Incisions and Retractions

What are Halsted’s Principles of Surgery?

1. gentle handling of tissue

2. meticulous haemostasis

3. preservation of blood supply

4. obliteration of dead space

5. minimum tension on tissues

6. accurate tissue apposition

7. strict aseptic technique

To achieve Halsted’s Principles what do we need to consider?

• incisions

• dissection

• haemostasis

• tissue retraction

• tissue handling

• lavage and suction

• drains

What is this scalpel blade used for?

long straight skin incisions

What is this scalpel blade used for?

stab incisions

What’s this scalpel blade used for?

stitch removal

What’s this scalpel blade used for?

thinner skin, curved incisions, areas where we need to follow a contour (e.g. paws)

What’s this scalpel blade used for?

like 10 but larger (long straight skin incisions)

What does this image show?

pen-grip

What is the pen grip useful for?

• allows more precise control

• useful for curves/achieving full thickness depth right into the corners of the incision

What does this image show?

shallower angle using more of the ‘belly’ of the blade than the tip

What is this grip useful for?

making long, straight incisions

What is the sharpest part of the blade?

belly

What are the 2 ways to make an incision?

• slide cutting

• stab incision

How do you do slide cutting to make an incision?

1. stretch out/place tension on skin with free hand (non-dominant)

2. one smooth incision, using belly of the blade

How do you do the stab incision to make an incision?

1. one clean movement, using point of blade

2. may need to elevate tissue being incised, so that you don’t damage structures underneath (e.g. linea alba)

What are the tip tips for making incisions?

• smooth incision - don’t go over multiple times - causes jagged edges

• avoid incising blood vessels

• don’t lean scalpel hand on patient whilst incising - hover

• know landmarks

• alter how firmly you’re pressing and angle of blade throughout incision to achieve consistent depth (press more firmly and steeper angle in corners, than the middle)

What size scalpel blade is best for excising a 2cm skin mass on the distal limb?

A) 10

B) 11

C) 12

D) 15

E) 20

D) 15

What are the 2 methods of dissection?

• sharp

• blunt

What does blunt dissection go along?

natural tissue planes or parallel to tissue fibres

Why do you need good visualisation and good anatomical knowledge when dissecting?

avoid damaging delicate structures in the area

Why should you avoid excessive dissection?

• increase dead space

• increase risk infection

What can you use to dissect?

• digitally

• scissors

Why is dissecting digitally useful?

for deep dissection so you don’t damage tissues you can’t see

What is undermining a form of?

dissection

What is undermining used for?

relieving tension when closing skin

Whilst making a skin incision, you cut through a small skin vessel which bleeds persistently. What is the best way to stop the bleeding?

• apply pressure (e.g. clamp, swab)

• ligating

Define ‘haemostasis’

stopping blood flow

Why is haemostasis important?

• decrease blood loss

• increase visibility surgical field

• decrease seroma and haematoma formation

• decrease dead space formation

• decrease risk of infection

What are the 3 ways we can achieve haemostasis?

• mechanical

• thermal

• chemical

How do you perform mechanical haemostasis?

• digital pressure

• haemostats

• ligatures

What is the aim of mechanical haemostasis using digital pressure?

stem flow for long enough that platelets form plug

How do you do mechanical haemostasis using digital pressure?

press directly on vessel with single sterile gauze swab for 1-5 mins

What is digital pressure mechanical haemostasis NOT for?

medium-sized or large vessels

What is a benefit of using digital pressure for mechanical haemostasis?

minimal trauma

How do you use haemostats (clamps)?

1. place perpendicular to the long axis of the blood vessel

2. crushing stimulates coagulation

3. leave in place for at least 5 mins

How do you hold haemostats?

tripod grip

What do these images show?

haemostats

What do you place prior to ligation?

haemostat

What type of suture material do you use for ligatures?

absorbable

What ligature do you use for small vessels?

• single

• circumferential

What ligature do you use for pulsating or large vessels?

• 2

• circumferential

• for very large vessels you can use trans-fixing

What type of ligature does this image show?

circumferential

What type of ligature does this image show?

trans-fixing

What is used for thermal haemostasis?

electro-coagulation (diathermy/electrocautery)

How does thermal haemostasis using electro-coagulation work?

protein denaturation in tissue cells

What other products can be used for haemostasis?

• cellulose/gelatin/collagen products

• bone wax

How do cellulose/gelatine/collagen products achieve haemostasis?

provides scaffold and promotes clot formation

What are cellulose/gelatine/collagen products used for?

small volume, low-pressure bleeding

How frequently are cellulose/gelatine/collagen products used for haemostasis? why?

rarely - can delay wound healing and promote infection

When is bone wax used for haemostasis?

orthopaedic procedures

What chemicals can be used for haemostasis?

