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TitleBoros Surgical Techniques
TagsSurgical Suture Shock (Circulatory) Wound Bleeding
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Table of Contents
                            Introduction
	Table of contents
	I. Asepsis and antisepsis
		1. Historical overview
		2.  Asepsis and antisepsis in surgical p
		3.  Surgical infections, sources of woun
		4.  Types of surgical wound contaminatio
		5.  Prevention of wound contamination
		6.  Risk factors of wound contamination
		7.  Postoperative wound management
		8.  Sterilization, elimination and inact
		9. Disinfection
		10. Asepsis
		10.1.  Preparation of the skin before th
		10.2.  Disinfection and scrubbing of the
		10.3.  Isolation of the operating area (
		11.  Basic rules of asepsis in the opera
		11.1.  Personnel attire in the operating
		12.  Scrubbing, disinfection and gowning
		13.  Personnel attire and movement in th
		14.  Basic rules of asepsis in the opera
		15.  Further important items to ensure a
		16.  Duties related to asepsis in the po
		17. Surgical antisepsis
	II. Theoperatingroom
		1.  Furniture, basic technical backgroun
		2. Standard equipment
		3. Theoperatingroompersonnel
		3.1.  Organization of the operating room
		4.  Positioning of the surgical patient
	III.  Surgical instrumentation. Basic su
		1.  Cutting and dissecting instruments
		2. Grasping instruments
		3. Retracting instruments
		4.  Wound-closing instruments and materi
	IV.  Basic wound-closing methods: suture
		1. Types of sutures
		2. Rules of wound closure
		3.  Correct position of the needle holde
		4. Interrupted sutures
		4.1.  Simple interrupted suture (sutura
		4.2.  Vertical mattress suture (sec. Don
		4.3.  Vertical mattress suture sec. Allg
		4.4. Horizontal mattress suture
		5. Continuous sutures
		5.1.  Simple continuous suture (furrier
		5.2. Locked continuous suture
		5.3. Subcuticular continuous suture
		5.4. Purse-string suture
		6. Methods of wound closure
		6.1.  Suturing with simple interrupted k
		6.2.  Suturing with Donati stitches (ski
		6.3.  Wound closure with metal clips (ag
		6.4. Other wound-closing methods
		7. Sutures in differenttissues
		7.1. Failures of suturing technique
		7.2. Removing sutures
		8. Surgical knots
		8.1. Types of surgical knots
		8.2. Two-handed knots
		8.3.  Knotting under special circumstanc
		8.3.1. Knotting close to the surface
		8.3.2. Tying under tension
		8.3.3. Tying knots in cavities
		9.  Wound closure in separate layers
		9.1.  Approximation of tissues in the de
		9.2. Closure of the subcutis
		9.3. Skin stitches
		10. Drainage
		10.1. Passive drainage
		10.2.  Active drainage (with negative pr
		10.3.  Important localizations of draina
		10.4. Drain removal
	V. Theoperation
		1. Basic surgical interventions
		2. Preparations for an operation
		3. Informed consent
		4. Operative risk
		4.1. Acute risk factors in surgery
		4.2. Chronic risk factors in surgery
		5. Preoperative management
		5.1.  Evaluation of preoperative investi
		6. Thepreoperativepreparation
		7. Postoperative complication
		7.1. Complications of anesthesia
		7.2.  Complications depending on the tim
		7.2.1. Intraoperative complications
		7.2.2. Postoperative complications
		7.2.2.1. Postoperative fever
		7.2.2.2.  Complications of wound healing
		7.2.2.3.  Postoperative nausea and vomit
		7.3.  Complications associated with the
		8. Minor surgery
		8.1.  A short historical survey oflocal
		8.2. Local anesthetic drugs
		8.2.1.  Main classes, the ”I” rule and t
