Introduction of the operative surgery

1. Introduction of the operative surgery
Surgical instruments
Surgical incision
Surgical suture

2. Operative surgery is a medical science
about techniques, methods and rules of
performing operations, and the usage of surgical
instruments.
Surgical operation is a traumatic approach to the
organs and tissues of the human body with the
aim to make diagnosis. Each operation consists
of three stages: 1st – operative access, 2nd –
operative maneuver, 3rd- way out of the
operation.

3. Terminology of operations
The name of an operation consists of the name of the
pathologically changed organ and operative maneuver.
Operative maneuvers are:
• Amputation - removal of the peripheral part of an organ, such as
amputation of the limb;
• Anastomy - creation of an artificial connection between the lumens of
two organs, such as gastroenteroanastomy;
• Centesis - puncture or piercing a surface, such as thoracocentesis;
• Ectomy - complete removal of an organ, such as pulmonectomy;
• Implantatio - insertion of an artificial organ or tissue into the body;
• Pexy - surgical fixation of an organ to another one, such as
neuropexy;
• Tomy - insition of an organs wall, such as laparatomy;
• Resection - removal of part of an organ, such as resection of the liver;
• Rrhaphy - stitching of an organ or tissue, such as myorrhaphy;
• Section - cutting of tissue, such as venesection.

4. Holding the instruments
• Better method is by finger tip pressure
wherein thumb and ring fingers are placed in
finger bows of the instrument. Precise fine
relaxed movements are essential for proper
work up of the instruments.
• Second method of holding the instruments is
tight vise like grip using fist of the hand. It
gives a good grip but precision may not be
adequate.

6. Making the incision

7. Langer’s lines, which are sometimes referred to as the skin cleavage lines, are a series
of lines drawn topographically across the human body. They correspond to the natural
orientation of collagen fibres in the dermis and usually lie parallel to underlying
muscle fibres. They are an important consideration in surgery and if incisions are made
in the direction of Langer’s lines they tend to heal better and produce less scarring
than those that cross them.

8. The position of the scalpel in the hand
Dinner knife position is used while
making lengthy incision. Sustained
pressure by the index finger over the
knife with depth control is the
technique
Pen holding/writing position is used
to make incision over the
vessels/nerves/tumors. Skin flap or
tissues without natural plane can be
dissected using this method

9. Fiddle bow position is used to
make incisions with less pressure
on delicate tissues. It is with least
pressure, fine dissection is done
with firm grip
Stab position of the knife is
used in draining an abscess or
making an incision to pass
drains.

10. Surgical instruments are classified by their function.
I. Manipulation - as you hold and interact with objects in your
hands, a surgeon may use the following instruments.
Dissecting forceps, also known as dissectors, pick-ups, grabbers
and thumb forceps. This is one of the instruments you are most
likely to be familiar with. Dissecting forceps look like a large pair of
tweezers and generally vary in size and shape (Figure 1). Forceps
are used to grasp and manipulate tissue as well as equipment such
as needles or swabs. You would use them as you would use your
finger and thumb. Importantly, the tip of the forceps can be non-
toothed (atraumatic) or toothed (traumatic).

12. Hinged forceps, resembling a pair of scissors
but instead of two blade-like parts, two arms
which meet to press together instead of cut.

13. Tissue clamps have a similar design to hinged-forceps and are used
to block or occlude blood vessels or other luminal tissues (such as
bowel). Depending on their use, clamps can be atraumatic (e.g. for
use on bowel), designed to crush tissue, or have features specific to
them so they don’t slip (e.g. for vessel occlusion).

14. Bowel clamp

15. Probes, long, slender and uncomplicated instruments,
probes also vary in size and the functional ends. Generally,
probes are used for exploring or examining anatomy as well
as fistulae or sinus tracts.

16. II. Retraction - to improve the view of the surgical field by tissue or
organs out of the way the following instruments may be used.
Handheld retractors, simple, versatile instruments which need to be
held and manipulated by an assistant. They have three main parts: a
handle which goes in the assistant’s hand, a blade which goes into
the patient and a shaft in-between. The blades come in many
different shapes, including hooks, teeth, right angles and curves.

