Principle Of Oral and Maxillofacial Surgery
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This document summarizes key principles of oral and maxillofacial surgery (OMFS). It covers pre-surgical evaluation and preparation, basic surgical necessities like visibility and assistance, infection control techniques, types of incisions and flap design, tissue handling techniques, hemostasis methods, wound closure approaches, and post-operative care considerations like edema control and nutrition. The document provides details on each topic and cites relevant studies to support the discussed principles.
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Principle Of Oral and Maxillofacial Surgery
- 2. Principle of OMFS surgery Presented by: Dr. Kamini Dadsena
- 3. Seminar presentation DEPARTMENTOF ORAL& MAXILLOFACIALSURGERY Guided by: Dr. Ramnik singh madan Dr. Vinay kharsan Dr. Akshay daga Dr. Abhishek balani Dr. Sumit tiwari Dr. Gazal parveen
- 4. Outline 1. Introduction 2. Pre-surgical evaluation 3. Basic necessities for surgery 4. Infection control and aseptic technique 5. Incisions 6. Flap design 7. Tissue handling 8. Hemostasis 9. Suturing technique 10. Dead space management 11. Decontamination and debridement 12. Edema control 13. Patient general health and nutrition 14. Wound management 15. summary 16. Reference
- 5. INTRODUCTION • The surgeon must have a clear and comprehensive knowledge of surgical physiology the anatomy of the region being operated The pathology of the condition under treatment.
- 6. Patient evaluation and diagnosis • Pre surgical evaluation • Collection of data • Making a dianosis • Consider the alternatives • Is picking up a knife the best thing to do?
- 7. BASIC NECESSITIES FOR SURGERY 1. ADEQUATE VISIBILITY Adequate access Ability to open mouth widely Surgically created exposure Tissue retraction Adequate light Surgical field free of excess blood and other fluids 2. ASSISTANCE
- 8. Advance in visibility • Surgical Loupe - 2x to 8x • Surgical microscope-
- 9. INFECTION CONTROL AND ASEPTIC TECHNIQUE 1. PREPARATION OF ARMAMENTARIUM 2. PREPARATION OF ENVIROMENT 3. PREPARATION OF PATIENT 4. PREPARATION OF SURGICAL TEAM 5. POST SURGICAL ASEPSIS
- 11. PREPARATION OF ENVIROMENT Sterilization of Operation Theatres Fumigation: Done with formaline fume Very pungent and carcinogen potential Room can be used after 12 to 14 hr after fumigation
- 12. Emerging Compounds in use for Sterilization of Operation theatres Bacillocid rasant Advantage- 1. Formaldehyde free 2. Used in low concentration 3. Provide complete asepsis in 30-60 min 4. Shutdown OT for 24 hr not required 5. Cleaning with carbolic acid not requied Active ingredient- Glutaral 100mg/g benzyl-‐C12-‐18-‐alkyldimethylammonium chlorides 60 mg/ g Didecyldimethylammonium chloride 60 mg/g
- 13. • VIRKON safe Virucidal Bactericidal, Fungicidal Mycobactericidal • Active ingredients -contains oxone (potassium peroxymonosulphate), sodium dodecylbenzenesulfonate, sulphamic acid; and inorganic buffers. • Disadvantages- Not effective against spores
- 14. PREPARATION OF PATIENT • Bathing, Clothing • Body parts preparation in wards shaving, at least 12 hr before surgery Painting with antiseptic solution • Preparation of oral cavity Inspection for septic foci, calculus or infected carious tooth Loose tooth should be removed Antiseptic mouth wash CHX, Betadine • Preparation on operation table Painting Draping
- 15. Preparation on operation table
- 16. Draping
- 19. PREPARATION OF SURGICAL TEAM
- 20. SURGICAL SCRUB • The surgeon begins his effort at aseptic technique with the hand scrub. • Purpose: To remove superficial contaminants and loose epithelium. • Agents Used: Soap or scrub solution and scrub brush. • Time Of Scrubbing: Acc to Dumphy and Way– 10min. 20
- 21. Alternative Scrubbing Technique: • Cutright and co-workers– Device utilizing pulsating water and soap lavage. • The surgeon insert his/her hands into the device for cleaning. • Time—90 sec. 21
- 22. Scrubing
- 23. DRYING 23
- 25. SELF GOWNING 25
- 27. REMOVING GOWN AFTER SURGERY 27
- 28. GLOVING 1.SELF – A. Open B. Closed 2.BY OTHER MEMBER - 28
- 29. Open tech
- 33. UNIVERSAL PRECAUTION • UNIVERSAL PRECAUTION • Protection of self,staff & patients from contamination by using barrier techniques when treating all patients as if they all had communicable disease 1. Wearing of barrier devices 2. Decontamination & disposing of all surfaces exposed to patient blood,tissue,secretions 3. Avoidance of touching & thereby contaminating surfaces with contaminated gloves or instruments