		8.2.2.  Dosage of local anesthetics and
		8.3. Main types
	VI.  Theperioperativeperiod
		1.  General preoperative preparation
		1.1. Rules, interventions
		1.2. Medication
		1.3. Instruments
		2.  Special preoperative preparation
		2.1.  Depending on the type of the opera
		2.2.  Preoperative preparation depending
		3. Theperioperativefluidbalance
		3.1. General rules
		3.2. Perioperative fluidrequirements
		4. Intravenous fluids
		4.1. Crystalloids
		4.2. Colloids
		5.  Perioperative fluidtherapyin practice
		6.  Clinical evaluation of the effectiven
		7.  Tools of volume correction: injectio
		8. Types of injection techniques
		8.1. Intracutaneous (ic.) injection
		8.2. Subcutaneous (sc.) injection
		8.3. Intramuscular (im.) injection
		8.4. Intravenous (iv.) injection
		9. Complications of injections
		10. About veins in details
		10.1. Technique of blood sampling
		10.2. Infusions
		10.3. Infusion pumps (IP)
		10.4.  Central venous catheterization, v
	VII.  Bleeding and hemostasis in surgery
		1. Hemostasis
		2. Main types of hemorrhage
		3. Clinical classification
		4. Direction of hemorrhage
		4.1. Gastrointestinal hemorrhage
		4.2.  Causes of gastrointestinal hemorrh
		5.  Preoperative – intraoperative – post
		6. Surgical hemostasis
		6.1. Historical background
		6.2.  Mechanical methods – temporary and
		6.3. Thermalmethods
		6.4. Chemical-biological methods
		7. Intraoperative diffusebleeding
		7.1. Main causes
		7.2.  Management of intraoperative diffus
		8.  Replacement of blood in surgery
		8.1. Historical background
		8.2. Auto(logous) transfusion
		8.2.1.  Preoperative autologous donation
		8.2.2. Blood salvage
		8.2.3.  Autotransfusion – adjuvant thera
		8.3. Artificialblood
		9. Postoperative bleeding
		10.  Local signs and symptoms of incompl
		11.  General symptoms of incomplete hemo
	VIII. Hemorrhagic shock
		1. General remarks
		2. Types of shock
		3.  Theessentialpatternsofcirculatory sh
		4. Anamnesis of shock
		5.  Compensatory mechanisms after blood
		5.1. Baroreceptor reflex
		5.2. Chemoreceptors
		5.3. Endogenous vasoconstrictors
		5.4. Brain ischemia
		5.5.  Changes in renal water metabolism
		5.6.  Reabsorption of tissue fluids(“fluid
		6.  Decompensatory mechanisms after bloo
		6.1. Cardiac failure
		6.2. Acidosis
		6.3.  Central nervous system depression
		6.4.  Disseminated intravascular coagula
		6.5.  Reticuloendothelial system dysfunc
		7. Stages of hemorrhagic shock
		7.1. Compensated shock
		7.2. Decompensated shock
		7.2.1.  Main microcirculatory phases dur
		7.3. Irreversible shock
		8. Signs of progressing shock
		9. Ischemia-reperfusion injury
		10. Intestinal mucosa injury
		11. Shock diagnosis
		12.  Relationship between mortality and
		13.  Treatment of hemorrhagic shock
		14.  Signs of cardiovascular stabilizati
		15. Medical – legal pitfalls
		16.  Variations in physiological respons
	IX. Wounds
		1.  Classificationofaccidentalwounds
		1.1.  Morphology / classificationdependin
		1.2.  Classificationaccordingto “cleanlin
		1.3.  Classificationdependingonthetime si
		1.4.  Classificationdependingonthenumber
		1.5.  Classificationdependingonthefactors
		1.6.  Classificationdependingonwound clos
		2. Surgical wounds
		2.1.  Determinants of healing of surgica
		2.2. Skin incision
		2.3. Therequirementsofskinincision
		2.4.  Main types of skin incisions
		2.5. Closure of surgical wounds
		3.  Early complications of wound closure
		4.  Late complications of wound closure
		5. Prevention of wound infection
		6. Signs of wound infections
		7. Phases of wound healing
