Beruflich Dokumente
Kultur Dokumente
Guy Raveh
Topic List:
1. Surgical Deontology.
2. Informed consent.
3. Classification of surgical tool.
4. Cutting instruments.
5. Haemostatic instruments.
6. Grasping Instruments.
7. Retracting instruments.
8. Special instruments.
9. Suturing material.
10. Definitions of operation and reoperation.
11. Definitions of elective, urgent and emergency operation.
12. Indication and contradiction. Absolute and relative indications.
13. Tools' order on the big table.
14. Tools' order on the Sonnenburg table for venous cutdown technique.
15. Tools' order on the Sonnenburg table for skin and muscle incision and closure.
16. Tools' order on the Sonnenburg table for lapratomy.
17. Tools' order on the Sonnenburg table for closure of the abdominal wall.
18. Tools' order on the Sonnenburg table for tracheostomy.
19. Tools' order on the Sonnenburg table for vascular surgery.
20. Tools' order on the Sonnenburg table for intestinal surgery.
21. Surgical needles.
22. Surgical clips. Staplers and their application fields.
23. Absorbable suture materials (classification, fiber characteristic).
24. Non-absorbable suture materials (classification, fiber characteristic).
25. Properties of the ideal suture materials. Reaction index.
26. Suturing and knotting techniques. Techniques of suture removal.
27. Behavioral rules in the operating theatre.
28. Scubbing, Gowning and gloving.
29. Methods of sterilization.
30. Disinfection and isolation of the operative field.
31. Surgical hemostasis.
32. Injection techniques in general (tools, steps); intracutaneus, subcutaneous, intramuscular and
intravenous injections.
33. Technique of blood sampling (Tools, steps, vacutainer tubes).
34. Infusion solutions. Technique of infusion (tools, steps).
35. Steps and instrumentation of venous cutdown technique.
36. Classification of lapratomy (direction, relation to muscles).
37. Median lapratomy (anatomy, operative techniques).
38. paramedian lapratomy (anatomy, operative techniques).
39. Abdominal wound closure in two layers (surgical anatomy).
40. Abdominal wound closure in three layers (surgical anatomy).
41. Wound types and characterization.
42. Basic principles of wound treatment. Main steps of wound healing, wound dressing.
43. Catheter types; catheterization in general.
44. Preparation of venous catheter.
45. Urinary bladder catheterization.
46. Drain in general. Puncture of the abdominal wall and thoracic cavity.
47. Conicotomy (indication, surgical anatomy, operative techniques).
48. Tracheostomy (indication, surgical anatomy, operative techniques).
49. Early and late complications of tracheostomy.
50. Priorities in upper airway obstruction.
51. Basic principles of intestinal surgery.
52. Adhesion problem in abdominal surgery.
53. Basic principles of liver surgery (surgical anatomy, terminology, operative technique).
54. Basic principle of spleen surgery (surgical anatomy, operative technique possibilities of organ
saving surgery).
55. Basic principle of renal surgery (surgical anatomy, operative technique).
56. Basic principle of pancreatic surgery (surgical anatomy, operative technique).
57. Transplantation possibilities of the abdominal parenchymal organs. Historical data.
58. Bioplasts - Definition, types, application fields/
59. Surgical tissue adhesives.
60. Basic principles of vascular surgery.
61. Basic principles of venous and lymphatic surgery.
62. Anastomosis; intestinal and vascular sutures in general.
SurgicalOperative
Techniques
Topic 2011,
Ravehdiscoveries.
instruments.
techniques,
famousGuy
surgeons,
263. SurgicalBasic
64. Differences between lapratomy and laparoscopic interventions
Before you will start, I want to thank to Eran Kalmanovich and Assaf Persitz who
wrote topics in 2003, and I got a lot of help from their topics.
I tried to collect all the information that I thought that it relevant for this test. I know
that it looks a lot, but it is much less than it really seems.
Wish you lots of Good Luck!
Guy
1. Surgical Deontology
By the surgical deontology, the surgeon has to be in good condition both mentally and
physically to give the best treatment. Mentally means that the doctor isn't upset,
nervous etc; and physically means that the doctor is in good shape (e.g. his hands
doesn't shaking), got enough sleep etc.
It is also important to remember that the work of the surgeon doesn't limited to the
time of the operation. It start before the operation where she\he informs the patient
with all the relevant date, such as risks and benefits concerning his\her operation, and
continuing after the operation when the surgeon give the right information of "what
going to happen from now". (for more information please read the next topic about
consult form).
2. Informed consent
The surgical instruments are divided into 5 categorize 1. Cutting instruments. (Topic 4)
2. Haemostatic instruments. (Topic 5)
3. Grasping Instruments. (Topic 6)
4. Retracting instruments. (Topic 7)
5. Special instruments. (Topic 8)
The names of the different instrument can derive from
Their Function.
Their Inventor.
or sometimes "Just because they decided".
Topics 4-8 are talking about the different categories.
(I don't know where you can found them, but we took movies of the different
instruments. So just try to get them somehow)
4. Cutting instruments
2. Changeable blade.
Scissors:
1. Cooper
2. Mayo
3. Knee
4. Peritoneal.
The Cooper, Mayo & Knee can be of different size and type (blunt/blunt,
Blunt/sharp, Sharp/sharp).