- 36. INCISIONS • Use sharp blade of proper size • Firm, continuous stroke • Avoid cutting vital structures • Incisions made wih blade perpendicular to the epithelial surface • Skin incisions • Langer's lines – in 1861 langer studied incisions & puncture wounds in cadavers & published the results as a shematic representation of the lines of greatest skin tension for all regions of the body . • Kocher 1907 – surgical incisions should be made along langers lines of normal skin tension so that skin would be closed under least amount of tension & resulting scar minimised
- 37. LANGERS LINES
- 38. Relaxed skin tension lines
- 39. • Langers theory has been disproved • Lines run parallel with skin creases , which are perpendicular to the action of underlying muscles, which would tend to pull a incision apart.(Rubin – 1948, kraissl – 1951, nunez – 1974) • Despite this skin incisions are generally placed within skin creases to hide the scar Mucosal incisions • Intraoral scars not visible • Placement of incisions & flaps – determined by – convenience, access & avoidance of damage to nerves & blood vessels
- 40. FLAP DESIGN • Surgical flaps are made to gain access to an area or to move tissue from one place to another • Complications of flaps • Flap necrosis, dehiscence, tearing • Basics of flap design followed to prevent them • Prevention of flap necrosis • Apex of flap should never be wider than base • Length of flap should never exceed width • Axial blood supply should be included in flap • Base of flap should not be excessively twisted, stretched or grasped as it may damage vessels & compromise blood supply feeding & draining the flap
- 42. • Prevention of flap dehiscence(separation) • Approximating edges of flap over healthy bone • Do not place flap under tension • Prevention of flap tearing • Create large flap at onset that is large enough to avoid tearing it or enlarging it later • Envelope flap – developed from simple straight incision • Access not adequate – extend length of incision or give releasing incision • Releasing incision – (vertical or oblique) • MADE AT 45º ANGLE FROM DIRECTION OF PARENT INCISION,SHOULD NOT BE MADE AT SHARP ANGLE FROM PARENT INCISION BUT CURVE GRADUALLY FROM IT • Reduces blood supply to flap • If flap is to include both mucosa & periosteum, incision made directly to bone with one cut & elevated in one piece without tearing periosteum
- 44. Principle of incisions • Sharp blade of proper size • Firm and continuous stroke is used • Avoid cutting vital structure • Blade should be made perpendicular to epithelial surface • Incision should be place in healthy bone avoid placing incision in unhealthy bone or unattached gingiva
- 46. Outline 1. Introduction 2. Pre-surgical evaluation 3. Basic necessities for surgery 4. Infection control and aseptic technique 5. Incisions 6. Flap design 7. Tissue handling 8. Hemostasis 9. Suturing technique 10. Dead space management 11. Decontamination and debridement 12. Edema control 13. Patient general health and nutrition 14. Wound management 15. summary 16. Reference
- 47. TISSUE HANDLING • Use tissue forceps to hold tissue delicately • Do not pinch together too tightly • Do not over aggresively retract tissue to gain greater surgical access • Use copious amounts of irrigation while cutting bone • Soft tissue protection – from frictional heat or direct trauma from drilling equipment • Do not allow tissue to desiccate • Open wounds – frequently moistened or covered with damp sponge
- 48. HEMOSTASIS • Decreased visibility – uncontrolled bleeding • Hematoma formation – increase tension on wound edges – culture media – infection Means of promoting wound hemostasis • Assist natural hemostatic mechanism • Fabric sponge – place pressure on vessel • Placing hemostat on bleeding vessel • Both cause stasis of blood in vessels , which promote coagulation
- 49. Thermal coagulation • Use heat to cause the ends of cut vessels to fuse closed • Heat applied through electrocautery tip touching the vessel directly or through a metal instrument such as hemostat holding the vessel Conditions--proper use of thermal coagulation • Patient grounded – allows current to enter the body • Cautery tip or metal in contact with it should not touch patient at any other point than bleeding vessel. Otherwise current follows undesirable path creating burns • Removal of all blood or fluid accumulated around vessel to be cauterized