• adrenaline

• potassium permanganate, silver nitrate

When is adrenaline used for haemostasis?

used as an adjunct (e.g. digital pressure with adrenaline soaked swab) - not effective on it’s own

How does adrenaline work for haemostasis?

potent a2-adrenergic agonist causing vasoconstriction

When are potassium permanganate and silver nitrate used for haemostasis?

bleeding claws - NOT SURGERY

Why is tissue retraction important?

• increase exposure and visibility

• decrease tissue trauma and time

How do we achieve tissue retraction?

• hand retraction (e.g. assistant)

• instrument retraction (hand-held retractors, self-retaining retractors)

Is hand or instrument retraction preferred for tissue retraction?

instruments (more gentle)

What types of retractors are there for tissue retraction?

• hand-held

• self-retaining

What are hand-held retractors?

single handle and blade, used as extension of assistant’s hand (you still need a scrubbed assistant)

Name 2 types of hand-held retractors

• Mathieu

• Hohmann

What type of retractor is this?

Mathieu retractor

What type of retractor is this?

Hohmann retractor

What are self-retaining retractors?

blades of retractor placed within incision and opened until tissues on each side of incision are spread maximally

Do you need an assistant to hold self-retaining retractors?

NO

What do you need to be careful with when using self-retaining retractors?

avoid damage caused by tips

Name 2 types of self-retaining retractors

• Gelpi

• Weitlaner

What type of retractor is this?

gelpi retractor

How do you use a Gelpi retractor?

place 2 at 90 degrees to each other to create maximal exposure

What is the name of this retractor?

Weitlaner retractor

What is different about Weitlaner retractors (photo) compared to Gelpi?

retract larger area of tissue compared to Gelpi due to multiple prongs so can’t be used in as small wounds as Gelpi

Which of these instruments typically require a scrubbed surgical assistant?

C

What are some top tips for good tissue handling?

• make incision long enough to have good exposure

• use natural tissue planes

• use appropriate instruments

• avoid excessive undermining

• don’t let tissues dry out

How can you make sure tissues don’t dry out?

• cover with moistened swabs

• flush with sterile fluids

What type of tissue forceps?

treves (rat-toothed)

What are Treves (rat-toothed) tissue forceps for?

dense tissue (e.g. skin)

What is an advantage to using Treves (Rat-toothed) tissue forceps?

allow good grip without tissue slipping away

What type of tissue forceps are pictured?

Adson

What are characteristics of Adson tissue forceps (pictured)?

• less traumatic rat-toothed

• mini rat-tooth - finer tip so can only grasp tiny amount of tissue

What are these forceps?

Adson - brown tissue forceps

What are the characteristics of Adson - brown tissue forceps?

• 2 longitudinal rows intermeshing teeth

• broad yet delicate grip without major trauma

What type of forceps are these?

dressing forceps

What are the characteristics of dressing forceps?

transverse sections

What type of forceps are these?

DeBakey and other smooth tissue forceps

What are the characteristics of DeBakey and other small tissue forceps?

• least traumatic

• smooth longitudinal grips

• use for delicate tissues (e.g. bowel, blood vessels)

Name the foreceps from most trauma/grip/dense tissues to least trauma/grip/dense tissues

• Treves (rat-toothed)

• adson

• adson - brown tissue forceps

• dressing forceps

• DeBakey (and other smooth tissues forceps)

Which image shows the correct way to hold thumb forceps?

image on the left

How should you hold thumb forceps?

pencil grip

What are forceps for?

manipulate and stabilise tissue during incising and closing

What is this?

Allis tissue forceps

What is this?

Babcock tissue forceps

What are locking forceps used for?

when prolonged tissue handling is required

What are Babcock tissue forceps used for?

less traumatic so used in more delicate tissue

What are Allis tissue forceps used for?

saw-toothed edge and crush tissue so should' not be used for delicate structures

What does this image show?

stay sutures

What are stay sutures used for?

• minimally traumatic - use for delicate tissues (e.g. bladder wall)

• confined areas where retractor instruments too bulky

What type of suture should you use for stay sutures?

synthetic monofilament suture

How do you apply a stay suture?

1. clamp 2 ends in haemostat and held by assistant/line on patient/table

2. large diameter suture & placed with taperpoint needle to avoid cheese-wiring/tearing through tissue

What can you use for tissue handling?

• thumb forceps

• tissue forceps

• stay sutures

What should you use to hold the skin whilst you are suturing it closed?

Treves - rat toothed forceps

Why lavage?

• decrease infection

• moistening of tissues

• increase visibility by removing blood