03 Surgical Operations

Principles of Surgery

Surgical Operations

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Setting up the Operation Theatre

Principles of Sterilization and

Disinfection
Sterilization

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

2009 YONG YONGS NOTES - SURGERY

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

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03 Surgical Operations

Principles of Surgery

Surgical Operations

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Daycare or Ambulatory Surgery

Principles and Anatomy of Surgical

Access

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

2009 YONG YONGS NOTES - SURGERY

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

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03 Surgical Operations

Principles of Surgery

Surgical Operations

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Basic Surgical Techniques

Hemostasis in Surgery

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
5-O = 0.10mm
4-O = 0.15mm
3-O = 0.20mm

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

2-O = 0.30mm
O = 0.35mm
1 = 0.40mm
2 = 0.50mm

Dressing - Ideal surgical dressing

1.
2.
3.
4.
5.
6.
7.

Absorbent, able to remove exudates

Maintain moist environment
Be leak-proof
Maintain temperature and gas exchange
Pain free, easy dressing
Be odourless
Be inexpensive

Plaster Casts

2009 YONG YONGS NOTES - SURGERY

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03 Surgical Operations

Principles of Surgery

Surgical Operations

_____________________________________________________________________
Basic Principles of Usage of
Implants and Prosthesis in Surgery

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

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

2009 YONG YONGS NOTES - SURGERY

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