FINAL surgical procedures( Finalize )

Surgical Setup

Q: What is a methodical approach to surgical setups?

A: A systematic approach that improves efficiency and consistency.

🔹 Sutures & Needles

Q: Monofilament vs Multifilament suture?

A: Monofilament = single strand; Multifilament = multiple braided/twisted strands.

Q: Detachable suture use?

A: For rapid placement of multiple interrupted sutures (e.g., anastomosis).

Q: Double-armed suture?

A: Suture with a needle at each end.

Q: Plain gut vs Chromic gut?

A: Plain = absorbed quickly, breaks down with infection; Chromic = gut treated with chromic salts, slightly longer lasting but also breaks down with infection.

Q: Vicryl Plus?

A: Polyglactin suture impregnated with triclosan (antibacterial).

Q: Polydioxanone (PDS) features?

A: High tensile strength, minimal tissue reaction, used in pediatrics & soft tissue.

Q: Nylon suture features?

A: Little tissue reaction, good for delicate tissue, loses tensile strength over time.

Q: Barbed suture?

A: Self-locking, grips tissue in one direction (no knots needed).

🔹 Needle Types

  • Blunt: For friable organs (liver, spleen, kidney).

  • Tapered: For soft tissues (GI, GU, dura, peritoneum).

  • Cutting: For fibrous tissues (skin, tendon, capsule).

  • Tapered-Cut: Dense fibrous tissue (fascia, tendon, periosteum).

  • Spatula/Side-cutting: Ophthalmic (cornea/sclera).

🔹 Suture Techniques

  • Continuous (Running): Fast, uses less suture.

  • Locking stitch: Adds strength to continuous.

  • Subcuticular: Cosmetic closure within dermis.

  • Interrupted: Strong, secure, less scarring.

  • Buried/Matress sutures: Extra wound security.

  • Retention sutures: Reinforce abdominal closures.

  • Purse-string: Circular closure (e.g., appendix stump).

Ligation & Ties

  • Free ties/Reels: For quick vessel ligation.

  • Stick tie (suture ligature): Prevents sliding off vessel.

  • Tie on passer: Used deep in wound with right-angle clamp.

  • Traction sutures: Held with hemostat for control.

🔹 Wound Healing

  • Classification I (Clean): No infection, closed primarily (3–5% risk).

  • II (Clean-contaminated): Entered GI/GU tract, no spillage (3–7%).

  • III (Contaminated): Spillage, major break in technique (10–17%).

  • IV (Dirty/Infected): Old traumatic wounds, infection (>27%).

Phases:

  1. Inflammatory → 2. Proliferative → 3. Remodeling.

Complications:

  • SSI: inflammation + serous discharge.

  • Seroma: fluid collection.

  • Hematoma: bleeding from incomplete hemostasis.

🔹 Minimally Invasive Surgery (MIS)

  • Access: Veress needle (closed) or Hassan trocar (open).

  • Insufflation: CO₂ warmed to prevent hypothermia & fogging.

  • Trocar-cannula: Creates ports for instruments.

  • Endocoupler: Connects camera to scope.

  • Flexible tip endoscope: Controlled at head.

Hemostasis in MIS: Clips, staplers, ultrasonic coagulation, bipolar energy.

Positions:

  • Reverse Trendelenburg → Upper abdomen, lower esophagus.

  • Trendelenburg → Pelvis.

  • Lithotomy → Prostate, GYN.

  • Lateral Decubitus → Thoracoscopic surgery.

Complications:

  • Ignition risk: hot fiberoptic cable on drape.

  • Damaged insulation: patient burns.

  • Loss of haptic feedback: challenge in robotic surgery.

🔹 Robotic Surgery

Components:

  • Vision tower (electronics, video).

  • Bedside unit (instrument arms).

  • Surgeon console (3D immersive view).

Systems:

  • Da Vinci: Common in general & GYN surgery.

  • Mako: Ortho (joint replacement).

  • Monarch: Bronchoscopy.

  • Trumpf table: Integrates with Da Vinci.

Movements:

  • Yaw (side-to-side), Roll (tilt like airplane), Pitch (up/down).

  • End effector = working tip.

  • Wristed instruments = 7 degrees freedom.

Limits:

  • No haptic feedback (vision only).

MIS / Endoscopy

Q: How should a telescope be handled?

A: Never by the shaft (to prevent damage).

Q: What does the clarity of a camera image depend on?

A: Number of pixels in the chip.

Q: What is a Pixel in MIS imaging?

A: Each silicon element in the chip = one pixel.

Q: What is the Extracorporeal suture method?

A: Knot tied outside cavity and pushed in with a knot pusher.

Q: What is the Intracorporeal suture method?

A: Knot tied inside the body with two instruments.

Q: What is the most effective way to prevent burns from electrosurgical instruments?

A: Active electrode monitoring.

Q: What is Ultrasonic technology’s role in MIS?

A: Coagulation/cutting via cool coagulum, minimal heat

🔹 Gynecology & Obstetrics

Anatomy/Terms:

  • Perineum: between vagina & anus.

  • Cervix: neck of uterus.