17. Self-retaining retractors, varying significantly in design from simple
hinged ratchet’s to complex operating-table-mounted frames, self-
retaining retractors hold themselves in place after they have been
positioned and applied. This is very useful, as it frees up the assistant’s
hands to do other more exciting things, reduces muscle fatigue and
allows the continuous provision of safe and stable levels of traction
during longer procedures.

18. III. Cutting and Dissecting Instruments - to open up tissue, such as the
skin during the beginning of an operation in the abdomen, and also to
separate tissues apart during an operation.
Scapels, is a fine-edge cutting instrument with a blade that allows the
surgeon to exert maximum control while cutting tissues, and is used to
make incisions in the skin or other tissues. Surgical scalpels consist of
two parts, a blade and a handle. The handles are often reusable, with
the blades being replaceable. In medical applications, each blade is only
used once (even if just for a single, small cut).

19. Scissors, are surgical instruments usually used for cutting. As
an assistant, it’s important to know that suture scissors are
generally straight, and fine dissecting scissors have a slight
curve at the tip.

20. Bone Cutter, is a surgical instrument used to
cut or remove bones.

21. IV. Grasping or holding instruments
Forceps, surgeons use forceps during surgical procedures to hold onto
or manipulate tissues and to clamp blood vessels. Surgical forceps are
hinged instruments, similar in design to scissors, but with tong-like or
flat tips that are used to hold, clamp or move tissues during surgery.
Forceps come in three varieties: tissue/dressing forceps, intestinal
forceps and hemostats (used to clamp blood vessels).

22. Haemostatic forceps

23. Diathermy, an energy device which is commonly used to
cut through tissue, but has both cutting and coagulation
properties. It works by a high-frequency electrical current
which heats the tissue to which it is applied.

24. V. Tissue unifying surgical instruments and materials - this is another
class of surgical instruments that include tissue unifying instruments and
materials such as needle holders, surgical needles, staplers, clips,
adhesive tapes.
Needle Holder, also called needle driver, is a surgical instrument, used
by doctors and surgeons to hold a suturing needle for closing wounds
during suturing and surgical procedures. The parts of a simple needle
holder are the jaws, the joint and the handles. Most needle holders also
have a clamp mechanism that locks the needle in place.

25. Surgical Needles, need to be strong enough to pass through tough tissue while causing
minimal trauma to delicate tissues and reducing tissue reactions. Needles are made of
steel, come in different sizes, have blunt or sharp points, and can be curved or straight.
Surgical needles are necessary for the placement of sutures in tissues. They are
composed of:
•The swaged end connects the needle to the suture
•The needle body or shaft is the region grasped by the needle holder. Needle bodies
can be round, cutting, or reverse cutting: round bodied needles are used in friable
tissue such as liver and kidney; cutting needles are triangular in shape, and have 3
cutting edges to penetrate tough tissue such as the skin and sternum, and have a
cutting surface on the concave edge; reverse cutting needles have a cutting surface on
the convex edge, and are ideal for tough tissue such as tendon or subcuticular sutures,
and have reduced risk of cutting through tissue
•The needle point acts to pierce the tissue, beginning at the maximal point of the
body and running to the end of the needle, and can be either sharp or blunt: blunt
needles are used for abdominal wall closure, and in friable tissue, and can potentially
reduce the risk of blood borne virus infection from needlestick injuries; sharp
needles pierce and spread tissues with minimal cutting, and are used in areas where
leakage must be prevented.

27. Stapler, is used in surgery in place of sutures to close
skin wounds, connect or remove parts of the bowels
or lungs.

28. Viewing- surgeons can examine body cavities, hallow organs,
or structures with viewing instruments including different
kinds of speculum (nasal, vaginal, rectal) and endoscopic
instruments.
Vaginal speculum

29. Nasal speculum

30. Suction - is used to clear the surgical field by removing blood
or other fluids. The suction tip is attached to a vacuum piping
outside of the sterile field.

31. The specific surgical incision will depend on the
underlying pathology, site, patient factors, and
the surgeon’s preference and experience. The key
principles of making surgical incisions are:
•Incisions should try to follow Langer’s lines where
possible, for maximal wound strength with minimal
scarring
•Muscles should be split and not cut (where possible)
Once the operation is over, surgical excisions can
be closed by sutures, staples, tissue glue, or a
combination of these agents. The wound can
be covered in a protective dressing and kept dry for a
few days, before normal washing can resume.