- 50. • Suture ligation • Pressure dressing over wound • Placing of vasoconstrictive substances – epinephrine in the wound • Applying procoagulants – thrombin,collagen
- 51. Dead space management • Dead space in a wound is any area that remains devoid of tissue after closure of wound Created by • Removing tissue in depths of wound • Not reapproximating all tissue planes during closure • Fills with blood creates hematoma - infection DEAD SPACE MANAGEMENT
- 52. DEAD SPACE ELIMINATED BY • Suturing tissue planes together to minimize post operative void • Pressure dressing over repaired wound • Place packing into void untill bleeding stops & then remove packing. Packing material usually impregnated with antibacterial medication • Use of drains – either by themselves or in addition to pressure dressings • Suction drains & nonsuction drains used
- 55. VAC- vacuum-assisted closure • Negative-pressure therapy • Useful for large avulsive defects • Removes interstitial fluid and edema and inflammatory mediators. • Vac decreases bacterial counts • Convenient to use and requires changing every 48 to 72 hours Steven V. Dryden, William G. Shoemaker, Jae H. Kim, Wound Management and Nutrition for Optimal Wound Healing Atlas Oral Maxillofacial Surg Clin N Am ;2013:21, 37-47
- 56. VAC- vacuum-assisted closure Steven V. Dryden, William G. Shoemaker, Jae H. Kim, Wound Management and Nutrition for Optimal Wound Healing Atlas Oral Maxillofacial Surg Clin N Am ;2013:21, 37-47
- 57. DECONTAMINATION • Repeated irrigation of wound during surgery & closure • Irrigation dislodges bacteria & other foreign materials & rinses them out of the wound • Sterile saline generally used. Solutions containing antibiotics can also be used Wound debridement • Careful removal from injured tissue of necrotic, foreign, severly ischemic material that would impede wound healing • Used in traumatically incurred wounds or severe tissue damage caused by pathologic condition
- 58. EDEMA CONTROL • Occurs after surgery due to tissue injury • Edema is an accumulation of fluid in the interstitial space because of transudation from damaged vessels & lymphatic obstruction by fibrin Degree of post surgical edema determined by • Greater the amount of tissue injury – greater the amount of edema • More loose connective tissue contained in injured region – more the edema present Control of post surgical edema • Minimal tissue damage during surgery • Ice application • Patient positioning in early post-operative period • Short-term , high dose systemic corticosteroids
- 59. Effect of the proteolytic enzyme serrapeptase on swelling, pain and trismus after surgical extraction of mandibular third molars Author- T. H. Al-Khateeb, Y. Nusair Sample size- 24 • Conclusion- There was a significant reduction in the extent of cheek swelling and pain intensity in the serrapeptase group at the 2nd, 3rd and 7th postoperative days Int. J. Oral Maxillofac. Surg. 2008; 37: 264–268
- 60. PATIENT GENERAL HEALTH & NUTRITION • Malnourished surgical patients are associated with an increased risk for morbidity and mortality. • Poor nutritional status can compromise the function of many organ systems, including the heart, lungs, kidneys, and gastrointestinal tract (GI)
- 61. PATIENT GENERAL HEALTH & NUTRITION Malnutrition causes the following deleterious consequences: 1) Increased susceptibility to infection 2) Poor wound healing 3) Abnormal nutrient losses through the stool 4) Overgrowth of bacteria in the GI tract 5) Increased frequency of decubitus ulcers James C. Fang, Desai N. Chirag, Harry Dym, Nutritional Aspects of Care, Oral Maxillofacial Surg Clin N Am ;2006:18, 115 – 130
- 62. • patients with moderate malnutrition (10%- 20% weight loss; serum albumin <3.2 g/dL to >2.5 g/dL) • severe malnutrition (>20% weight loss; serum albumin <2.5 g/dL) and • who can tolerate waiting at least 7 days for an elective operation Steven V. Dryden, William G. Shoemaker, Jae H. Kim, Wound Management and Nutrition for Optimal Wound Healing Atlas Oral Maxillofacial Surg Clin N Am ;2013:21, 37-47
- 63. Enteral nutrition Indications for enteral nutritional support are • Inability to ingest food normally, • Obstruction of GI tract if access can be placed below obstruction, • Impairment of digestion or absorption, • Physiologic deterrents to food intake, protein-energy malnutrition, and psychiatric illness. Stuart S, Stuart M, Unger LD. Enteral and parenteral nutrition support. In: Morrison G, Hark L, editors. Medical nutrition and disease. Cambridge (MA)7 Blackwell Science; 1996. p. 339– 52.