		8. Wound healing disorders
		9.  Wound management of accidental wound
		10. Dressing – bandaging
		10.1. Types of bandages
		10.2. Layers of bandages
		10.3. Types of bandages
		11.  Innovations in wound treatment
		11.1.  Lucilia sericata, Phaenicia seric
		11.2.  Vacuum-assisted closure therapy
		11.3. Biological dressings
		11.3.1. Human skin
		11.3.2. Xenogenous skin
		11.3.3. Skin supplements
		11.3.4.  Biosynthetic materials (culture
		11.4. “Wet wound healing”
Surgical Techniques, 2
	Advanced Medical Skills
	Preface
	I. Laparotomy
		1. History of abdominal surgery
		2.  Technical background of laparotomies
		3.  Basic principles determining the typ
		4.  Recapitulation: Anatomy of the abdom
		5.   Principles of healing of laparotomy
		6.  Prevention of wound complications
	II. Incisions
		1. Longitudinal incisions
		1.1.  Characteristics of longitudinal in
		2. Oblique incisions
		2.1.  Thebasictypeofobliqueincisions
		3. Transverse incisions
		3.1.  Basic characteristics of transvers
		4.  Special extraperitoneal incisions fo
	III.  Laparotomy in surgical training
		1. General rules
		2. Middle median laparotomy
		3. Some important details
	IV.  Basic surgical procedures on the in
		1. Thehistoryofappendectomy
		1.1.  Recapitulation: relevant anatomy
		1.2. Open appendectomy
	V. Anastomoses
		1. Healing of the anastomosis
		2.  Causes of anastomosis insufficiency
		3.  Thecharacteristicsofa good technique
		4. Complications
		5. Anastomosis techniques
		5.1.  Two-layered anastomosis technique
		5.2. Single-layered technique
		5.3. Stapler-made anastomosis
		6.  Surgical techniques of intestinal an
		7. Closure of enterotomy
		8.  Surgical unificationofbowelsegments b
	VI. Abdominal drainage
		1.  Historical background of invasive di
		2.  Indication of diagnostic peritoneal
		2.1. Open system
		2.2. Closed system
		3.  Therapeutic(chronic)lavage:peritonea
		4.  Therapeutic(postoperative)rinsing dr
	VII.  Basic thoracic surgical practicals
		1. Types of pleural effusion
		2.1.  Mechanism/causes of thoracic effusi
		2.2. General principles of treatment
		3. Hemothorax
		3.1. Treatment of hemothorax
		4. Pneumothorax (PTX)
		4.1. Etiology of PTX
		4.2. Clinical signs of PTX
		4.3. Types of PTX
		4.4. Closed PTX
		4.5. Open PTX
		4.5.1. Signs of open PTX
		4.5.2. Treatment of open PTX
		4.6. Tension PTX
		4.7.  Signs and symptoms of tension PTX
		5. Treatment of PTX
		5.1. Basic questions
		5.2. Treatment of simple PTX
		5.3.  Treatment of simple PTX with needl
		5.4.  Emergency needle decompression
		5.5.  Percutaneous thoracocentesis for t
		5.6. Chest drain – chest tubes
		6. Chest drainage system
		6.1. Indications
		6.2. Types
		7. Flail chest
		8. Cardiac tamponade
	VIII. Tracheostomy
		1.  States evoking mechanical respirator
		2.  States evoking functional respirator
		3.  Advantages of intubation and tracheo
		4.  Thesurgicaltechniqueofintubation – p
		IX.  Basics of minimally invasive surger
		1.  A brief history of minimally invasiv
		2.  Present status of minimally invasive
		3.  Advantages of minimal access surgery
		4.  Thetechnicalbackgroundofminimally in
		4.1. Endoscopes
		4.2. Diathermy
		4.3. Suction and irrigation
		5.  Physiology of laparoscopy. Thepneumo
		5.1.  Complications of pneumoperitoneum
		6.  Basic instruments for minimally inva
		7. Laparoscopic cholecystectomy
		8. Laparoscopic appendectomy
		9. Training in a box-trainer
		8.2.1. Reef knot or sailor’s knot
		8.2.2. Surgeon’s knot
		8.2.3. Viennese knot
		8.2.4. Instrument tie
                        
