Tissue Layers and Incisions

8/10/2019 Tissue Layers and Incisions

1/19

Sterile means free of microorganisms including the pores while asepsis means absence ofmicroorganisms that cause disease . Sterile techniques are methods employed inside theoperating room to prevent contamination of organisms throughout the surgical procedure.It is very important for nurses to know and understand the principles governing sterility topromote safety of the patient during operation.

When are sterile techniques used or applied?

1. Preparation for an invasive procedure2. In preparation of the sterile team to handle sterile supplies and contact to the

surgical site (gowning, gloving and scrubbing)

3. Skin preparation and draping of the patient

4.

Sterility maintenance throughout the operation

Principles of Sterility

Principle Number 1 : Only sterile items are used within the sterile field.

Drapes, basins, sponges are obtained from a stock room with sterile packages. Theinstruments used are sterilized and are placed in a sterile table. Any person who holds thesterile equipments should be very cautious to maintain sterility. One importantconsideration in implementing sterility is this: IF YOU ARE IN DOUBT ABOUT THE

STERILITY OF A CERTAIN OBJECT, CONSIDER IT UNSTERILE. Any suspected or knownunsterile items should not be placed the sterile field.

Any sterile package found in an unsterile or contaminated area is consideredunsterile.

If the actual timing or sterilization procedure is undetermined and the nurse isunsure about the sterilization process, the equipments sterilized with the suspectedprocedure are considered contaminated.

A sterile table which has been touch or rubbed accidentally by an unsterile personor vice versa is no longer considered sterile.

If the packaging material is broken or has missing pieces it is no longer sterile.

Microorganisms can enter a packed sterile package when it is damp or wet. Thus,damp packages are unsterile.

A sterile package dropped on a floor is considered contaminated.

Principle Number 2: Sterile persons are gown and gloved.

When wearing a gown, the considered sterile area is the part where you can see in frontdown to the level of the sterile field. Thus, gowns are only considered sterile in front of the


2/19

chest, sleeves above the elbow to the cuffs down to the level of the sterile field. Certainmethods should be employed in the OR:

Gowning is not done on the sterile table to avoid dripping water onto the sterileequipments. Gloving and self-gowning should be done in a distinct sterile surface.

Stockinette cuffs of the gowns are absorbent and may retain moisture, thus makingit a suitable area for bacteria or microorganisms to thrive in. because of the saidprinciple, stockinette cuffs should be inserted beneath the sterile gloves.

Principle Number 3 : Tables are only sterile at Table Level

Edges and sides of the table drape are considered contaminated. Below the tablelevel is also considered unsterile.

Any sterile person who touches a part of the drape hanging below the table level isconsidered unsterile. Any object or equipment that drops below the table surface isconsidered contaminated.

In unfolding and placing a sterile drape any portion of that falls below the tablesurface is unsterile and should not be moved or touched or brought back up to thelevel of the table.

To prevent cords and tubing from sliding to the edge of the table, it should befastened with a non-sharp device or object.

Principle Number 4: Sterile Persons Touch ONLY Sterile Items while Unsterile ORPersonnel Touch Only Unsterile Items

Sterile OR personnel comes in direct contact with persons who wears gowns andgloves only. The items that they will touch are the sterile equipments. Any supply

brought by an unsterile staff should transfer the item in a sterile manner. Unsterile OR personnel (circulator), should not directly come in contact with a

gowned and gloved person.

Principle Number 5 : Unsterile persons avoid reaching over sterile field and sterilepersons avoid touching or leaning over an unsterile area.

In cases where a solution has to be poured into a sterile basin, the unsterile ORpersonnel should only hold the lip of the bottle over the basin to prevent any contactwith the sterile area.

To prevent the circulator from reaching over a sterile area when pouring solutions,the scrub person places the basin and glasses or any container for solutions near theedge of the table. This prevents the circulator from reaching over the sterile area byjust standing near the edge of the table to fill the container with the liquid solution.

When surgeons perspire on their brows, he or she should to turn away from thesterile field and have the sweat removed by the circulator.

In draping or covering an unsterile table the scrub person drops the sterile drape atthe center of the table while holding the fan-folded drape high and standing backfrom the table to protect the sterile gown.


3/19

Sterile gloves are protected by cuffing a drape. The sterile OR personnel shouldplace the gloved hands inside the sterile part of the drape.

