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Зміст2. Duration of studies
4. Basic knowledges, abilities, skills, that necessary for the study themes (interdisciplinary integration)
The surgical instruments and rules of their use
1. The Instruments for the Parting of Tissue
The resection knives
The surgical saws
The principles of soft tissues disconnection
2. The Instruments for the Arrest of Bleeding
The Technique for the Arrest of Bleeding by Kocher’s Clamps
The Technique of Arrest of Bleeding by the Billroth’s Clamp
3. The Instruments for the Suturing of Tissue
4. The Accessory Surgical Instruments
The Special Surgical Instruments
Types of suture material
Synthetic Nonabsorbable Braids
Synthetic Nonabsorbable Monofilaments
Ministry of Health of Ukraine
Bukovinian State Medical University
on methodical meeting of the Department of Anatomy, Topographical anatomy and Operative Surgery
“………”…………………….2008 р. (Protocol №……….)
The chief of department
for the 2d-year foreign students of English-spoken groups of the Medical Faculty
(speciality “General medicine”)
for independent work during the preparation to practical studies
the Theme of studies
“The surgical instrumentation and usage rules”
“Topographical Anatomy and Operative Surgery
of the Head, Neck, Thorax and Abdomen”
“Topographical Anatomy and Operative Surgery of the Head and Neck”
Chernivtsi – 2008
1. Actuality of theme:
The topographical anatomy and operative surgery are very importance, because without the knowledge about peculiarities and variants of structure, form, location and mutual location of their anatomical structures, their age-specific it is impossible to diagnose in a proper time and correctly and to prescribe a necessary treatment to the patient. Surgeons usually pay much attention to the usage rules of surgical instruments.
^ 2 working hours.
3. Objectives (concrete purposes):
To know the definition of topographical anatomy and operative surgery, surgical operation.
To know classification of surgical instrumentation.
To know surgical instrumentation and usage rules.
To be able to define the surgical instrumentation.
5. Advices to the student.
5.1. Table of contents of the theme:
The surgeon realizes the mechanical influence on organs and tissues by his surgical instruments. There are a few classifications. According to the government standard 19126-79E (“Metal medical instruments. General technical conditions”) they are divided by character of mechanical action:
The classification by function is more comfortable for surgeons:
I. General surgical instruments:
II. Special surgical instruments (neuro-surgical, traumatologic, stomatologic, ophthalmologic and other).
The structure of surgical instrument. An instrument consists of working portion (blade of an instrument), which is acted on patient tissues and handle kept by a surgeon. The construction of instrument is conditioned by character of its mechanical acting on tissues. The greater part of instruments (clamps, scissors and others) consist of two parts – branches, connected by a lock. The blade of an instrument can have grinds, windows, incisions, teeth on its tips, and others. For the firm keeping of instrument in hand the handles should have rings, incisions or lugs. For fixing of branches in the clamped position on handles can be rack gear. For the firm keeping in a hand an instrument should have three points of fixing. For example, clamps, needle-holders, scissors kept by 1st, 2nd and 4th fingers.
The surgical instruments applied in pediatric surgery have less sizes and weight, fine tips of an instruments (for example, less length and width of grips of clamps).
For disconnection of soft tissues the scalpels, operating knives, scissors are utilized. For bone tissue – the surgical saws, chisels are utilized. In addition, the properties of electric current, laser and radiation emanation, ultrasonic waves.
^ is an instrument of piercing and cutting action. For realization of mainly cutting action abdominal scalpels are utilized, for piercing – spoking (sharp-pointed) ones. There are also other configurations of cutting edge, conditioned by the features of form of organs and tissues to dissect.
There are entire-stamped, non-permanent and with a removable blade scalpels. There are certain receptions of using a scalpel. The position of “writing pen” provides exact, dosated cuts of precise length and depth. The position of bow provides long and superficial cuts of soft tissues, the position of table-knife – deep cuts. For realizing a skin cut a scalpel is set almost at the beginning of future cut vertically, and then it is inclined and cuts a skin and hypodermic cellular tissue. At the end of cut a scalpel is again transferred in a vertical position.