They also can be straight or curved.
5. Haemostatic instruments
We have 6 of them:
4 Haemostatic clamps:
1. Pean (smooth).
2. Kocher (toothed).
3. Lumnitzer (toothed) "mega Kocher". (remember also in grasping)
4. Mosquitoes.
And
5. Deschamps to go under blood vessels.
6. Diathermy (electro-surgical tools) can do both cutting & coagulation
function.
The Kocher was invited by Theodor Kocher (1841-1917), which gave him
the Nobel Prize.
The Pean & the Kocher can come in different sizes, where the biggest Kocher
actually is the Lumnitzer.
They also can be straight or curved.
6. Grasping Instruments
Clamps:
1. Towel clamps.
2. Backhouse.
3. Doyen.
4. Peritoneal.
5. Lumnitzer (remember also in haemostatic).
7. Retracting instruments
We have to divide it into two groups Manual retractors & Automatic retractors.
Manual retractors:
1. Langenbeck (1 prong).
2. Rake Retractors (2 8 prongs).
3. Deep surgery.
4. Spatula.
5. Skin Hook.
Both the Langenbeck and the Rake Retractors can have a sharp or blunt tip.
Automatic retractors:
1. Finochetto Chest retractor.
2. Gosset Abdominal retractor.
3. Mastoid retractor.
8. Special instruments
This topic is a bit messy. There are many special instruments (Read them all in page 18 in the book,
or under "Special Instruments if they will ever change it)
Vascular clamps:
1. Satinsky.
2. DeBakey.
3. Blalock.
4. Bulldog.
11
9. Suturing material
Consist of Needle holder, needles, suturing material and clip instruments.
Needles:
1. Skin - or 3/8; Triangular body, sharp tip.
2. Muscle or 5/8; Triangular body, sharp tip.
3. Serosal - ; Round body, sharp tip.
4. Parenchyma - Blunt tip.
Needle holders:
1. Mathieu (conventional).
2. Hegar (atraumatic).
3. Zweifel (atraumatic).
11
12
13
Few examiners ask here to show the table for lapratomy, the others ask for a Mathieu,
2 surgical forceps and 3 Cooper scissors.
14
15
different
16
A. Natural
1. Cat gut (animal origin).
2. Collagen (animal origin).
B. Synthetic
1. Polyglycolic acid.
2. Polyglactin 910.
3. Polydiaxanone.
4. Polyglyconate.
5. Lactomer 9-1.
6. Glycomer 631.
7. Glyconate.
8. Polyglecaprone 25.
9. Polyglytone 6211.
10. L-lactid\glycolid.
It dissociates \ abbsorbs by hydrolysis or by proteolyric enzymes.
Time: 10 days to 8 weeks
It uses for internal organs and peritenium.
Complications can cause inflamation.
Non Absorbable:
A. Natural
1. Silk (animal origin).
2. Linen (plant origin).
3. Steel (mineral origin).
B. Synthetic
1. Polyamide.
2. Polyester.
3. Polypropylene.
4. Polytetrafluoroethylen.
5. Polybuteser.
Used in places with constant pressure like heart\bladder, and also in the
skin\vascular surgery.
Cause to a lesser immune response, which means less scaring.
The advantage of synthetic over natural is that the synthetic contains more disinfectant.
Fiber Characteristics:
It can be Monofilament.
Polyfilament:
o Twisted.
o Braided.
Pseudo-Monofilament (It has a polyfilament with a "coat").
17
18
Ri = D
X
Ri Reaction index.
D Diameter of the suture material.
X Diameter of reaction area.
D
X
X
19
Knotting techniques:
A. Mariner knot (=square knot).
B. Surgical knot (=surgeon's knot).
The advantages of Surgical knot over Mariner is it has more friction and it is
more secure. (and actually this is the only one that we are really going to use)
Suture techniques:
A. Interrupted sutures
1) Simple.
2) "Mattress"
a. Vertical (Donati).
b. Horizontal.
3) Paranchymal
a. U.
b. X.
c. Z.
d. 8.
It uses to close wounds.
If it easy to put another one instead of one who damages\ruin.
B. Continuous suture
1) Simple.
2) Special (locked).
Advantages (of the continuous over simple):
Quicker for doing.
Less material has to be used.
Less places for the infection to arbor.
Disadvantages:
Can cause more damage.
If fail, all the suture has to be replace.
More painful to remove.
General properties:
Start suture from left to right.
Suture towards you.
Suture removal technique:
First, you have to swab the wound and remove the exudates. Then grasp the knot and
gently elevate it. Lastly, cut the suture with scissors where it enters the skin. (If you use
anatomical forceps then hold the suture material but if you use surgical then hold the knot itself.)
21
In general I think that this topic is stupid but I suggest you just say all the things that you think
that are not appropriate to do in the room during surgery.
Aim: Preventing contact with microorganisms and make the surgery procedure with
the safest that it can be.
From the moment that you are in the operation theater When you dont use your hands they should be up in the air.
Dont touch anything that is sterile.
Dont rub any part of your body.
Dont run in the operation toom.
These rules are importatnt to all the people who are in the room starting from the
surgeon and ends in the obsorber (i.e. student).