The scrub person unfolds the drape towards him or herself first to allow him or herto move closer to the table when working on the opposite side of the table since thefirst part of the unfolded drape now protects the sterile gown.

Principle Number 6: Edges of anything that encloses sterile contents are consideredunsterile

Sterile supplies are packed. In opening sterile packages, the area within 1 inch fromthe edges is considered unsterile. Supplies are handled by the circulator. The upperportion of the package is flapped away from the self and turns the side under. Indoing so, the end of the flaps is secured by the band of the circulator to prevent itfrom dangling loosely. The other flap is pulled towards the circulator; hence, thecontents are exposed yet away from the unsterile hands.

To open a sterile package, the flaps on peel-open packages should be pulled not

torn. The sterile contents should be flipped and lifted upward. The circulator shouldprevent the sterile contents to slide over the unsterile edges.

When lifting contents from packages, sterile personnel should lift the object straightup while holding their elbows high.

In cases where a sterile wrapper is used as a table cover instead of a drape, it shouldcover the entire table surface. Only the interior surface of the wrapper is consideredsterile.

Sterile bottles when opened cannot be recap without contaminating the pouringedges. Thus, all contents must be used or in cases where there is still a solution left,it should be discarded.

Principle Number 7: Sterile field is set-up just before a surgical procedure

The longer a sterile item is exposed to air and environment, the higher thepossibility of contamination.

The practice of covering a sterile set-up does is not in the best interest of the patient.Sterility cannot be guaranteed by just covering a sterile set-up, unless it is under aconstant surveillance.

Covering and uncovering a table may contaminate the sterile items.

Principle Number 8: Sterile areas are continuously kept in view.

Sterility cannot be guaranteed by just covering a sterile set-up, unless it is under aconstant surveillance.

Sterile persons should face the sterile area. While waiting for the patient to come inside the OR, someone must stay in the sterile

area to maintain vigilance on the sterile set-up. Direct observation ensures sterility.

Principle Number 9: Sterile persons keep well within sterile area.


4/19


5/19

If any part of the package becomes damp or wet it is considered unsterile andshould be discarded or re-sterilized.

Tables used for operation should be dried before draped. If the sterile drape is soaked with a solution the wet area should be covered with an

impermeable sterile towels or drape.

Sterile items should be placed not only in clean but also in dry areas. In handling sterile packages, the hands should be dried first. Air can also cause contamination. Thus, undue pressure on sterile packs should be

avoided. This prevents the ejection of sterile air and the entry of unsterile air intothe pack.

Principle Number 13: Microorganisms must be kept to irreducible minimum

Sterilization is the process of removing ALL microorganisms including the bacterial spores.However, not all things or area can be sterilized. The following principles are employed toemploy sterile technique in:

Skin

Skin cannot be sterilized thus, it can be very good source of contamination in anyoperation. To prevent entrance of microorganism to the patients wou nd the following aredone:

1. Surgical hand washing2. Chemical antisepsis of the skin around the surgical site3. Gowning and gloving4. Application of sterile draping.

Air

Air contains dust, droplets and shedding that may cause contamination. Environmentalcontrol measures include:

1. Movement around the sterile field is kept to a minimum.2. Drapes are not flipped and fanned to avoid the spread of dusts.3. Talking inside the operating room is kept to a minimum because moisture droplets

are expelled with force into the mask when a person is talking.


6/19

Deciding the right type of surgical incision is extremely important.

The ideal incision allows:

ease of access to the desired structures can be extended if needed ideally muscles should be split rather than cut heals quickly with minimal scarring

aesthetically pleasing

It is also important that incisions are placed in the direction of lines of cleavage of the skin(Langer's lines) so that a hairline scar is the outcome. These lines correspond to thedirection of collagen fibres in the dermis and epidermis.

Incisions should also be placed as far as possible from stoma sites in order to avoidinterfering with the stoma site and causing complications such as retraction and prolapseof the stoma.

Surgical incisions on the abdomen can be divided into transverse, vertical and

oblique incisions.

Vertical incision 1: Midline incision

Use : Virtually all abdominal procedures may be performed through this incision.


7/19

Location: in the midline of the abdomen, and can extend from the xiphoid process to justabove the umbilicus. It can be continued to below the umbilicus by curving the incisionaround the umbilicus.

Layers of the abdominal wall: skin, fascia (camper's and scarpa's), linea alba,transversalis fascia, extraperitoneal fat and peritoneum.