- 64. Contraindications for enteral nutritional support • Complete gastric or intestinal obstruction if access cannot be placed distal to obstruction, • Ilieus, • High-output enteric fistula (>500 ml/d), • Moderate to severe acute pancreatitis, • Severe diarrhea or vomiting • Refusal of nutrition support by the patient or the patient's legal guardian
- 65. Complications of nasogastric tube feeding (1) erosive tissue damage—nasopharyngeal, erosions, pharyngitis, sinsitis, and gastrointestinal (GI) tract perforation ; (2) hyperglycemia; (3) pulmonary aspiration; and (4) GI complications—nausea, vomiting, and diarrhea. James C. Fang, Desai N. Chirag, Harry Dym, Nutritional Aspects of Care, Oral Maxillofacial Surg Clin N Am ;2006:18, 115 – 130
- 66. The Nasojejunal tube Indications for its use are patients who are at risk for aspiration or who have poor gag reflexes and those patients who have gastroparesis or delayed gastric emptying. most common complication is diarrhea .
- 67. Gastrostomy tubes 1. Surgically placed gastrostomy tubes or 2. percutaneous endoscopic gastrostomy (PEG) tubes INDICATIONS patients with swallowing disorders or patients with impaired small-bowel absorption POTENTIAL COMPLICATIONS aspiration, irritation around tube exit site, peritoneal leak, and obstruction of pylorus.
- 68. Enteral feeding protocol 1. Bolus feeding - nasogastric or gastrostomy feeding tubes 2. Continuous infusion- patient has nasojejunal, gastorjejunal, or jujunal feeding tubes. Feeding rate- Bolus feeding- starts at 50 mL every 4 hours and increases in 50- mL increments until the intake goal is reached. Continuous infusion- initiated at 20 mL/h and increased in 20-ml/h increments every 4 hours until the desire goal is reached. The diagnosis of tracheal aspiration Glucose oxidase reagent strip. Methylene blue (1 mg/l) added to the feeding formulas bolus feeding and continuous infusion
- 69. Parenteral nutrition Some indications for peripheral TPN are as follows:179 Nutritional status not severely compromised Patient able to tolerate some nutrition orally or internally Recovery time predicted to be short Good venous access Some indications for central TPN are as follows:179 Poor nutritional status Patient unable to tolerate any nutrition internally Expected prolonged need of nutritional support Poor peripheral venous access
- 70. Complications of parenteral nutrition • 1. Metabolic complication—fluid overload, hypoglycemia, hyperglycemia, and hypercalcemia • 2. Infectious complications—most often caused by staphylococcus epidermis and staphylococcus aureus • 3. Metabolic bone - bone pain, bone fractures • 4. Thrombosis and pulmonary embolous • 5. Mechanical complications • 6. Hepatobiliary complications - cholelithiasis, cholecystitis, elevated serum aminotransferase, and alkaline phosphatase.
- 71. Wound management • Initial wound management is then directed toward reducing the number of organisms present in the wound. • This reduction is carried out by vigorous cleansing, careful débridement of grossly nonvital tissue, and copious irrigation under pressure with normal saline only.
- 72. Changing the dressing at least twice daily accomplishes two goals • 1. It permits observation of the wound bed to determine whether an infection is developing. • 2. The removal of the pack results in débridement of dead cells and exudate that have adhered to the gauze surface. •
- 73. Summary • The primary tenet of the Hippocratic Oath, Primum non nocere (“First, do no harm”). • Preoperative evaluation • Aseptic technique • Tissue handling should be gentle • Nutritional aspect • Wound management
- 74. Reference • Oral & maxillofacial surgery - volume 1 daniel m. Laskin • Textbook of oral & maxillofacial surgery Gustav o. Kruger • Contemporary oral & maxillofacial surgery larry j. Peterson • Steven V. Dryden, william G. Shoemaker, jae H. Kim, wound management and nutrition for optimal wound healing atlas oral maxillofacial surg clin N am ;2013:21, 37-47 • James C. Fang, desai N. Chirag, harry dym, nutritional aspects of care, oral maxillofacial surg clin N am ;2006:18, 115 – 130 • Stuart S, Stuart M, Unger LD. Enteral and parenteral nutrition support. In: Morrison G, Hark L, editors. Medical nutrition and disease. Cambridge (MA)7 Blackwell Science; 1996. p. 339– 52.