^ are the instruments of crushing and cutting action. It is not recommended to cut a skin, vessels, nerves and internal organs by scissors because of their excessive injuring. The fascias, apo-neurosis, suture material are cut by scissors. By the form of branches the scissors may be straight and curved (Richter scissors – by plane, Cooper scissors – by axis). By the form of form ends may be blunt-pointed, sharp-pointed and button-type scissors (scissors of Lister for the bandages removal). The scissors are hold in a hand with help of 1st, 2nd and 4th fingers.
The special type of scissors is laparotomy scissors of Metzenbaum, or dissector. They are arcuated by plane, have rounded surfaces, narrow blunt ends, long handles. They are applied for cutting off of suture material, dissecting of connections in the body cavities, and also for blunt disconnection of tissues by separation of branches or piercing of non-vascular areas of copulas and frills by closed ends (e.g. during organ’s mobilization).
The ends of the bound are cut away by scissors by certain rules: 1) having strained threads by a left arm, the separated scissors’ tips carefully approached to the tied knot; 2) after stopping in the knot the branches are turned on 90° and cut away the threads excess. Such mode provides necessary minimum length of knot ends – approximately 3 millimetres.
^ have the wide back of blade, allowing to make additional effort for disconnection of dense tissues.
The catling (small, middle and large) is utilized for the single-stage dissection of soft tissues during amputations. For this purpose the surgeon holds the knife blade up and edge toward himself.
^ disconnect bone tissues: flat bones – by the saws of Jeegly and Olivecrone, tubular bones – by dissecting blade, knife, arched and circular saws. For the bones dissection is used also cutters of Liston, Lyuer, Dalgran, Schtille and others.
During operations on bones the surgical chisels is used (straight and grooved). Before a bones dissection a periosteum is detached layer by a layer by raspatories (straight and arcuated).
For the dissection of skull cavity (trepanation) is used a trepan with the set of pinned and spherical milling cutters, for the dissection of tubular bones cavity – the osteotome.
During the disconnection of tissues a surgeon must provide:
Among these are vascular and hemostatic forceps (clamps).
The arteries and veins of middle and large gauge are pinched by vascular clamps to prevent hemorrhage during operations on vessels and organs (heart, lungs, kidneys, gallbladder and others). Among these are the vascular clamps of Satinsky, Hophner, Pyrogov, Mayo, Negus, Well and others.
The final hemostasis is carried out by hemostatic forceps. They are used for cross-clamping of vessels of small gauge, damaged during access or separation of organ from surrounding tissues. Such clamps are different by a construction, but they can be divided to two groups: 1) clamps with teeth on the ends of working portion (Kocher’s clamps); 2) clamps without teeth (Billroth’s, “mosquito”, Pean’s clamps and others).
The straight clamp with teeth on the tip Kocher firstly applied for vessels’ pinching of thyroid gland. The hemostasis is carried out by damaged vessel cross-clamping together with surrounding tissues by blade of instrument (except teeth). The teeth do not permit the instrument to slip off. Under a clamp is got the thread or piercing ligature. After making the first knot a clamp is carefully taken off, not breaking off to tighten the first knot and making the second one.
The clamp is applied for haemostasis of the damaged hypodermic vessels. The bleeding vessel’s opening (without surrounding tissues) is pinched by clamp’s tips. The ends of grips are carefully turned inside out to let them appear in the assistant’s field of vision putting the thread under ends. During tightening the first knot a clamp is carefully taken off then the second knot is tied.
For arrest of bleeding the blunt-pointed ligature needle of Deschamp is applied. It has an eye on a tip. An eyed thread is put by an instrument under the prepared segment of vessel. The Deschamp’s needle is delivered from a wound, and a thread is fixed and cut on two parts by which the ligatures are put.