Advantages

1. Adequate exposure of most if not all of the abdominal viscera2. Minimal blood loss as the incision is through the linea alba

3. Minimal nerve injury4. Minimal muscle injury5. Can be quickly made, such as in an emergency and quickly closed with a mass closure

technique

Disadvantages

1. Care needs to be taken just above the umbilicus where the falciform ligament is2. Midline scar

Vertical incision 2: Paramedian incision

Use: provides laterality to the midline incision, allowing lateral structures such as thekidney, adrenals and spleen to be accessed.
http://www.fastbleep.com/assets/notes/image/2228_1.jpg


8/19

Location: about 2- 5cm to the left or right of the midline incision. Incision is over themedial aspect of the transverse convexity of the rectus.

Layers of the abdominal wall: skin, fascia (camper's and scarpa's) and the anterior rectussheath are incised. The anterior rectus muscle is freed from the anterior sheath andretracted laterally. The posterior rectus sheath (if above the arcuate line) or transversalisfascia (if below the arcuate line), extraperitoneal fat and peritoneum are then excisedallowing entry to the abdominal cavity.

Advantages

1. Provides access to lateral structures2. Rectus muscle is not divided3. Incisions in anterior and posterior sheath is seperated by muscle which acts as a

buttress, therefore closure is more secure4. Can be extended by a curvilinear incision towards the xiphoid process if required

Disadvantages

1. Takes longer to make and close2. Incision needs to be closed in layers3. Difficult extension superiorly as limited by the costal margin


9/19

4. Tends to strip the muscles of their lateral blood and nerve supply resulting in atrophy ofthe muscle medial to the incision

Vertical incision 3: Mayo-Robson incision

This is really a paramedian incision that has been curved towards the xiphoid process. Itallows a bigger and wider opening. Dissection continues in the same fasical planes as theparamedian incision.

Transverse incision 1: Transverse incision

Use: right or left colon, duodenum, pancreas, subhepatic space.

Location: This incision is made just above the umbilicus, dividing one or both of the rectus

muscles.Layers of the abdomen: skin, fascia, anterior rectus sheath, rectus muscle (+/- internaloblique, depending on the length of the incision), transversus abdominus, transversalisfascia, extraperitoneal fat and peritoneum. The medial aspect of this incision will bethrough the layers just like as in the midline incision.


10/19

Advantages

1. Less pain than a midline incision2. Good access to midline upper GI structures3. Transverse incisions cause the least amount of damage4. As the recti have a segmental nerve supply, it can be cut transversely without weakening

a denervated segment5. Muscular segments can be rejoined6. Commonly used in children and the obese as greater abdominal exposure is gained in

comparison with the vertical midline. This is due to the longer transverse length of theabdomen in children and the obese.

Disadvantages

1. Limited lateral access in comparison with midline incisions that can then be extended2. More wound infections compared to midline thought to be due to greater difficulty in

controlling bleeding and haematoma formation.

Transverse incision 2: Subcostal incision

Use: gallbladder and biliary tract, spleen. It is also known as the Kocher subcostal incision,after the person who discovered it. With the roof top or Chevron modification, access to


11/19


12/19

Use: This is the incision of most appendicetomies and can be used in the left lowerquadrant in left sided colonic pathology.

Location: McBurney's point, as described by Charles McBurney in 1884, is two thirds fromthe umbilicus and a third from the right anterior superior iliac spine. The incision isoblique beginning laterally from above and ending medially.

If palpation reveals a mass, perhaps an appendiceal abcess, then the incision is madedirectly over the mass.

Nowadays, the incision is made transverse and placed in a skin crease, the so calledtransverse Lanz incision as this is more aesthetically pleasing and the scar is hidden in thebikini line.

If it is anticipated that the incision will need to be extended, the oblique incision is usedwith lateral extension and as a muscle splitting (gridiron) surgical technique. Musclesplitting involves spitting the muscles fibres in a direction that is parallel to the direction ofthe muscle fibres.

Layers of the abdominal wall: skin, fascia, internal oblique medially and external obliquelaterally, transversus abdominus, transversalis fascia, extraperitoneal fat and peritoneum.

Advantages

1. Aesthetically pleasing incisions as they both follow Langer's skin lines


13/19

2. A wide range of pathologies in the right and left lower quadrants can be dealt with, withroom for extension if required

3. Minimal damage to muscles as muscle splitting techniques can be utilised4. Avoids damage to local nerves

Disadvantages

1. The ilioinguinal and iliohypogastric nerves cross the appendicectomy incision and thereis a risk of injury. This can then predipose to inguinal hernia formation post-operatively.This is more evident with the Lanz incision.