Editor's Notes
- The practice of surgery rests on certain fundamental principles which remain unchanged, though to apply them the surgeon may have to modify techniques to suit the anatomical field, the type of operation and the conditions obtaining at the time.
- Most of the important decisions concerning a surgical procedure should be made long before the administration of anesthesia. 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 Patient interviews and physical examinations should be performed in an unhurried, thoughtful fashion. Clinicians must also be thoughtful observers. Whenever a procedure is performed, they should reflect on all aspects of its outcome
- Two principle requirement Retraction of tissue not only improve visibility bt also protect them to get injured during surgical procedure Light can be hamppered during surgery this can be avoide by using more than one overhead light and headlight High vaccume suctioning device with a relatively small tip Performance of good surgery is extremely difficult with no or poor assistance Assistance must be sufficiently familier with surgical procedure being performed to anticipate the surgeons need
- Used when doing surgery on delicate structure Neurosurgery, microvascular surgery, plastic surgery Loupes are mounted on glasses and are custom made for individual surgeons a/c to corrected vision, interpupillary distance, and desire focal distance
- Antiseptics- chemical agents applied to living tissues to reduce the number of micro-organisms present by inhibiting their activity or by destruction. Disinfection :It is the destruction or removal of infectious or harmful microorganisms from nonliving objects by physical or chemical methods. Sterilization: Defined as a process that result in the destruction or elimination of all forms of life including bacterial spores. Detol- chloroxylenol 4.8 Savlon chx gluconate 7.5, cetrimide 16 Phenol 0.5 Cidex 2glutaraldehyde Cetavon cetrimide 0.5, 68 abs alcohol Betadine 5-10 topical solution Surgical scrub 7.5
- Sterilisation Means Eradicating Germs completely, Which Is not 100% Possible In An operation theatre. The Sources Of Bacterial Contamination Are From Air And The environment, Infected Body fluids, Patients articles, Equipment etc. Most commonly used Generated by 40% formaline with pot. Permagnate crystals Formaline liquid can be dispersed by sprayer device Contact time of 6-8 hr is required Formaldehyde must be neutralised by ammonia requiring contact time 2 hr to neutralised amformaldehyde prior to use ot For 1000cu ft 500ml formaldehyde requi room is seal for 24 hr 250 ml of ammonia / 1 lit of formaldehyde used
- Bacillocid rasant A newer and effective compound in Environmental decontamination With very Good cost/benefit ratio, good material compatibility, excellent cleaning properties and virtually no residues.
- Newer non-‐Aldehyde compound. and Non Toxic compounds.
- Bath to remove all dirt and outside clothing should be discarded and should provide clean hospital clothing Cleaned and shaved part is scrubbed vigorously with antiseptic sol like savlon, CHX, povidine iodine and mopped with sterile gauze Cleaned part is again painted with mercurochrome or 2% picric acid covered with sterile pad and sealed with adhesive tape to isolate it and prevent contamination with fomites
- The part which is preliminary prepared in the ward preoperatively is finally prepared on the table before the surgery is started. The part on which the surgery is to be performed and its adjoining area is scrubbed vigorously using a sterile swab holding forceps with a no touch technique, i.e. the surgeon does not touch the swab or any other area with his gloved hands. The scrubbing is started from the center and goes to periphery and the swab is discarded This exercise is first done with swab soaked in antiseptic soap solution like savlon, cetrimide or povidon iodine (beta scrub) for about 2 minutes. The detergent facilitates reduction of surface tension of the dirt particles and their easy removal. it also reduce microbiological colonies and reducing their count of due to antiseptic action The area is then mopped with dry sponge or sponge soaked in sterile normal saline to remove the residue of the antiseptic agent and detergent, which could be irritating or harmful to the exposed deeper tissue during surgery. Finally the area is painted with 5 percent povidon iodine solution and this should not be wiped off because microbial activity is sustained by release of free iodine as the agent dries and color fades from skin. It should remain on skin for at least 2 minutes. Alternatively alcohol may be painted on the area without friction Isopropyl and ethyl alcohol are broad spectrum agents that denature proteins in cells. Because alcohol coagulates protein, it is not applied to mucous membranes or used on an open wound. Isopropyl alcohol is more effective fat solvent than ethyl alcohol. Both are volatile and flammable. They must not pool around or under the patient, especially if an electrosurgical unit or laser will be used. Chloromycetin eye appicabs to prevent drying covered with sterile pad to prevent entry of anticeptic solution to cause chemical injury Oral cavity prepared again with chx or 5%betadine
- Draping the patient Purpose is to isolate the surgical site from other parts of the body that have not been prepared for surgery & also from non-sterile operating room equipment & personell Initial drape of single thickness, then second drape called front sheet put which completes major isolation Patient head wrapped with double sheet technique, using a drape as lower sheet & hand towel as upper sheet Sterile drapings secured with towel clips Additional drapes placed over endotracheal tube & adjacent unscrubbed areas to complete isolation of surgical site
- Purpose Antiseptic soap Design of sink doctors tap, paddle operated tap or automated tap prevent spashing of rebound water Time stroke method 3 min 20 to 30 strok
- Incision refers to a fine cut produced surgically by a sharp instrument that creates an opening into an organ or space in the body. Incisions are used to gain surgical access to deeper tissues with minimal damage to the surrounding vital structures. A sound anatomical knowledge is thus essential in planning incisions. A Pen grasp’ Is used to hold the scalpel in one hand, while the other hand is used to firmly hold and stabilise the skin or mucosa. Incision should be made with Sharp blade of proper size in a single firm continuous stroke of uniform depth to the full thickness. Multiple interrupted strokes can cause tearing of the tissues and hence excessive scar formation.