21
These are the procedures that we are doing before entering into the operation theater.
The purpose of them is to clean our hands, and to cover our body with isolated cloths.
Before starting with that. We are chance our cloths and shoes with clean ones (can be
also disposable cloths). This include:
1. scrub suite shirt & trousers.
2. theare shoes\sliper & sockes (the shoe cover).
3. surgical cap.
4. surgical face mask (or protective glasses).
A. Scrubbing: the process of removing all the pathogenic agents (microorganisms) from the skin surface of our hands. (Transient flora completely,
Resident flora - partially). Also it reduces the number of the bacterial count in
the deep pores and fixing them.
Requirements:
They have to form a film on the skin.
They mustnt reduce the effect of blood and other tissue fluids.
They mustnt dry the skin
They mustnt cause to any allergy.
Effects:
Bactericidal kill bacteria. (i.e. tubercuoloid)
Virucidal kill viruses (I.e. HBV, HIV)
Fungicidal kill fungi.
Sporocidal kill\destroys spores.
Scrub solutions:
Skinman soft N.
Skinman asept.
Biotensis.
Sterillium.
Desmanol.
Descoderm.
Desderman N.
Spitaderm.
Ditensimed.
The technique:
a. Before entering into the scrubbing room, take off the jewelries and cut your
nails (artificial fingernails) also nail-polish isn't allowed.
b. Wash your hands and forearms with soap and warm ruining water for 1-2 min.
c. Rinse from the hands downward toward the elbow.
d. Rub the antiseptic scrub solution (5 ml) on hands and forearms for about 1
min.
e. Repeat section d for 5 times, where every time you rubbing a little bit less
(first time till the elbow and in the 5th time only rub your hand).
Total length of the scrub is minimum 5 min.
Hands have to be dry in the eng of the scrubbing!
22
B. Gowning:
The gowns are kept in schimmelbusch box. On the gowns there is an indicator tape
which changes its color from yellow to brown. (Brown means it's ready!). (I do have to say
that there is a chance that I'm wrong about the color, so check this!)
You open the schimmelbusch box with something that you have for the leg (have
no idea how to call it), and then you take the gown, handle it from the collar area open it, and put your hands into the sleeves. Then, when you are done, ask from
someone to tie your gown from behind.
C. Gloving:
This is the procedure of putting on the gloves.
Someone who already has his gloves on opens one glove from the outside and you
take your opposite hand to open it (from inside of glove) then you put your hand
inside it. Then that someone will hold the other glove, and you open it again, only this
time you do it from the outside (as you have glove on the hand that you open it with).
When you done with both hands you can fix the gloves so they will be
comfortable not before!
If you want, you can also use talcum can be used dont put too much.
The gloves come in different sizes 6-8 (jump in 0.5).
When you done never put your arms below the waist level.
There is another way that we put the gloves alone. But we dont do that.
2 people worth mentioning:
Ignac Semmelweis(Hungarian) (1818-1865) in1847 invented hands wash with
chloride of lime.
William Stewart Halsted (1852-1922) in 1886 invented the surgical gloves.
I think that in this topic probably the best thing is open with why we have to
sterilize. In general the aim of it is to protect the patient from infection by microorganisms and prevent complication. I'm sure that you will find more reasons.
1) Steam autoclaving (atm-oC) for gowns, isolation towels & instruments.
(120 oC, 2.5 atm, 15-30 min).
2) Dry heat (oC): for instruments. (160oC - 2hours or 180oC 1 hour).
3) Gases (using Ethylene Oxide) for gloves, Catheters, tubes.
4) Gamma irradiation - for suture materials, solution, gloves.
5) Cold sterilization (using Glutaraldehyde) for plastic devices, endoscopic
instruments.
23
(I know that there is a chance that the first part is not really a part of the topic, but I saw what Kalmanovitch & Persitz wrote, so I
used some of theirs and added what I thought is more important for this topic)
Disinfections are the products which help removing of all the pathogenic microbes.
First, there is disinfection of the operation theater. For this we use compounds like:
Isopropyl alcohol.
Benzalconiumchlorid.
Undecylenacid.
Ethyl-alcohol.
Benzyl alcohol.
Hydrogen peroxide.
Requirements:
Wide range of effectively.
Short reaction time (about 5-10 min.).
Good solubility and penetration ability.
Effective in small concentrations for the micro-organisms.
Doesn't damage the surface.
Doesn't discolor.
Stable.
Doesnt have bad smell.
Economical.
Effects:
In general the disinfection compounds function as detractors or inhibitors of live
infective agents thus their function is:
Bactericidal kill bacteria. (i.e. tubercuoloid)
Virucidal kill viruses (I.e. HBV, HIV)
Fungicidal kill fungi.
Sporocidal kill\destroys spores.
(I think that from this part it is more relevant for this topic)
At the beginning of the operation, we have to disinfect the skin and isolate it.
Skin disinfection:
This process been done in the operative field by the usage of scrubbing of the skin
with disinfectants like
Betadine.
Dodesept.
Kodan.
Cutasept.
Technique:
There are two techniques, where in both you start from the center and work outwards:
Concentric circles.
Stripes on both sides
Repeat for minimum of two times.