  • Myometrium: muscular uterine layer.

  • APGAR: newborn assessment.

  • Breech: feet/buttocks first.

  • Cord prolapse: cord precedes head.

  • Leiomyoma: benign uterine fibroid.

Procedures:

  • Cerclage: reinforce cervix.

  • Episiotomy: enlarge vaginal opening.

  • Myomectomy: removes fibroids, preserves fertility.

  • LAVH: laparoscopic-assisted vaginal hysterectomy.

  • Colporrhaphy: vaginal wall repair.

  • Hysteroscopy: scope of uterus/fallopian tubes.

  • Tuboplasty: repair fallopian tubes.

Pelvic defects:

  • Cystocele = bladder prolapse.

  • Rectocele = rectum prolapse.

  • Enterocele = small bowel prolapse.

What is a Missed abortion?

A: Products of conception remain in uterus.

Q: What is Amniotic fluid?

A: Protective liquid around fetus in amniotic sac.

Q: What are Amniotic membranes?

A: Membranes around fetus inside amniotic sac.

Q: What is Meconium?

A: First stool of newborn; indicates fetal distress if passed in utero.

Q: Which drug aids placental expulsion?

A: Pitocin (oxytocin).

Q: What instrument retracts the cervix in GYN surgery?

A: Hulka uterine tenaculum forceps.

Q: Which dilators are used in reconstructive fallopian tube surgery?

A: Hegar dilators.

Q: What is Intravasation in hysteroscopy?

A: Absorption of irrigation fluid into vascular system (risk of overload).

Q: What is a Posterior repair?

A: Repair of rectocele/posterior vaginal wall defects.

Abdomen / Hernias

Q: What is Mobilization in surgery?

A: Freeing tissue from attachments before resection/anastomosis.

Q: With what is the spermatic cord retracted?

A: Small Penrose drain.

Q: What are the layers of the abdominal wall (superficial → deep)?

A: Skin → Subcutaneous fat → Fascia → Muscle → Parietal peritoneum.

Q: Which muscles form the abdominal wall?

A: Rectus abdominis, external oblique, internal oblique, transversus abdominis.

Q: What is the Linea alba?

A: Avascular connective strip at midline (common incision site).

Q: What are Adhesions?

A: Scar bands between peritoneum & viscera; lysed during surgery.

Q: What is Cross-clamping?

A: Placing clamps perpendicular to a vessel or tube.

Q: What is Thermoregulation’s role in GI surgery?

A: Prevents hypothermia; warm fluids + forced-air warming.

Q: What are Haustra?

A: Pouches of large intestine formed by contractions of teniae coli.

Q: What is Villi function in small intestine?

A: Nutrient absorption via large surface area.

Breast & Thyroid

Q: What are reconstructive considerations after mastectomy?

A: Body image, immediate vs delayed reconstruction, psychological support.

Suture Choice by Tissue Layer

Q: Common sutures by layer?

  • Peritoneum: 0 absorbable running

  • Fascia: 0 or 2-0 synthetic braided

  • Muscle: 2-0 or 3-0 absorbable interrupted

  • Fat: 3-0 absorbable

  • Skin: Staples or subcuticular

🔹 Abdominal Incisions

  • Midline: Stomach, liver, colon.

  • Right paramedian: Biliary/pancreas.

  • Left paramedian: Spleen/sigmoid.

  • Right subcostal (Kocher): Gallbladder, spleen.

  • Chevron (bilateral subcostal): Liver transplant.

  • McBurney: Appendix.

  • Inguinal (oblique): Hernia, spermatic cord.

  • Pfannenstiel (low transverse): C-section, bladder, uterus.

🔹 Hernias

  • Direct inguinal: Weakness in Hesselbach’s triangle.

  • Indirect inguinal: Congenital, sac follows spermatic cord.

  • Femoral: Below inguinal ligament.

  • Spigelian: Rare, between rectus & transversus.

  • Umbilical: At umbilicus.

  • Incarcerated: Stuck, reducible risk.

  • Strangulated: Cut-off blood supply → emergency.

Repair: Mesh (tension-free repair, fibroplasia).

🔹 GI Surgery

  • Billroth I: Stomach → duodenum.

  • Billroth II: Stomach → jejunum.

  • Whipple: Remove pancreatic head + duodenum + bile duct + gallbladder.

  • Stoma: Surgical opening (colostomy).

  • Isolation technique: Prevent contamination with bowel/tumor.

Small intestine parts: Duodenum → Jejunum → Ileum.

Large intestine function: Absorbs water & electrolytes.

🔹 Breast & Thyroid Surgery

Breast Support: Cooper’s ligaments.

SLNB (sentinel node biopsy): First draining lymph node → dye or technetium-99.

Mastectomy types:

  • Simple = breast only.

  • Modified radical = breast + axillary nodes.

  • Radical = includes chest wall.

Thyroid:

  • Secretes T3, T4, calcitonin.

  • Parathyroid → calcium regulation.

  • Risks: injury to recurrent laryngeal nerve, parathyroid removal.

  • MIVAT (video-assisted) = small incision, faster recovery.