- Relaxed skin tension lines. These lines are the result of adjacent collagen fibers and run perpendicular to the lines of maximum extensibility.
- The difference between an acceptable and an excellent surgical outcome often rests on how the surgeon handles the tissues. The use of proper incision and flap design techniques plays a role; however, tissue also must be handled carefully. Excessive pulling or crushing, extremes of temperature, desiccation, or the use of unphysiologic chemicals easily damages tissue. Therefore, the surgeon should use care whenever touching tissue. When possible, toothed forceps or tissue hooks should be used to hold tissue When bone is cut, copious amounts of irrigation should be used to decrease the amount of bone damage
- Prevention of excessive bleeding important for preserving patients oxygen carrying capacity. However maintaining meticulous hemostasis during surgery is imp Even high volume suction cant keep surgical field dry Pressure required Small vessels – 20 to 30 sec Large vessels – 5 to 10 min Dab on vessels do not wipe as it reopens vessels that already plugged by clotted blood
- A second mean of obtaining hemostasis is by use of heat to coz the end of cut vessels to fuse
- Suture ligation- if sizable vessels is severed each end is grasped with hemostats both end are suture ligated with non resorbable suture
- 2. The dressing compresses tissue planes together until they are bound by fibrin or pressed together by surgical edema (or both). This usually takes about 12 to 18 hours. (3) technique is usually used when the surgeon is unable to tack tissue together or to place pressure dressings (e.g., when a bony cavity remains after cyst removal). (4)Suction drains continually remove any blood that accumulates in a wound until the bleeding stops and the tissues bind together, eliminating any dead space. Nonsuction drains allow any bleeding to drain to the surface rather than to form a hematoma
- Exampie of nonsuction drain. This is a Penrose drain and is made of flexible, rubberized materiai that can be pierced into wound during closure, or after incision and drainage of abscess, to prevent premature sealing of wound before blood or pus coiiections can drain to surface. Draining materiai runs aiong and through Penrose drain. in this iiiustration, a suture has been tied to drain and drain is ready for insertion into wound. Needled end of suture wiii be used to attach drain to wound edge to hoid drain in piace.
- because of the application of a controlled sub atmospheric pressure to a wound covered with a foam dressing The wound VAC system is useful for large avulsive defects that are difficult to close primarily The negative pressure removes interstitial fluid and edema to improve tissue oxygenation. . It also removes inflammatory mediators that suppress the normal progression of wound healing The wound VAC decreases bacterial counts to allow spontaneous healing and granulation tissue formation sooner than other methods The negative pressure dressing is convenient to use and requires changing every 48 to 72 hours with minimal complications.
- Application for wound VAC. (A) Wartime shrapnel wound showing large avulsive areas of right postauricular head and neck. (B)Application of wound VAC dressing. (C) Wound VAC activation. (D) Forty-eight hours after first wound VAC application. Wound bed appears healthy with small focal areas of granulation forming.
- Bacteria invariably contaminate all wounds that are open to the external or oral environment Because the risk of infection rises with the increased size of an inoculum, one way to lessen the chance of wound infection is to decrease the bacterial count. This is easily accomplished by Wound de’bridement is the careful removal of necrotic and severely ischemic tissue and foreign material from injured tissue that would impede wound healing. In general, débridement is used only during care of traumatically incurred wounds or for severe tissue damage caused by a pathologic condition.
