Surgery - Exam 2: Clampers gonna Clamp

Study Tillson's Study Guyde

"Okay!" said the diligent student

What are the advantages of stainless steel?

Doesn't rust, high strength, good temperature tolerance

What is a disadvantage of stainless steel?

It is magnetic (pros and cons)

What metal is non-magnetic, and typically stronger and lighter?

Titanium

Polished metals tend to be more reflective, which may interfere with visibility. What other finishes help reduce this problem?

Satin (less reflective) and ebonized (non-reflective, for lasers)

T/F: You should have a "safe" zone for sharps on the surgical table, and never leave sharps on the sterile field

True

T/F: Forceps with serrations cause more tissue damage than those with small, sharp teeth

True

T/F: Instruments should be cleaned immediately after the procedure to minimize damage

True

T/F: Blades can be retrieved from the package using your hand, but a needle holder should be used to to seat the blade on the handle

False, should not hold the blade at all, retrieve with a needle holder at a 45 degree angle

What cutting instrument elevates tissue off of underlying bone, with a cup like tip allowing for scraping?

Curette

What cutting instrument has opposing cups with sharpened edges used to cut bone?

Rongeurs

To close a lumen without damaging it is what?

Occlusion

Closing a lumen by damaging it for the purpose of hemostasis is what?

Clamping/Crushing

T/F: Smooth forceps are more useful for surgery

False, toothed is better for tissues

Thumb forceps with "rat tooth" configuration, with two teeth on top and on one the bottom, are what?

Adson

Thumb forceps similar to Adson but with more teeth are what?

Brown-Adson

Thumb forceps with smaller teeth and longer shafts for more delicate tissue are what?

Debakey

Thumb forceps with a flat, grooved surface not used on tissue, but gauze and fabric, are what?

Bandage forceps

How much blood does a laparotomy sponge hold?

100 mL

How much blood does a 4x4 sponge hold?

15 - 20 mL

How much blood does a dog hold?

~90 mL/kg

How much blood does a cat hold?

~60 mL/kg

What are the four methods to achieve hemostasis?

Mechanical,

Thermal,

Chemical, and

Physical

The use of suture to occluded blood vessels is called what?

Ligation

A ligature placed around the vessel is called what?

Encircling ligation

A ligature placed through and around the vessel is called what?

Transfixation ligation

Which transfixing ligation has one needle pass with two sets of knots?

Halstead

Which transfixing ligation has two needle passes with one knot?

Figure of 8

T/F: Vascular clips, topical hemostatics, and tourniquets are all methods of mechanical hemostasis

True

T/F: Battery powered tools that use current heat the metal end piece to be used on tissue is electrosurgery

False, electrocautery

The passage of current from the instrument through the tissue and back to the instrument is what?

Electrosurgery

What are the three things that always apply to electricity?

Takes the path of least resistance,

Always seeks ground, and

Must be a complete circuit

What is the difference between electrosurgery and radiowave surgery?

Electrosurgery uses a lower frequency, and radiowaves have less tissue penetration and lateral spread

When the generator produces a constant oscillating frequency, this is best used for what?

Cutting

When the generator sends out intermittent waves, this is best used for what?

Coagulation

What thermal effects can electrosurgery have on tissue?

Denatured collagen,

Desiccation,

Cell rupture, and

Carbonization

What allows for cutting to occur between the machine and the tissue?

The air gap between them ionizes

If you have an oozy surface bleeding, what setting is right for you?

Fulguration coagulation, where the machine is held away from the tissue and sprays electricity on the area, doing minimal damage

Clamping a vascular lumen then applying current to create a collagen weld is called what?

Coaptive coagulation

Current passed from the generator through the patient and returned via an electrode is what?

Monopolar electrosurgery

What is necessary of the environment for monopolar electrosurgery?

Must be dry

How is bipolar electrosurgery different from monopolar?

Bipolar has the active and return electrodes on the same instrument (looks like tweezers)

T/F: Laser SUCK and we HATE them cuz they are USELESS

"Yes"

-Paraphrased from Dr. Matz

How do bipolar vessel sealing devices work?

Clamp then denature collagen and elastin while measuring impedence

What is the safety concern of electrosurgery?

Smoke, use a ventilation system

What is the first phase of wound healing?

Inflammatory, which removes contaminants and dead tissue

What is the second phase of wound healing?

Proliferative, where blood supply, ECM, and epithelium return

What is the third phase of wound healing?