With a purpose of arrest of bleeding surgical diathermy (thermal effect of electric current) is applied. The electric current with certain characteristics is put to the vessel through a metallic instrument (clamp, forceps). The electric field at this moment is closed. The arising thermal effect at passing of current through biological tissues with a little electric resistance causes coagulation and hemostasis.
The tissues connection is carried out suture material by medical needles, needle-holders and also by Michel’s cramps put by special forceps, staplers and by the mechanical sutures devices.
The suture material is classified after high-quality and quantitative characteristic of elemental fibres. By the structure of fibre the suture material is divided on monofilament and polyfilament (twisted and wattled).
The main destination of suture material is to approach, adapt and fix biological tissues which are to be connected on a term necessary for formation of adhesion (seam, scar).
The general requirements regarding suture material:
- Cheapness of raw material and production.
The elastic suture material is conducted through
tissues for their connection by surgical needles. The needles are held up by the needle-holders of different constructions (Hegar, Troyanov and Mathieu).
The needles are classified by their different characteristics. There are straight, circle and steep needles by a form. The surgeon choice of needle of necessary form is determined by angle of operative action. At large angle (up to 180°) it is comfortable to use a straight needle, for example, for creation of anastomosis between the intestinal loops, and at small angle (to 30°) a steep needle is better, for example, for the plastic surgery of femoral canal.
The needles are made with the various form of cross-section (flat, round, triangular and multangular), but the widest distribution have round (piercing) and triangular (cutting) surgical needles. Piercing needles pull apart the fibres of biological tissue and provide impermeability of tubular structures sutures; that is why they are applied for connection of muscles, intestine walls, vessels. The cuttings needles conduct suture material through a skin.
By the method of suture material fixing the needles are divided into traumatic and atraumatic. The traumatic needle has an eye (round, automatic, helical and others). The atraumatic, or swagged, needle is as though the continuation of suture material. The absence of eye and double thread determines the minimum injuring of tissues at putting of cosmetic suture.
There is the special place for its fixing of needle-holder on a needle, which is located nearer to the eye.
The needle-holder of Hegar is most widespread (small, middle and large). It should be remembered that this needle-holder is expected to act during 600 work cycles (600 reliable, without motions and fixings of needle), that is why it would be bad to leave an instrument lying idle with the clamped needle.
For conducting of suture material through paren-chymal organs the sharp-pointed Deschamp’s needle also is utilized.
After stitching up the wound edges are drawn together, compared and fixed by tying a knot with threads ends.
During the tying of surgical knot it is necessary to provide permanent moderate intension of suture material. A minimum of knots – 2, but, depending on properties of suture material, there are can be more knots to prevent of untying and rupture of wound edges.
The most reliable is square knot (reef knot, sailor’s knot). A surgeon’s knot (surgical knot, friction knot) allows comparing and fixing the wound edges now at the first tying, but for bandaging of vessels of small diameter this knot isn’t worth utilizing.
There are a lot of methods of knot’s tying. The best method is that by which the surgeon wields perfectly.
The basic moments of knot’s tying (a right arm – “handle”, a left one – “working”):
In microsurgery, ophthalmology, pediatric surgery the instrumental methods of knots tying are often applied, so to say without a touch by fingers but only by instruments to prevent the possible infecting of suture material.
The Principles of Tissues Connection
For providing favourable conditions for regeneration, minimum cosmetic defects and violations of physiologic functions of organs and tissues a surgeon follows the certain rules of biological tissues connection. A surgeon must provide:
1. Anatomic and physiologic continuity of tissues, that is:
2. Prophylaxis of festering and septic complications, that is:
3. Reliable hemostasis and prophylaxis of bleeding after an operation, that is:
4. Optimum conditions for wound regeneration and healing by initial intension, prophylaxis of tissues necrosis, that is:
These are designed for holding, fixing and pushing back (retract) of tissues and surgical garb. Among these are retractors, flat hooks of Farabeuf, hepatic mirrors, pincers (anatomical, surgical, gripping, fenes-trated), dressing forceps, pumps, hooks for surgical garb, clamp of Miculicz and others. By these instruments is provided the important general surgical principle – the instrumentality – for the minimum injuring of biological tissues and preventing of their infecting by the surgeon hands.
