diathermy

ii. Bipolar Diathermy

d. Patient body forms part of the

electrical circuit

2. Monopolar Diathermy

a. Current passes between active

electrode and patient plate

electrode (70cm2

) current passes through pt.

b. Localized heating is produced at tip

of instrument, minimal heating effect

at patient plate electrode

3. Bipolar Diathermy

a. Two electrodes are combined in the

instrument (e.g. forceps)

b. Current passes between tips and not

through patient

4. Risk and Complications

a. Interfere with pacemaker

b. Arcing can occur with metal

instruments and implant

c. Superficial burns if skin had spirit

d. Burn at patient plate electrode

e. Channeling effect if used on penis or

testis



Surgical Operations

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Surgical Drains

1. Clinical Applications

a. Postoperative drainage

i. Drain infective focus

ii. Drain normal body fluid

iii. To collapse dead space

iv. To detect leak

v. To assist re-expansion

vi. To aid healing

b. Therapeutic

i. Pneumo-, hemo-, pyothorax

ii. Intestinal obstruction, ileus

iii. Drain abscess

iv. Acute urinary retention

c. Prophylatic

i. Chest tube - # rib

ii. Caecostomy colon op iii. NG tube postop ileus

2. Type of Drain

a. Close Drain

i. By gravity

ii. By suction

b. Open Drain

i. Gauze

ii. Rubber corrugated drains iii. Latex penrose drains

Basic Principles of Usage of

Implants and Prosthesis in Surgery

1. Prosthesis Fitting of artificial parts into the body

2. Basic principles

a. Easily and reliably manufactured

b. Reasonable cost

c. No adverse reaction

d. Degree of incorporation into the

body

i. Metallic, silicone are isolated

with collagen capsule

ii. Polytetrafluoroethylene (PTFE)

allow ingrowth of fibroblast

3. Implant materials

a. Surgical-grade stainless steel

b. Alloys Vitallium c. High density polyethylene

d. Silicone

e. Dacron and PTFE

4. Risk factors for infection

a. Immuno-compromised host

b. Active infection in host

c. Cross infection in hospital

d. Failure of sterilization / packing

e. OT inadequate ventilation f. Poor operative technique

g. Inadequate antibiotic prophylaxis

Basic Principles of Minimal Access

Surgery

1. Advantages

a. Early return to work

b. Less postop pain

c. Better cosmetic

d. Short hospital stay

e. Less morbidity

2. Disadvantages

a. Specialized training surgeon, staff

b. Expensive equipment

c. Increased Complication

Documents

03 Surgical Operations