- Edema occurs after surgery as a result of tissue injury. Edema is an accumulation of fluid in the interstitial space because of transudation from damaged vessels and lymphatic obstruction by fibrin. Two variables help determine the degree of postsurgical edema: (l) The greater the amount of tissue injury, the greater is the amount of edema; and (2) the looser the connective tissue that is contained in the injured region, the more is the edema that occurs. For example. attached gingiva has little loose connective tissue. so it exhibits little tendenq toward edema; however, the lips and lloor of the mouth contain large amounts of loose connective tissue and can swell significantly. ice applied to a freshly wounded arm decreases vasotlarity and thereby diminishes transudation and edema. However, no controlled study has verified the effectiveness of this practice. having the patient try to keep the head elevated above the rest of the body as much as possible during the first few postoperative days. Short-term, higlbdose systemic corticosteroids, which have an impressive abilityto lessen inflammation and uansudation (and thus
- 24 helthy 5 mg or This enzyme is believed to induce degradation of insoluble protein products like fibrin, biofilm and inflammatory mediators. It also reduces the viscosity of exudates, facilitates drainage and alleviates pain by inhibiting the release of bradykinin, apain-inducing amine12 . Serrapeptase was shown to significantly reduce the amount of buccal swelling after maxillary sinus serrapeptase is an effective preparation for the reduction of postoperative swelling of the ankle joint. Serrapeptase has also been used for the treatment of a number of inflammatory conditions
- Several recent studies also have delineated the association between degrees of nutritional deficit and poor outcomes in the surgical patient [2–4]. Immune function and muscle strength also are impaired, leaving these patients more vulnerable to infection and the need for prolonging mechanical ventilation time [6]. Wound healing also is delayed, leading to prolonged surgical recovery [7]. All these factors associated with poor nutrition contribute to a longer hospital stay, higher readmission rates, and markedly increased health care costs
- The stress of surgery or trauma increases protein and energy requirements by creating a hypermetabolic, catabolic state. A redistribution of macronutrients (fat, protein, and glycogen) from the labile reserves of adipose tissue and skeletal muscle to more metabolically active tissues, such as liver, bone, and visceral organs, occurs. This response can lead to the onset of protein calorie malnutrition (defined as a negative balance of 100 g of nitrogen and 10,000 kcal within a few days).
- Preoperative nutritional support is generally recommended If intestinal function is maintained in a patient, enteral nutritional support is generally preferred, as it is associated with the maintenance of gut mucosal barrier function, the decreased activation of gut-associated lymphoid tissue, and lower costs of administration than parenteral nutrition. Total parenteral nutrition is reserved for patients with ineffective gastrointestinal function, not compromised oral function.
- Ilieus is disruption of normal propultive ability of git leads to blockage of food materials
- Nasogastric tubes are chosen when the stomach is intact and empties normally in a short-term (weeks) clinical situation186; in addition, the patient must have a normal gag reflex accompanied by good mental status The position of the nasogastric tube is confirmed by injecting air and auscultating, aspirating gastric acid, or by chest radiograph
- it extends from the nose and then by way of the pylorus into the duodenum with or without the aids of fluoroscopy or endoscopic loop186, with its position verified by abdominal radiograph. The nasojejunal tube is also used in short-term feeding but requires a continuous drip with a pump, and its
- If enteral feeding is required for more than 3 to 4 weeks, other modes of enteral feeding tubes should be considered nonsurgically placed by way of balloon migration and
- The residual gastric volume should be measured every 4 hours before the next feeding bolus is administered and if the residual volume is greater than 50% of the previous bolus, the next feeding should be withheld. Approximately 30 mL of water should be used to flush the feeding tube to prevent the tube occlusion. Tracheobronchial aspiration can be prevented by elevation of the patient's head to between 30° and 45° during feeding and from 1 to 2 hours after each feeding. If a glucose concentration is greater than 20 mg/dL, aspiration is indicated.