Transverse incision 4: Pfannenstiel incision

Use: Allows exploration of the lower GI and UT, as well as the pelvic reproductive organs.

Location: A convex 12cm incision, located a the suprapubic skin crease about 5cm abovethe pubic symphysis. Once the peritoneum is reached, it is incised vertically, taking care toavoid the bladder.

Layers of the abdominal wall: skin, fascia, anterior rectus sheath, rectus muscle,transversalis fascia, extraperitoneal fat, perineum.

NOTE: this incision is below the arcuate line and this there is no posterior rectus sheath.

EXTRA: MAYLARD INCISION

This incision is placed a couple of cm's above the pfannenstiel and also provides goodexposure of the pelvic organs. It cuts through the rectus fascia and muscle as well asexternal and internal obliques. Once transverse abdominus and transversalis fascia arereached, a muscle splitting technique is employed.


14/19

Advantages

1. A convex incision is made instead of a transverse as this parallels the course of thesegmental nerves that are cut and so minimising muscle parasthesia and paralysis post-operatively. It also follows the cleavage lines in the skin resulting in less scarring

2. Location of incision means it is hidden in the pubic hair line

Disadvantages

1. Limited exposure of the abdominal organs. Use of incision is therefore restricted to thepelvic organs

2. High risk of injury to the bladder especially because the fascia thins towards the lowerabdomen, leaving the bladder relatively exposed, and if the bladder is not catheterisedduring surgery

3. Extension of the incision is difficult laterally

4. Exploration of the deep pelvic organs is difficult making dissection in the obese difficult

Oblique incision: Thoraco-abdominal incisions


15/19

Thoracoabdominal incisions may be located in the RUQ or LUQ. They convert the pleuraland peritoneal cavities into one. They allow good access to the lungs, liver and spleen. Theleft incision can also provide good exposure to the oesophagus and the stomach.

Laporoscopic incisions

These incisions are small cuts in the skin made in the abdominal wall to allow theinstruments of laparoscopy access to the contents of the abdominal cavity.

Their location will depend on the organ being operated on. Generally there will be 3-4.One is always at the umbilicus to allow a port for the camera. The other incisions will belocated in one of the 4 quadrants for tools such as the griper, cutting and dissecting scissorsand so on.


16/19

Care of the surgical incision

Surgical incisions may be closed with sutures, staples, steri-strips or local tissue glue.

It is important to keep the wound site clean and incisions are often covered with a

protective dressing. Patients are encouraged to keep the wound as dry as possible to limitwound infection. Showering and bathing can resume after a couple of days. Wounds thatare closed with nonabsorbable sutures and staples require removal of these materials first.

While gentle exercise is encouraged, it is important to avoid pressure, pulling andstretching on wounds.

As wounds heal, it is common for patients to see their wounds becoming itchy, red, swollenand wounds may even ooze sero-sangiunous fluid. These all represent the healing process.It is important to know what is normal so that abnormalities in wound healing that mayrepresent infection, wound dehiscence, hypertrophic and keloid scars may be detected.


17/19

Tissue Layers

Tissue Layers: Skin, subcutaneous tissue, superficial fascia, muscle, extraperitoneal fascia(deep fascia), peritoneum

Layers of the abdomen, from interior to exterior as follows: peritoneum, extraperitonealfascia, muscle, deep fascia, superficial fascia, subcutaneous tissuek and skin.

A: Fascial closure, B: Looping the 0-PDS at the vertex, C: Continuous suture, D: Two PDSmeet in the middle of the incision, tie together, and cut.


18/19

The skin is the largest organ of the body, with a total area of about 20 square feet. The skinprotects us from microbes and the elements, helps regulate body temperature, and permitsthe sensations of touch, heat, and cold.Skin has three layers:

The epidermis, the outermost layer of skin, provides a waterproof barrier andcreates our skin tone. The dermis, beneath the epidermis, contains tough connective tissue, hair follicles,

and sweat glands. The deeper subcutaneous tissue (hypodermis) is made of fat and connective tissue.

The skins color is created by special cells called melanocytes, which produce the pigmentmelanin. Melanocytes are located in the epidermis.