Document Text Contents
Page 2

Surgical Techniques

Textbook for medical students

Edited by Mihály Boros

University of Szeged
Faculty of Medicine

Institute of Surgical Research

Szeged, 2006

Supported by ROP–3.3.1–2005–02–0001/34. project

Page 60

 The vein is pressed down with the ring finger above the
end of the catheter while the needle is drawn back about
1 cm, until the appearance of blood in the plastic cathe-
ter. This means that the catheter is positioned in the ves-
sel lumen. The catheter is pushed forward into the vein
lumen. The drawing-back of the needle stabilizes the iv.
catheter during the introduction (preventing its inclina-
tion), without damaging the wall of the vein.

 A sponge is placed under the end of the braunule.
The catheter tip is touched by the right hand finger
under the skin and pressed gently. The catheter is
held with the thumb and index finger while the nee-
dle is removed with the other hand, and connected
to a closing cap or infusion set.

 The tourniquet is released.
 Blood retraction: The needle is held with the left

hand while the right hand draws back the plunger of
the syringe. For blood sampling, the needle is fixed
with one hand, while the blood sampling tubes are
changed with the other hand.

Removing the needle or braunule
 An alcoholic sponge is first pressed onto the site of

the puncture and the sponge is then pushed while
the needle or braunule is removed. Next, the alco-
holic sponge is pressed on the puncture site again
until the bleeding has stopped (at least 1 min). The
arm of the patient remains extended.

Blood sampling tubes
The sample is shaken gently to avoid damage to the
blood cells, and it is mixed with anticoagulant. The co-
agulation (green), sedimentation (purple) and hemato-
crit (red) tubes should be filled exactly to achieve the
correct dilution.

The sequence of sampling: a sample is first taken in the
serum (white) tube, since the serum K+ level may be elevat-
ed within 30 min as a consequence of stress. The second
tube is green and serves for determination of coagulation
factors. Coagulation occurs in the tube. (For this purpose,
a blood sample must not be taken in the first tube because
it might contain air or the concentrations of coagulation
factors can be changed in the needle.) Other tubes should
be filled thereafter. Blood sedimentation is usually evaluat-
ed at the department, and the sample should therefore not
be sent to the laboratory for this.

Fixation of braunule
Adhesive tape is placed on the site of the puncture. The
iv. catheter is fixed with the prepared adhesive tapes.
The infusion tube is relaxed at the adhesive tape, the
joint is fixed with a splint if necessary and apply gauze
bandage is applied.
 It is important for the cannula to be fixed so as not to be

pulled out or broken when the patient moves the arm.
Mechanical irritation of the vein must be avoided.

 If the cannula remains in the vein for a longer peri-
od, a piece of gauze should be placed under the brau-
nule in order to prevent pressure-induced injuries.

 A piece of adhesive tape fixed to the injection port
provides protection against contamination. Further-
more, customary kits for fixation are available.

Final fixing
A loop of infusion tube is made and fixed with anoth-
er adhesive tape. This will prevent the cannula being
pulled out unintentionally. If the cannule is close to a
joint, fixing of the joint with a splint may be helpful.
In anxious patients, the limb should be covered with a
bandage or fixed with a splint (e.g. children).

Checking
The tap of the connected infusion is opened for a few
seconds. If the flow of the fluid is uninterrupted and no
swelling can be seen at the site of the puncture, the can-
nule is very probably in the right position. This check
can be performed prior to fixing too.

10.2. Infusions

In the event of a serious loss of fluid, or electrolyte and
fluid imbalances, fluid substitution is the first thing to do.
If this is not possible orally, fluid must be administered
parenterally, most often as an iv. infusion. Infusion thera-
py provides a possibility for the administration of a major
volume of fluid, electrolytes and drug into the circulatory

SURGICAL TECHNIQUES 59

VI. THE PERIOPERATIVE PERIOD

Page 61

system. The rate and duration of fluid administration can
be regulated. If the concentration of a drug exceeds the
physiological range, it can be administered in an infu-
sion. Thus, a longer period of administration and a con-
stant concentration in the blood can be achieved.

