principles of general surgery
by : DR: Kaled Omar
1. PRINCIPLES OF SURGERY MALIHA MALIK ROLL NO. 1007
2. CONTENTS • • • • • DEVELOPING A SURGICAL DIAGNOSIS BASIC NECESSITIES FOR SURGERY ASEPTIC TECHNIQUE INCISIONS FLAP DESIGN Prevention of flap necrosis Prevention of flap dehiscence Prevention of flap tearing TISSUE HANDLING HEMOSTASIS Means of promoting wound hemostasis Dead space management DECONTAMINATION AND DEBRIDEMENT EDEMA CONTROL PATIENT GENERAL HEALTH AND NUTRITION
3. PRINCIPLES OF SURGERY Human tissues ,due to their innate properties ,react to injury fairly predictably. So ,with experience certain set principles are evolved for optimal healing.These are called as BASIC PRINCIPLES OF SURGERY.
4. DEVELOPING A SURGICAL DIAGNOSIS Important decisions regarding surgery are made from : Identifying signs and symptoms by 1. Complete and thorough history 2. Physical examination Radiographic findings Laboratory investigations Record keeping/data in an organized form Differential diagnosis
5. BASIC NECESSITIES FOR SURGERY 1. Adequate visibility is based on Adequate access- m o uth o p e ning , s urg ic a l e x p o s ure , re tra c tio n Adequate light Surgical field free of excess blood and other fluids. 2. Assistance
6. ASEPTIC TECHNIQUE It includes minimizing wound contamination by pathogenic microbes through: Medical asepsis Surgical asepsis
7. ASEPTIC TECHNIQUE(CONTD..) 1. 2. 3. Universal precautions are applied to prevent sepsis and efforts fall under the following headings. Instrument sterilization. Operatory disinfection. Surgical staff preparation. Hand and arm preparation. Clean technique. Sterile technique.
8. INCISIONS Incisions are necessary for many OMFS procedures. The following principles apply. Use a sharp blade of proper size . Use firm continuous strokes. Avoid cutting vital structures. Incise perpendicular to the epithelial surface. Intraoral incisions should be properly placed.
9. FLAP DESIGN 1. 2. 3. Principles of flap design help to prevent: Flap necrosis. Flap dehiscence Flap tearing.
10. 1.Preventing flap necrosis 1. 2. 3. 4. The tip should never be wider than the base unless a major artery is present at the base. The length of a flap should be no more than twice the width. In the oral cavity, the length should never exceed the width. When possible, include an axial blood supply in the base. The base should not be twisted, stretched or grabbed with instruments that can interrupt or destroy the blood supply feeding and draining the flap.
11. 2.Preventing flap dehiscence Dehiscence (separation) is avoided by approximate the edges over healthy bone, handling the edges gently and minimizing tension. Dehiscence exposes underlying bone leading to pain,bone loss, infection and scarring.
12. 3.Preventing flap tearing Make incisions long enough to give adequate access. Make more than one releasing incision if more access is needed.
13. TISSUE HANDLING Apart from careful flap design and incision technique, the careful handling of the tissues is also necessary for optimal and uncomplicated healing. Excessive crushing, pulling, extremes of temperature, desiccation and harsh chemicals damage tissues and these should be avoided. Toothed forceps and skin hooks are preferred to forceps that crush the wound edges.
14. TISSUE HANDLING(CONTD..) Avoid excessive pulling forces to retract tissue. Use copious irrigation when drilling or cutting bone to decrease bone damage from heat. Protect soft tissue when drilling from frictional heat and direct trauma. Wounds should never be allowed to desicate. Only physiologic substances should come in contact with the living tissue.
15. HEMOSTASIS Prevention of excessive blood loss is important for : Preserving patient’s oxygen-carrying capacity Increased visibility To prevent formation of hematomas
16. HEMOSTASIS(CONTD..) MEANS OF PROMOTING WOUND . HEMOSTASIS 1.Assist natural clotting processes by applying pressure on a bleeding vessel or a hemostat. 2.Use of heat(thermal coagulation). 3.Suture ligation. 4.Use of vasoconstrictive substances(epinephrine) 5.By applying procoagulants(commercial thrombin & collagen)
17. HEMOSTASIS(CONTD..) DEAD SPACE MANAGEMENT Dead space is an area that remains devoid of tissue after wound closure. It is created by removing tissue in the depths of the wound or by not reapproximating all tissue planes during closure. These are usually filled with blood (hematoma) which delays healing and predisposes to infection.
18. HEMOSTASIS(CONTD..) DEAD SPACE MANAGEMENT Can be managed in 4 ways: 1. Suture all tissue planes. 2. Pressure dressing. 3. Packing(with an antibacterial medication). 4. Use of drains.
19. DECONTAMINATION AND DEBRIDEMENT
20. DECONTAMINATION AND DEBRIDEMENT(CONTD..) Debridement with copious irrigation of wound with sterile saline during surgery and after closure.(large volumes of fluid under pressure) To remove debris . To reduce the bacteria count and minimizes the likelihood of infection. To remove necrotic, foreign and devitalized tissue .
21. EDEMA CONTROL 1. 2. Results from the collection of serum(fluid)in the interstitial spaces due to the transudation from damaged vessels and lymphatics obstruction by fibrin. Variables help determining the degree of postsurgical edema: Tissue injury Loose connective tissue
22. EDEMA CONTROL(CONTD..) • Post-surgical edema is minimized by: 1. 2. 3. 4. Careful and gentle tissue handling Short term steroids(prior to surgery) Use of ice packs(controversial) Head kept elevated above the rest of the body for few postoperative days
23. PATIENT GENERAL HEALTH AND NUTRITION PROPER WOUND HEALING
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