The subcutaneous tissue is the third of the three layers of skin. The subcutaneous layer

contains fat and connective tissue that houses larger blood vessels and nerves. This layer isimportant is the regulation of temperature of the skin itself and the body. The size of thislayer varies throughout the body and from person to person.

Superficial fascia is found in the subcutis in virtually all regions of the body, blending withthe reticular layer of the dermis. It is present on the face, over the upper portion ofthe sternocleidomastoid, at the nape of the neck, and overlying the sternum. It is mainlyloose areolar connective tissue and adipose and is the layer that primarily determines theshape of a body. In addition to its subcutaneous presence, this type of fascia surroundsorgans and glands, neurovascular bundles, and is found at many other locations where it

fills otherwise unoccupied space. It serves as storage medium of fat and water; as apassageway for lymph, nerve and blood vessels; and as a protective padding to cushion andinsulate

Characteristics of muscle:

excitability - responds to stimuli (e.g., nervous impulses) contractility - able to shorten in length extensibility - stretches when pulled elasticity - tends to return to original shape & length after contraction or extension

Functions of muscle:

motion maintenance of posture heat production


19/19

Types of muscle:

skeletal:o attached to bones & moves skeletono also called striated muscle (because of its appearance under the microscope,as shown in the photo to the left)o voluntary muscle

smooth (photo on the right)o involuntary muscleo muscle of the viscera (e.g., in walls of blood vessels, intestine, & other

'hollow' structures and organs in the body) cardiac:

o muscle of the hearto involuntary

Extraperitoneal fascia (deep fascia) fascial plane of mainly loose areolar tissue betweenthe parietal peritoneum and the internal muscular (iliopsoas and inner lamina ofthoracolumbar fascia) and transversalis fascia of the body wall; its quality and quantityvary considerably, being very thick and fatty posteriorly, as pararenal fascia around thekidneys, but thin and fibrous anteriorly, deep to the linea alba of the anterior abdominalwall.

The peritoneum is the serous membrane that forms the lining of the abdominal cavity orthe coelom it covers most of the intra-abdominal (or coelomic) organs inhigher vertebrates and some invertebrates (annelids, for instance). It is composed of alayer of mesothelium supported by a thin layer of connective tissue. The peritoneum bothsupports the abdominal organs and serves as a conduit for thei rblood and lymph vesselsand nerves.

http://www.fastbleep.com/medical-notes/surgery/8/8/37

http://www.rnpedia.com/home/notes/medical-surgical-nursing-notes/principles-of-sterility
http://www.wikipedia.org/wiki/Serous_membranehttp://www.wikipedia.org/wiki/Abdomenhttp://www.wikipedia.org/wiki/Coelomhttp://www.wikipedia.org/wiki/Vertebratehttp://www.wikipedia.org/wiki/Invertebratehttp://www.wikipedia.org/wiki/Annelidhttp://www.wikipedia.org/wiki/Mesotheliumhttp://www.wikipedia.org/wiki/Connective_tissuehttp://en.wiktionary.org/wiki/conduithttp://www.wikipedia.org/wiki/Bloodhttp://www.wikipedia.org/wiki/Lymphhttp://www.wikipedia.org/wiki/Nerveshttp://www.fastbleep.com/medical-notes/surgery/8/8/37http://www.rnpedia.com/home/notes/medical-surgical-nursing-notes/principles-of-sterilityhttp://www.rnpedia.com/home/notes/medical-surgical-nursing-notes/principles-of-sterilityhttp://www.rnpedia.com/home/notes/medical-surgical-nursing-notes/principles-of-sterilityhttp://www.rnpedia.com/home/notes/medical-surgical-nursing-notes/principles-of-sterilityhttp://www.fastbleep.com/medical-notes/surgery/8/8/37http://www.wikipedia.org/wiki/Nerveshttp://www.wikipedia.org/wiki/Lymphhttp://www.wikipedia.org/wiki/Bloodhttp://en.wiktionary.org/wiki/conduithttp://www.wikipedia.org/wiki/Connective_tissuehttp://www.wikipedia.org/wiki/Mesotheliumhttp://www.wikipedia.org/wiki/Annelidhttp://www.wikipedia.org/wiki/Invertebratehttp://www.wikipedia.org/wiki/Vertebratehttp://www.wikipedia.org/wiki/Coelomhttp://www.wikipedia.org/wiki/Abdomenhttp://www.wikipedia.org/wiki/Serous_membrane

Documents

Tissue Layers and Incisions