32. Suture material can be classified as either absorbable or non-absorbable.
Absorbable sutures do not require a doctor to remove them. This is because enzymes found in
the tissues of a human body naturally digest them.
Non-absorbable sutures will need to be removed by a doctor at a later date or in some cases
left in permanently.
Types of absorbable sutures:
•Gut: This natural monofilament suture is used for repairing internal soft tissue wounds or
lacerations. The gut should not be used for cardiovascular or neurological. The body has the
strongest reaction to this suture and will often scar over. It is not commonly used outside of
gynecological surgery.
•Polydioxanone (PDS): This synthetic monofilament suture can be used for many types of soft
tissue wound repair (such as abdominal closures) as well as for pediatric cardiac procedures.
•Poliglecaprone (MONOCRYL): This synthetic monofilament suture is used for general use in
soft tissue This material should not be used for cardiovascular or neurological procedures. This
suture is most commonly used to close the skin in an invisible manner.
•Polyglactin (Vicryl): This synthetic braided suture is good for repairing hand or facial
lacerations. It should not be used for cardiovascular or neurological procedures.

33. Types of non-absorbable sutures: these types of sutures can all be used
generally for soft tissue repair, including for both cardiovascular and
neurological procedures.
•Nylon- a natural monofilament
•Polypropylene (Prolene)- a synthetic monofilament
•Silk- a braided natural
•Polyester (Ethibond)- a braided synthetic
When your sutures are removed will depend on where they are on your
body.
•scalp: 7 to 10 days
•face: 3 to 5 days
•chest or trunk: 10 to 14 days
•arms: 7 to 10 days
•legs: 10 to 14 days
•hands or feet: 10 to 14 days
•palms of hands or soles of feet: 14 to 21 days

34. Monofilament
sutures consist of
a single thread.
This allows the
suture to more
easily pass
through tissues.
Braided sutures
consist of several
small threads
braided together.
This can lead to
better security,
but at the cost of
the increased
potential for
infection.

35. Suture selection and techniques
There are many different suture techniques. Some of them are:
Continuous sutures: This technique involves a series of stitches that use
a single strand of suture material.
Interrupted sutures: This suture technique uses several strands of
suture material to close the wound. After a stitch is made, the material
is cut and tied off. This technique leads to a securely closed wound. If
one of the stitches breaks, the remainder of the stitches will still hold
the wound together.
Deep sutures: This type of suture is placed under the layers of tissue
below (deep) the skin. They may either be continuous or interrupted.
This stitch is often used to close fascial layers.
Buried sutures: This type of suture is applied so that the suture knot is
found inside (that is, under or within the area that is to be closed off).
This type of suture is typically not removed and is useful when large
sutures are used deep into the body.

36. Purse-string sutures: This is a type of continuous suture that is placed
around an area and tightened much like the drawstring on a bag. For
example, this type of suture would be used in your intestines in order to
secure an intestinal stapling device.
Subcutaneous sutures: These sutures are placed in the dermis, the layer
of tissue that lies below the upper layer of human skin. Short stitches
are placed in a line that is parallel to a wound. The stitches are then
anchored at either end of the wound.

38. Principles of suturing – The needle should be grasped at
approximately 1/3rd the distance from the eye and 2/3rd from the point.
The knot should never lie on the incision line.

39. Type of wire knot:
Square knot: it is made up of two single knots with opposite directions.
It is characterized by the overlapping lines of ligatures, firm knots and
not easy to loose. It is the most commonly used knot in surgery and is
suitable for less.
Surgical knot: the wire is retwisted twice when the first single knot is
made to increase the friction between the wires. It is not easy to slip or
loose when hitting the second knot, so it is relatively strong, but
because it takes time, it is only large in ligation.
Slip (granny) knot: when the square knot is struck, the second-
hand force is uneven when the operator pulls the wire. It is made
up of two single knots with one direction, and third tie in opposite
direction.
For practice the canals on youtube: Surgical Teaching,
MiniMedLessons.