It is important to remember NEVER clean same place twice with same pad.
24
25
II.
III.
Definitely method
This is done in the hospital
a. Closing of the lumen this is done by the hemostatic instrument (topic 5).
1. Pean.
2. Kocher.
3. Lumnitzer.
4. Mosquitoes.
Don't forget: it is Traumatic, Permanent, and Crushing.
b. Reconstruction of the lumen of the vessel
Here you have to use the vascular clamps from the special instruments (topic 8)
1. Satinsky.
2. DeBakey.
3. Blalock.
4. Bulldog.
Again, don't forget: Temporary, Atraumatic & Non-crushing.
26
27
When we are talking about this topic, there are few points that we have to talk about
in each one
1. Where do we do it?
2. When do we use it?
3. Contradictions when we will not use it.
4. Complications.
Intra-cutaneous injection
1. In the dermis level.
We use a relative small angel during injection.
2. We use it for diagnostic purposes cutaneous reaction, allergy reaction
tuberculosis screening and local anesthesia.
3. We will not use that in case of serious dermatopathy (disease of the skin).
4. Complications can be serious local reaction or even necrosis.
Sub-cutaneous injection
1. In the subcutaneous fat level.
We use a 45O angel into a raised skin fold.
2. Administration of slowly absorption drugs (i.e. insulin).
It is important to do this injection in different locations in case of long
treatment.
Intra-muscular injection
1. Into muscles deltoid m., gluteal region or in babies in the thigh region (as the
muscles are still now strong enough) (for the different techniques look at the relevant pages
in the book).
28
Technique
Before starting you have to prepare all the equipment the material that you
are going to inject (check the dates & signature)
Put on gloves.
Ask the patient if he has any known allergies or that he is under any
anticoagulation drugs (aspirin, heparin etc).
Usually use the yellow\green\blue needle.
Then, it doesn't matter what the injection is, in all of them you clean the area
with alcohol pad.
Important to remember to take out the air bubbles!
Intravenous injection
1. Put on the tourniquet.
2. Palpate the vein (Cleaning should be done after this step in this case).
3. Puncture the vein, the hole of needle have to face up in a 15-30o angle.
4. Suck blood to see if you are in the right place.
5. Release the tourniquet.
6. Start injecting.
7. Pull out the needle.
8. Apply pressure on a sterile sponge swap as soon as the needle is out.
In the others, remember the angels Subcutaneous 45o.
Intracutaneous 10-15 o
Intramuscular 90o.
29
Test
Cap Color
Anticoagulant
Use:
Obtain blood for diagnostic.
Monitor level of components of the blood.
Instruments:
31
Required medium
31
32
Skin incision.
Stop the bleeding (with pads if the bleeding isn't too big or with ligatures see topic 31,
under "methods for closing of the lumen").
For the people who are interested, before the test we asked one of the teachers if he
can say few words on the different topics, so this is his version for the Technique:
1. First you have to take the patient in modified Jackson position, and see where the
vein is.
2. Than clean the skin and isolate it by textiles.
3. Prepare the cannula (cut down the butterfly needle from the tube, Fill the syringe
near the half of it, take out the air bubbles, connect with the cannula and fill it.
Then close it with a rubbered Pean near the syringe).
4. Make a skin cut perpendicularly to the vein.
5. Stop the bleeding (if there is any).
6. Fix the skin to the textile by Doyens.
7. Prepare the vein by Mayo scissors and anatomical forceps.
8. Take 2 surgical materials under the vein.
9. Close the distal part (distal ligature).
10. Then ask the assistant to elevate the vein.
11. Make the V-shape cut, by knee scissors and dental forceps (on the model just by
sharp - sharp scissors and anatomical forceps, because the rubber-veins wall is
too thick).
33
12. Go in with the cannula about 6-8cm, remove the rubbered pean, suck back (pull
back the cylinder of the syringe) to check if it works or not, wash back, and close
again the cannula by rubbered pean
13. Check the infusion: what is in it, date of expiry, who signed it, if there is any
corpuscular contamination in it. (I suggest saying that in the beginning).
14. Ask the circulating nurse to give you the infusion (only the end of the infusion is
sterile, so you can touch only this).
15. Remove the syringe, connect the infusion.
16. The circulating nurse first removes her rubbered Pean, than you removes yours,
then she will set the speed of the infusion, but you have to say her how fast it
should be.
17. Do the proximal ligature.
18. Take another surgical material under the vein for the U-stitch.
19. Cut down the 2 holding stitch (proximal & distal ligatures) just above the knot.
20. Ask a widow (Mathieu together with skin needle without surg. material).
21. Make the U stitch, make a first half of a surgical knot, take a gaze-ball on it, and
make a normal knot on it (as on your shoes).
22. Close the skin.
23. Make the flying stitch.
34
35
In paramedian Lapratomy, you have to cut the rectus sheet, which is close to the
Linea Alba, and then the muscles deep to the rectus sheet are cut as well.
36
37
38
Definition of wound: the wound is a pathological state of the normal continuity of the
tissue and structures by external damage or spontaneously.
There are two classifications - morphological and etiological.
Morphological
1. Superficial wound.
2. Medium deep wound.
3. Deep wound.
Etiological
1. Incised wounds - caused by a clean, sharp-edged object such as a knife, a razor
or a glass splinter.