This is the most numerous group of various surgical instruments by construction, which are utilized in gynaecology, urology, neurosurgery, otolaryngology and other spheres of medicine.
The ophthalmologic, neurosurgical, cardiac and pediatric surgery’ instruments are differing by small sizes and weight. The form of microsurgical instruments is adapted to the operative conditions.
The operations for children’s require application of atraumatic needles and modern synthetic suture material. During an operation the special exactness and delicacy of manipulations is necessary: the tissues are disconnect mainly sharply, avoiding compression, crushing and exfoliation. The electric coagulation and using of electric knife must be limited and applied with a maximal carefulness, because the impossibility of the exact adjusting of influence intensity on tender tissues can bring to burn and injury of nearby organs and structures.
The careful control on loss of blood and its supplying is obligatory to during an operation (but not after it’s finishing). In surgery of newborns is especially justified the aspiration to the rational acceleration of operation, however without a loss for its delicacy and atraumatic measures.
The general principles of pediatric surgery:
Plain catgut is not commonly used in modern surgery. Although its rapidity of absorption might seem to be an advantage, this rapidity is the result of an intense inflammatory reaction that produces enzymes for the digestion of the organic material. Plain catgut is acceptable for ligating bleeding points in the subcutaneous tissues and not for very much else.
Chromic catgut has the advantage of a smooth surface, which permits it to be drawn through delicate tissues with minimal friction. It may be depended upon to last for about a week and is suitable only when such rapid absorption is desirable. It is completely contraindicated in the vicinity of the pancreas, where proteolytic enzymes produce premature absorption, and in the closure of abdominal incisions and hernia repair, where it does not hold the tissues long enough for adequate healing to occur. Chromic catgut is useful for the approximation of the mucosal layer in a two-layer anastomosis of the bowel. For this purpose, size 4-0 is suitable. Bear in mind that wound infection will increase the rapidity of catgut digestion.
Polyglycolic synthetic sutures (PG), such as Dexon or Vicryl, are far superior to catgut because the rate at which they are absorbed is much slower. Even after 15 days, about 20% of the tensile strength remains. Digestion of the polyglycolic sutures is by hydrolysis. Consequently, the proteolytic enzymes in an area of infection have no effect on the rate of absorption of the polyglycolics. Also, the inflammatory reaction they incite is mild as compared with catgut. Their chief drawback is that their surface is somewhat rougher than catgut, which may traumatize tissues slightly when the PG suture material is drawn through the wall of the intestine. This characteristic also makes the tying of secure knots somewhat more difficult than with catgut. However, these appear to be minor disadvantages, and these products have for many purposes made catgut an obsolete suture material.
Natural nonabsorbable sutures, such as silk and cotton, have enjoyed a long period of popularity among surgeons the world over. They have the advantage of easy handling and secure knot tying. Once the knots are set, slippage is rare. On the other hand, they produce more inflammatory reaction in tissue than do the monofilament materials (stainless steel, Prolene) or even the braided synthetics. Silk and cotton, although classified as nonabsorbable, do indeed disintegrate in the tissues over a long period of time, whereas the synthetic materials appear to be truly nonabsorbable. In spite of these disadvantages, silk and cotton have maintained worldwide popularity mainly because of their ease of handling and surgeons’ long familiarity with them. Because there are no clear-cut data at this time demonstrating that anastomoses performed with synthetic suture material have fewer complications than those performed with silk or cotton, it is not yet necessary for the surgeon to abandon the natural nonabsor-bables if he or she can handle them with greater skill. With the exception of the monofilaments, a major disadvantage of nonabsorbable sutures is the formation of chronic draining sinuses and suture granulomas. This is especially marked when material larger than size 3-0 is used in the anterior abdominal fascia or in the subcutaneous tissue.