Maturation, where collagen is reorganized and wound strength returns

What are the stages of the inflammatory phase?

Wound with hemostasis,

Endothelin for coagulation and constriction, and

Platelet alpha granule release to attract other cells

What cytokines stimulate neutrophil influx in the inflammatory phase?

TGF,

PG,

TNF, and

IL1

Neutrophil killing is dependent on what?

High partial pressure of oxygen

Monocytes mature to macrophages in the prescence of what?

TGF

The proliferative phase takes place how many days after the wound?

4 - 12

Capillary growth is mediated by what cytokine?

VEGF

T/F: Systemic antibiotics are recommended for a wound with granulation tissue

False

What cytokines from platelets stimulate epithelial proliferation?

EGF and TGF

MMPs break down matrix in their path, are are stopped by what?

Contact inhibition (epithelial cells hit each other)

Which collagen is first produced in the wound?

Type III

Which collagen replaces the previous to increase stiffness?

Type 1

What is the wound strength at 1 week, 3 weeks, and 3 months?

1 week: 3%

3 weeks: 30%

3 months: 80%

What layer of does the esophagus and rectum not have?

Serosa

What is the holding layer of the GI tract?

Submucosa, thus we do full thickness suture

What is necessary for a fluid tight seal in the GI tract?

Fibrin

T/F: GI tract wound strength decreases within the first couple of days

True, collagenase breaks down collagen, called the lag phase

What is the difference in fascial healing versus other tissues?

It has a slow healing rate due to low vasculature and fibroblasts with higher glucose needs

What is the difference in bladder healing versus other tissues?

Very responsive to injury and returns to 100% strength in 3 weeks

T/F: Cats heal slow

True

What amount of bacteria leads to a 50% to 100% chance of infection?

10^5 per gram (in case you wanted to count them?)

T/F: Steroids help the wound healing process

False, hinder

What is a primary closure?

Sutured wound

What is a delayed primary closure?

Sutured before granulation tissue (3 - 5 days)

What is a secondary closure?

After granulation tissue presents

What is a second intention closure?

Heals on its own

How fast does re-epithelialization occur?

1 mm/day

Incisions should be created parallel to what?

Lines of tension

A wound that is how old can be closed primarily if there are fresh edges and adequate vasculature?

3 - 6 hours

Describe the wound classes by time since injury

1: 0 - 6 hours (contaminated)

2: 6 - 12 hours (grey zone)

3: 12+ hours (infected)

What are the first steps for wound treatment?

Sterile jelly, clip hair, and lavage

T/F: Every drain should have an entry point and an exit point directly in the primary incision

False, should have one exit and never in the primary incision, and cover it!

If you get a little hill ate the end after sewing a wound, this is called what?

A dog ear

Skin growth over time, causing stretch (like a tumor) is called what?

Biological creep

Acute skin stretching by elongating collagen by displacing water (done in surgery) is called what?

Mechanical creep

Suture placement in the muscle as an anchor to stretch the skin is called what?

Walking sutures

Suture that leverages mechanical creep and stress relaxation to close a wound over several days before surgery is what?

Pretensioning suture

A tension relieving option that involves small incisions to allow for extra stretch of the skin is called what?

Multiple punctate relaxing incisions

What are two types of plasty that allow for relieved tension of an incison?

V to Y, where you cut a V next to the incision and sew it as a Y, and

Z plasty, where you cut a Z and swap the two triangles position

Cutting a section of skin on three sides so that it is still connected and alive, then moving it to and attaching it to the wound site is known as what?

Random Pattern Flaps

Cutting only part way into a flap before elevating the whole flap a few weeks later allows for the amount of blood supply in the flap to be improved from 40% to 90%. This is known as what?

The Delay Phenomenon

A curved incision adjacent to the shortest side of the defect to allow the flap to moves slightly to cover the wound is called what?

Rotation flap

A flap developed within 90 degrees of the long axis of the defect so that it can be rotated to cover that area is called what?

Rectangular pedicle flap

A flap that is distant to the defect that creates a handle, useful for limbs, is called what?

Interpolation flap

Flaps that incorporate a direct cutaneous artery and vein, allowing for a larger and more viable flap, is what?

Axial pattern flap

Moving deading segments of skin is what?

Free skin graft

T/F: A skin graft must be very clean and immobile

True

When does re-innervation occur?

Day 40