2. Puncture wounds - caused by an object puncturing the skin, such as a nail or
needle.
3. Shot wounds - caused by a bullet or similar projectile driving into or through
the body. There may be two wounds, one at the site of entry and one at the site
of exit, generally referred to as a "through-and-through."
4. Penetration wounds - caused by an object such as a knife entering and coming
out from the skin.
5. Tear wounds - irregular tear-like wounds caused by some blunt trauma.
6. Burn wounds caused by burning or by touching very hot things.
7. Bite wounds caused by a bite from an animal, highly contaminated and
infected.
While we are talking about properties of the wound, we also have to pay attention to
the next points:
Position of the wound: location on the body.
Number of wounds.
Type of the wound (according to the etiological classification)
Characteristics of the wound necrotic, coated, granulated and epithelisant.
Volume of wound secretion minimal, mild or large quantities.
Type of the secretion serous, purulent, heamo-serous, odorless or putrid.
Characteristics of wound edge under-expanded, edema, cavity formation,
eczema, laceration, dry or wet.
Wound pain Yes\no.
39
41
3. Epithelization phase:
The formation of granulation tissue in an open wound allows the reepithelialization phase to take place, as epithelial cells migrate across the new
tissue to form a barrier between the wound and the environment. Basal
keratinocytes from the wound edges and dermal appendages such as hair
follicles, sweat glands and sebaceous (oil) glands are the main cells
responsible for the epithelialization phase of wound healing. They advance in
a sheet across the wound site and proliferate at its edges, ceasing movement
when they meet in the middle. In this phase the wound is called pink wound.
Wound dressing:
A dressing is an adjunct used by a person for application to a wound to promote
healing and prevent further harm. A dressing is designed to be in direct contact with
the wound, which makes it different from a bandage, which is primarily used to hold a
dressing in place.
Various types of dressings can be used to accomplish different objectives including:
Controlling the moisture content, so that the wound stays moist or dry.
Protecting the wound from infection.
Removing slough.
Maintaining the optimum pH and temperature to encourage healing.
Types:
1. Covering bandages.
2. Adherent bandages.
3. Pressing bandages.
4. Compressing bandages.
5. Fixing bandages.
41
Catheter is a tube that can be inserted into a body cavity, duct or vessel. They allow
drainage, injection of fluid access or removal by surgical instruments. The process of
inserting a catheter called catheterization.
Properties of catheters:
Shape.
Thickness.
Material.
Number of lumens.
Holding position.
The different between catheter and cannula is that catheter is longer and
flexible, unlike the cannula which is shorter and more rigid.
Diameter of catheter:
The external diameter is coming in French (F) or Chariere (Ch) units.
Where 0.33 mm = 1F = 1Ch.
Common places:
Blood vessels administration of drugs.
o Veins (external\internal jugular v., subcalvian v. or femoral v.).
o Arteries (radial a., femoral a. or pulmonary a.) -> swan-ganz catheter.
Gastrointestinal tract checking of blood the cavities (peritoneal lavage).
Urogenital tract catheterization of urinary bladder.
In children (newborns) catheterization of the umbilical vessels ("spaghetti"
catheter).
Types:
The catheters can be soft, Medium or hard.
Soft catheters (p. 115 for pictures)
They can be made out of latex, rubber, plastic or silicon (these made of silicon can be
used for longer time 4-6 weeks)
1. Nelaton strait.
2. Thiemann strait and tip in the end.
3. Foley (read more in topic 45) a balloon is situated in the end in order to fix
the catheter in the bladder. It can come with one balloon, two balloons
or three lumens (one for the drainage, one for injection and the other
use to prevent blood clotting formation).
4. Pezzer used after urinary bladder and prostate operation. (Not used
anymore).
5. Malecot.
Medium (mercier) catheters
These catheters made out of silk with special impregnation. They are soft in
body temperature and become rigid at 10oC.
Hard catheters
They made out of metal, plastic or glass. (i.e. kovacs catheter).
42
43
Surgical drains are inserted to empty existing fluids and those that might collect later.
If we use them correctly, we can minimize the post-operative complications and help
the healing process of the patient, but in case we don't use it right then in can cause
serious complications!
Through the drainage we can collect:
Blood.
Pus.
Body secretion.
Air.
Introduced fluids.
Types:
1. Rubber wick.
2. Penrose drain (prevent from fluid storage).
3. Redon drain with\without vacuum system.
4. Drain with double lumen.
5. Robinson drain.
6. Easy flow drain.
7. Shirly drain.
8. Sump drain (use suction).
Position:
Subcutaneous.
Sub-fascial and intramuscular.
Extra-\intra- peritoneal.
Pleural cavity.
Abscess, cysts and fistulas.
Most important is to put the drainage in the button of the cavity.
NEVER damage important structures (like vessels \ anastomosis).
Advantages:
Reduce the post-operative complications.
Reduce the infection of the wound.
Help in the healing process.
Disadvantages:
Can cause tissue irritation or even necrosis.
Blood clots may obstruct the drainage.
Can have an opposite effect and cause infection.
Foreign body feeling.