Synthetic braided sutures include those made of Dacron polyester, such as Mersilene, Ticron (Dacron coated with silicone), Tevdek (Dacron coated with Teflon), and Ethibond (Dacron with butilated coating). Braided nylon (Surgilon or Nurolon) is popular – in the United Kingdom. All these braided synthetic materials require four or five knots for secure closure, compared to the three required of silk and cotton.
Monofilament synthetics like nylon and Prolene are so slippery that as many as 6-7 knots may be required. They and monofilament stainless steel are the least reactive of all the products available. For this reason, 2-0 or 0 Prolene has been used by some surgeons for the abdominal closure in the hope of eliminating suture sinuses. Because of the large number of knots, this hope has not been realized, but the sinuses have turned out to be fewer than when nonabsorbable braided materials are used. Prolene size 4-0 on atrau-matic needles has been used for the seromuscular layer of intestinal anastomoses. Both Prolene and various braided polyester sutures have achieved great popularity in vascular surgery.
Monofilament stainless steel wire has many characteristics of the ideal suture material; however, it is difficult to tie. Also, when it has been used for closure of the abdominal wall, patients occasionally have complained of pain at the site of a knot or of a broken suture. True suture sinuses and suture granulomas have been extremely rare when monofilament stainless steel has been used – no more than 1 in 300 cases. Size 5-0 monofilament wire has been used for one-layer eso-phagogastric anastomoses and for colon anastomoses. Three square throws are adequate for a secure knot in tying this material. If steel wire in the form of a braid is used, the incidence of suture sinuses is not less than experienced with braided silk.
Dermalon – monofilament nylon.
Ethibond – braided Dacron polyester with buti-lated coating.
Ethilon – monofilament nylon.
Mersilene – braided Dacron polyester.
Nurolon – braided nylon.
PDS – Polydiaxanone, synthetic monofilament absorbable suture; slowest rate of absorption of cur-rendy available suture materials.
PG – polyglycolic acid, Dexon, polyglactin, Vicryl.
Prolene – monofilament polypropylene.
Surgilene – monofilament polypropylene.
Surgilon – braided nylon coated with silicone.
Tevdek – braided Dacron polyester coated with Teflon polytetrafluorethylene.
Thumbtack – titanium hemorrhagic occluder pin with applicator.
Ticron – braided Dacron polyester coated with silicon.
Vicryl – Polyglactin, synthetic absorbable suture material.
As there mustn’t ever be any tension on an anastomosis in the gastrointestinal tract, it is not necessary to use suture material heavier than 4-0. Failure of healing is often due to tearing of a stitch through the tissue and almost never to a broken suture. When two layers of sutures are used for an anastomosis in the gastrointestinal tract, the inner layer should be 5-0 Vicryl. This layer provides immediate and accurate approximation of the mucosa and, in some instances, hemostasis. Therefore, this layer of suture material doesn’t need persist more than 4-6 days before it is absorbed. In esophagogastric anastomoses, interrupted 4-0 PG should be used for the inner layer, which has the additional function of contributing strength to the anastomosis. For this purpose, slower absorption is desirable. When taking large bites of tissue that has considerable tensile strength, such as in the closure of the abdominal wall, heavier suture material is indicated. Here, 1-0 PDS is suitable. Obviously, the size of the suture material must be proportional to the strength of the tissues into which it is inserted and to the strain it has to sustain.
1. Give a demonstration of correct using of surgical instruments for the parting of tissue.
2. Give a demonstration of correct using of surgical instruments for the arrest of bleeding.
3. Give a demonstration of correct using of surgical instruments for the suturing of tissue.
4. Give a demonstration of correct using of the accessery surgical instruments.
5. Give a demonstration of knots tying.
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