- Mechanical complications—during placement, the following complications can occur: pneumothorax, carotid or subclavian artery puncture, hemothorax, and thoracacio duct injury
- . Primary wound management must be performed with anesthetic for thoroughness. Local anesthetics, if used, should be administered by a field block to prevent deep wound inoculation of bacteria, which may occur if the anesthetic is injected directly into the wound. Solutions without epinephrine should be used to prevent local tissue ischemia.33 A decision should be reached early about whether primary or delayed closure will be performed. In general, only wounds that are treated early and can be adequately decontaminated should be closed primarily. Because of their rich vascular supply, facial wounds may be closed primarily after a greater delay than would be acceptable in other areas of the body. The risk of infection in facial wounds is reduced because the preinjury quantity of bacteria in the facial region is usually much less than in other areas, such as the foot, in which the numbers and types of bacteria result in a much higher infection rate. Therefore, many authors believe that up to 24 hours following injury is an acceptable period in which to attempt primary closure of facial injuries.216 Wounds of the face are usually closed primarily. Puncture wounds are preferably left open to heal by secondary intention to reduce the potential for infection caused by the trapping of bacteria within the wound. Secondary healing of puncture wounds may also lead to an aesthetically satisfactory scar, especially on a concave surface, such as the medial canthus and nasolabial fold.217 If adequate débridement, irrigation, and principles of closure are followed, this primary closure of facial wounds that are deeper or more extensive provides the most aesthetically satisfying result. In severely contaminated wounds or those in which a significant delay in treatment has occurred, a delayed primary closure technique should be used. In this technique, the wound is thoroughly débrided, irrigated, and packed open with frequent dressing changes. A wet to dry dressing is applied, which involves moistening sterile gauze in contact with the wound bed and overlaying this with layers of dry gauze. This dressing has a wick effect and draws out serous and any other exudate from the wound.
- Initial wound management is then directed toward reducing the number of organisms present in the wound. This reduction is carried out by vigorous cleansing, careful débridement of grossly nonvital tissue, and copious irrigation under pressure with normal saline only. Primary wound management must be performed with anesthetic for thoroughness. Local anesthetics, if used, should be administered by a field block to prevent deep wound inoculation of bacteria, which may occur if the anesthetic is injected directly into the wound. Solutions without epinephrine should be used to prevent local tissue ischemia.33 A decision should be reached early about whether primary or delayed closure will be performed. In general, only wounds that are treated early and can be adequately decontaminated should be closed primarily. Because of their rich vascular supply, facial wounds may be closed primarily after a greater delay than would be acceptable in other areas of the body. The risk of infection in facial wounds is reduced because the preinjury quantity of bacteria in the facial region is usually much less than in other areas, such as the foot, in which the numbers and types of bacteria result in a much higher infection rate. Therefore, many authors believe that up to 24 hours following injury is an acceptable period in which to attempt primary closure of facial injuries.216 Wounds of the face are usually closed primarily. Puncture wounds are preferably left open to heal by secondary intention to reduce the potential for infection caused by the trapping of bacteria within the wound. Secondary healing of puncture wounds may also lead to an aesthetically satisfactory scar, especially on a concave surface, such as the medial canthus and nasolabial fold.217 If adequate débridement, irrigation, and principles of closure are followed, this primary closure of facial wounds that are deeper or more extensive provides the most aesthetically satisfying result. In severely contaminated wounds or those in which a significant delay in treatment has occurred, a delayed primary closure technique should be used. In this technique, the wound is thoroughly débrided, irrigated, and packed open with frequent dressing changes. A wet to dry dressing is applied, which involves moistening sterile gauze in contact with the wound bed and overlaying this with layers of dry gauze. This dressing has a wick effect and draws out serous and any other exudate from the wound.
- The wound is repacked at least twice daily and observed for 3 to 5 days. If no signs of infection are present, the wound margins are sharply incised and primarily closed. Wounds treated by delayed primary closure will heal as fast as those closed primarily, because the reparative processes have already been initiated. It has been shown that as long as a clean wound is closed within 4 days following an incision, the wound strength is equivalent to 7 days, regardless of whether primary closure or delayed primary closure was used.218
- The first and last most important principles of omfs is, coupled with the primary tenet of the Hippocratic Oath, Primum non nocere (“First, do no harm”), will serve the oral and facial surgeon well. Second important step is Preoperative evaluation. Because it may alter the usual approach to the patients surgical problem. Third imp thing is Aseptic technique. Surgeon should follow aseptic tech. because it not only affect surgical outcome and Surgeons also have a responsibility to themselves, residents in training, and other staff to maintain a high standard in regard to prevent cross infection. The process of wound healing is complicated and requires optimization of wound bed conditions locally through wound management and systemically through proper nutritional care. The OMS should be capable of assessing the patient's nutritional status and nutritional requirements and developing appropriate recommendations for proper nutritional management. Knowledge of the various modalities of nutritional support should be readily available to the OMS practitioner.