Puncture of the thoracic cavity:
1. Patient is sitting and leaning forward.
2. Disinfect the area (midclavicular line, 4cm below the tip of the scapula at the
upper margin of the rib not to hurt any vessel or nerve),
3. Anesthetize.
4. Insert needle.
5. Once reaching the fluid, take out the needle and attach the syringe.
44
45
Procedure:
1. Patient lie in Jackson position (pillow under his shoulder)
2. Orientation (looking for the place to do the hole).
3. Skin incision (2 fingers under thyroid cartilage).
4. Cut cricothyroid membrane
5. Keep hole open in any way.
46
We have 3 options for that Tracheostomy superior above thyroid gland isthmus.
Tracheostomy inferior under isthmus.
Tracheostomy media cut isthmus.
Procedure:
1. Patient lie in Jackson position (pillow bellow the shoulder).
2. Orientation get know the patient's anatomy (SCM muscle, thyroid cartilage cricoid
cartilage thyroid gland clavicles).
3.
4.
5.
6.
7.
8. Check the Luer tube (if the lumen is potent), then insert the tube.
9. Wound closure (muscle and skin stitches)
10. Fixartion of the tube.
47
Intraoperative complications:
Injury of nerves:
o Vagus nerve.
o Recurrent laryngeal nerve.
Injury of vessels;
o Common carotid artery.
o Jugular vein.
o Inferior thyroid artery (also known as ima artery).
o Thyroid plexus.
Injury of the esophagus.
"fossa route" to put that in the wrong place (i.e. in esophagus instead
trachea).
Postoperative complications:
Early complications Hematoma.
Bleeding.
Subcutaneous emphysema air in the subcutaneous tissue.
Late complications
Laryngitis sicca infection of the larynx.
Stenosis (stricture) narrowing of the trachea.
Arrosive bleeding when the blood vessels narrowing.
Chondromalacia when the hard "C" cartilages become soft.
48
In upper airway obstruction, the main problem is the lack of oxygen supply. We have
about 4 minutes before a brain damage will be form, due to the lack of the oxygen
supply.
Before doing tracheostomy\ Conicotomy, we have a few things that we have to try
doing in a specific order\priorities:
1. Mechanical cleaning making sure the base of the tongue doesn't obstruct
the airway or any other thing that might get stuck in there.
2. Pharyngeal airway (pipe) you put that in the mouth of the patient, and
besides preventing from him to chock, you also prevent from him to swallow
his tongue.
3. Endotracheal tube - a catheter that is inserted into the trachea in order for the
primary purpose of establishing and maintaining a patent airway and to ensure
the adequate exchange of oxygen and carbon dioxide.
4. Needle cricothyroidotomy this is use to increase the air flow for only a
short time as a needle can't really maintain the air supply that a patient need to
survive. But in this case we have time to take the patient to hospital and to do
him tracheostomy.
5. Tracheostomy - more secured procedure. Cleaner. When we have time then
we will do that.
6. Conicotomy - should be made only as emergency. If no possibility to make a
quick tracheostomy.
The Conicotomy which is more dangerous long term and its an emergency
procedure only.
49
51
6. Suture info
a) Sutures types:
i.
Lembert Seromuscular stitch. Since the serosa is very thin, it is not possible
to suture only the serosa.
ii.
Albert all layers stitch.
b) The sutures can be either:
i.
Interrupted sutures mostly preferred on children (as they are still growing).
ii.
Running sutures (continuous) only in adults.
c) Technique
i.
The sutures need to be free of tension to avoid suture insufficiency.
ii.
The depth of the sutures needs to be around 3 mm.
iii.
The distance between the sutures is around 3 mm.
d) Suture materials
i.
Monofilament or pseudo-monofilament
ii.
Size 3/0 or 4/0
iii.
Needle round body, serosal (atraumatic), and circle.
iv.
Staplers linear or circular.
7. Types of anastomosis
a) End to end - physiologically.
b) End to side.
c) Side to side.
8.
i.
ii.
iii.
iv.
v.
vi.
The techniques
Skeletozation clumping of the arcuate vasa recta.
Use intestinal clumps 3 cm on each side of the place that going to be sutured
Make two "holding" sutures.
Close the posterior wall of the intestine.
Anterior suture of the intestine
Suture of the mesentery.
9.
10. Count & make sure check again for bleeding or remains of materials in the
abdominal cavity. Also count the number of instruments and towels. In the test
the teacher asked me if I know how we can see if we forgot any towels in the body on the
patient. She said that there is a blue sign on the towels that can be seen in X-ray.
51
Adhesions are fibrous bands that form between tissues and organs, often as a result of
injury during surgery. They may be thought of as internal scar tissue. It is a natural
part of the bodys healing process after surgery, while some adhesions do not cause
problems, others can prevent tissues and organs from moving freely, sometimes
causing organs to become twisted or pulled from their normal positions.
The Main problem that can occur in intestine operation is adhesion, which can be
caused:
1. Serosa problem there is a damage to the serosa. Can be because we didn't do
the work good enough or due to post-operation complication.
2. Traumatic work we weren't carful enough and we damaged the area.
3. The bowels weren't kept wet enough.
4. There was not a clear work too much blood or fluid.
5. Assistant work Sure Let's blame him . (Have no idea what they really
want... but probably they want us to say that he didn't do his work properly).
6. "Foreign Bodies" we forgot something inside or even the suture material
itself. That is why we have to count and check for all the instruments in the
end.
7. Body temperature if the body's temperature increases it may make the
adhesion process faster.
52
The Decathlons of the liver (Decathlons, according to the department is Parenchymal organs'
surgery):
1. Atraumatic we don't want to damage the structure of the liver. That is why
we will use Parenchymal needle (blunt tip)
2. Capsule the livers capsule, the Glisson capsule, is sometimes not very
strong, sometimes it can hold the stitch and sometimes it cannot.
3. Segments of the liver from the surgical point of view the liver have 8
segments (I-VIII), which are not the same with the anatomical division of the
liver.
a) Segmentectomy 1 segment removed.
b) Bisegmentectomy 2 Segments removed.
c) Trisegmentectomy 3 segments removed.
d) Lobectomy right or left lobe removed.
e) Hemihepatectomy 4 segments removed.
a. Hepatectomy all the liver removed.
The liver has a great ability to regenerate, till about 75% can be regenerate.
I heard that someone was asked about "can you tell me the segments of the liver and
how does it been divided". Do whatever you want with the following information:
Traditional gross anatomy divided the liver into four lobes based on surface features. The falciform
ligament is visible on the front (anterior side) of the liver. This divides the liver into a left anatomical
lobe, and a right anatomical lobe.
If the liver is flipped over, to look at it from behind (the visceral surface), there are two additional
lobes between the right and left. These are the caudate lobe (the more superior) and the quadrate lobe
(the more inferior).
From behind, the lobes are divided up by the ligamentum venosum and ligamentum teres (anything left
of these is the left lobe), the transverse fissure (or porta hepatis) divides the caudate from the quadrate
lobe, and the right sagittal fossa, which the inferior vena cava runs over, separates these two lobes
from the right lobe.
4. Blood supply - The liver is supplied by the portal vein and the hepatic artery,
which then divided further and further to be part of the hepatic triad.
5. Suture info
a) Sutures types :
i. U suture.
ii. Z Suture.
iii. 8 suture.
iv. "Mattress" horizontal\vertical.
b) Surgical techniques
i. Baron's maneuver pressing the hepatodeudonal ligament for 10 minutes.
ii. Pringle maneuver clamping of the hepatodeudonal ligament, and by that
controlling of bleeding.
iii. Finger fracture technique pressing with the finger to look where the
bleeding is coming from.
iv. Cavitron ultrasonic surgical aspirator suction of fluids.
v. Laser.
vi. Ultrasound.
vii. Infra-red.
viii. Staplers
53
54
Atraumatic
Capsule
Segments
Blood
supply
Spleen
Kidney
Pancreases
Working atrumaticly to prevent further damage
Very thin and Have three capsules:
Thin capsule
sensitive.
Proper capsule
Very hard to
located on the
handle.
surface of the
kidney. It is made
of strong
connective tissue
fibers, but they can
pale off easily.
Fatty capsule
surrounds the
kidney. Expand
into the renal
sinuses as well.
Renal fascia outer
most layer. It is the
connective tissue
fascia of the
kidney.
Usually 2, but
5 segments apical,
4 segments head,
sometime can
lower, upper, middle
body, tail and neck.
also be 3.
and posterior.
Via the
Via renal artery
Anterior &
splenic artery
(from abdominal
posterior superior
(from the
aorta).
gastrodeudonal &
pancreaticodeudonal
celiac trunk).
(from celiac trunk)
Anterior &
posterior inferior
pancreaticodeudonal
(From superior
mesentery artery)
Inferior, caudal
and dorsal
pancreatic arteries
(from the splenic
artery)
Moving and
holding
relation of
the traction
and Blood
Pressure
55
Suture info
a) Sutures types :
i.
U suture.
ii.
Z Suture.
iii.
8 suture.
iv.
Mattress horizontal\vertical.
b) Surgical techniques
i.
Cavitron ultrasonic surgical aspirator suction of fluids.
ii.
Laser.
iii.
Ultrasound.
iv.
Infra-red.
c) Needles serosal needle.
d) Suture materials absorbable, monofilament.
Bioplast &
tissue
adhesives
Juice
problems
Must be used
Can be used
Must be used
Bleeding problem
Important thing: don't forget to mention in the case of the spleen partial resection of
the spleen it is possible that it will regenerate, and also that it is possible to make autotransplantation of the spleen after trauma to it.
56
Pioneering work in the surgical technique of transplantation was made in the early
1900s by the French surgeon Alexis Carrel, with Charles Guthrie, with the
transplantation of arteries or veins. Their skillful anastomosis operations, the new
suturing techniques, laid the groundwork for later transplant surgery and won Carrel
the 1912 Nobel Prize in Physiology or Medicine. From 1902 Carrel performed
transplant experiments on dogs. Surgically successful in moving kidneys, hearts and
spleens, he was one of the first to identify the problem of rejection, which remained
insurmountable for decades.
The first attempted human deceased-donor transplant was performed by the Ukrainian
surgeon Yu Yu Voronoy in the 1930s; rejection resulted in failure. Joseph Murray and
J. Hartwell Harrison, M.D. performed the first successful transplant, a kidney
transplant between identical twins, in 1954, successful because no
immunosuppressant was necessary in genetically identical twins.
Timeline of successful parenchymal transplants:
1954: First successful kidney transplant by Joseph Murray (Boston, U.S.A.).
1966: First successful pancreas transplant by Richard Lillehei and William
Kelly (Minnesota, U.S.A.).
1967: First successful liver transplant by Thomas Starzl (Denver, U.S.A.)
1995: First successful laparoscopic live-donor nephrectomy by Lloyd Ratner
and Louis Kavoussi (Baltimore, U.S.A.).
1998: First successful live-donor partial pancreas transplant by David
Sutherland (Minnesota, U.S.A.).
57
58
Most of the time I tried not to put pages from the department, but this time I found it
hard to organize it well for you, so
59
Materials that make immediate and permanent connection between the wound
edges.
In recent years, topical cyanoacrylate adhesives ("liquid stitches"), also known as
super glue; have been used in combination with, or as an alternative to, sutures in
wound closure. The adhesive remains liquid until exposed to water or watercontaining substances/tissue, after which it cures (polymerizes) and forms a flexible
film that bonds to the underlying surface. The tissue adhesive has been shown to act
as a barrier to microbial penetration as long as the adhesive film remains intact.
Limitations of tissue adhesives include contraindications to use near the eyes and a
mild learning curve on correct usage.
Skin glues like Histoacryl were the first medical grade tissue adhesives to be used.
These worked well but had the disadvantage of having to be stored in the refrigerator,
were exothermic so they stung the patient, and the bond was brittle. Nowadays, after
changing the chemical structure they being more flexible, making a stronger bond,
and being easier to use.
Types:
1. Gelatin-resorcine-formaldehyde (GRF) adhere in about 2 min.
2. Cyanoacrylate (histoacryl blue) most in use.
3. Fibrin (tissucol, beriplast).
Advantages:
Secure joint of wound edges application.
Good conditions for wound healing.
Good haemostatic effect.
Absorbable.
Minimal tissue resection.
Minimal functional parenchymal loss.
61
61
iv.
7. Prosthesis or grafts
i.
Patch technique closure of small holes.
ii.
Bypass to put another vessel instead parallel to a blocked one.
iii. Resection and Anastomosis to cut the damaged area and then reconnect.
We can use also graft that is taking mostly from the Great saphenous vein in
the leg.
8. Anticoagulant therapy
Local or general therapy should be used in order to avoid complications.
62
63
Anastomosis is the joining of two hollow organs (viscus), usually to restore continuity
after resection, or to bypass an unrespectable disease process. Historically such
procedures were performed with suture material, but increasingly mechanical staplers
and biological glues are employed. While an anastomosis may be end-to-end, equally
it could be performed side-to-side or end-to-side depending on the circumstances of
the required reconstruction or bypass. The term re-anastomosis is also used to
describe a surgical reconnection usually reversing a prior surgery to disconnect an
anatomical anastomosis, e.g. tubal reversal after tubal ligation.
Anastomosises are typically performed on:
Blood vessels: Arteries, veins and lymph. Most vascular procedures, including
all arterial bypass operations (e.g. coronary artery bypass), aneurysmectomy of
any type, and all solid organ transplants require vascular anastomosis. An
anastomosis connecting an artery to a vein is also used to create an
arteriovenous fistula (abnormal connection or passageway between
two epithelium-lined organs or vessels that normally do not connect) as an
access for hemodialysis.
Gastrointestinal tract: Esophagus, stomach, small bowel, large bowel, bile
ducts, and pancreas. Virtually all elective resections of gastrointestinal organs
are followed by anastomosis to restore continuity; pancreaticoduodenectomy
is considered a massive operation, in part, because it requires three separate
anastomosis (stomach, biliary tract and pancreas to small bowel). Bypass
operations on the GI tract, once rarely performed, are the cornerstone of
bariatric surgery. The widespread use of mechanical suturing devices (linear
and circular staplers) changed the face of gastrointestinal surgery.
64
I collected all the famous people that did something in the book. I suggest to choose
few (3-5) and to learn a little bit more on them - learn very basic things.
Nobel Prize winners:
Theodor Kocher (1841-1917) invented the Kocher scissors. Got the Nobel
Prize in 1909.
Alexis Carrel (1874-1944) invented the triangular technique (in vascular
surgery). Got the Nobel Prize in 1912.
Hungarians inventors:
Sandor Lumniezer (1821-1892) - invented the Lumniezer scissors.
Petz Alar (1888-1956) invented the surgical staplers.
Ignaz Philip Semmelweis (1818 -1865) invented the hand wash with
chloride lime (1847).
The rest:
Sir astley Cooper (1768-1841) - invented the Cooper scissors.
Charels Horace Mayo (1865-1939) invented the Mayo scissors.
Emile Jules Pean (1830-1839) - invented the Pean clamps.
Lord Joseph Lister (1827 -1912) invented the hand wash with soap and
carbolic acid.
Alfred Blalock (1899-1964) invented the Blalock vascular clumps.
William Stewart Halsted (1852-1922) invented the surgical gloves (1886).
65
66