Infusion therapy is proposed before admission in the
following cases:
 acute myocardial infarction, left heart failure,
 pulmonary embolism,
 stroke, hypertensive crisis,
 status asthmaticus,
 acute bleeding,
 shock, allergic reaction, burns,
 an unconscious state,
 acute artery blockade in the extremities,
 acute metabolic comas (hyperglycemia),
 Addison, or a hyper- or hypothyroid crisis.

Infusions are usually delivered into superficial veins
(in the forearm, or the dorsum of the hand/foot); most of-
ten, it is delivered into the cubital vein. If a vein cannot
be reached by punctures, it must be exposed surgically.
In a long-term continuous infusion, etc, a catheter may
be inserted into the superior vena cava after the exposure
and dissection of the jugular veins. This catheter can al-
so be used to measure the central venous pressure. The iv.
infusion therapy involves many risks, and should be per-
formed strictly in accordance with the rules of asepsis.

Infusions

Devices for iv. infusion
A sterile plastic infusion bag (infusion glass bottle), a
sterile iv. administration set, hypodermic needles (“but-
terfly” and braunule), disinfecting solution, gauze, tapes,
an infusion stand, and sterile disposable gloves.

The infusion set
The sterile set is wrapped in a double package (plastic and
paper). The package should be opened only just before use.
Sets of damaged packages must not be used (sterility!).

Parts of the iv. administration set
A spike, a drip chamber (flexible), and long tubing with
the flow regulator (a plastic roller clamp for control of
the flow rate):

The protective covering is removed from the port of the
infusion bag and from the spike of the set, and the spike is

inserted into the bag. The bag is hung on the stand; the low-
er part of the drip chamber is squeezed to set the fluid lev-
el, until the drip chamber is approximately one-third full.
If the level of the fluid is too low, the chamber is squeezed
to remove air to the bag. If the chamber is overfilled, the
bag is lowered to below the level of the drip chamber and
some fluid is squeezed back into the bag. The flow regula-
tor is opened and the fluid is allowed to flow into the tub-
ing (removing air). The end of the tubing is connected to
the iv. catheter in the patient’s vein, and the flow rate is ad-
justed as desired. After a loop has been made in the tubing,
the catheter is secured to the skin with strips of tape. Dur-
ing infusion, the patient, the administration set and the
flow of fluid must be controlled continuously.

Dosage of infusion
 There are two types of drip chambers: microdrip (60

drops/mℓ; for the administration of medication or fluid
delivery in pediatrics), and macrodrip (10–15 drops/mℓ;
for routine/rapid fluid delivery or keeping the vein open).

 The volume of infusion fluid/drugs should be calculat-
ed. A formula to calculate drops: volume of infusion flu-
id (mℓ) × drop factor (drops/mℓ) / time to infuse (min)
= drops/min. As an example, an infusion of 1000 mℓ of
saline during 12 h with a microdrip chamber should be
delivered at a rate of 1000 × 60/720=83 drops/min.

 The amount of the infusion depends on different fac-
tors (the body surface area, the physical condition, the
age and the osmolarity of the infusion fluid).

 At the end of the infusion, the tubing is clamped, the
tapes are removed, followed by the needle or braunule
catheter, and sterile gauze is placed on the site of the
puncture.

Other iv. administration sets
1. Set with hydrophobic bacteria filter

2. Dual drip infusion iv. set (with a micro- and a macr-
odrip chamber)

SURGICAL TECHNIQUES60

VI. THE PERIOPERATIVE PERIOD

Page 120

puration does not occur (even in cases of advanced pu-
rulent inflammation); in obese patients and those with
a thick abdominal wall, it is an ideal surgical interven-
tion.

9. Training in a box-trainer

 The goal of the training is to adapt the tradition-
al open techniques to the laparoscopic setting (this
transition is not too simple). Training should begin
with exercises in a simulator (suturing trainer box)
using inanimate material. This provides an oppor-
tunity for the operator to become familiar with the
equipment, the instrumentation, and the particulars
of intracorporeal suturing and knot tying. In a “box-
trainer” (“MAT-trainer”) practice should be per-
formed with the same quality optical-video-moni-
tor setup as used in the operating room. This creates
true and correct eye-hand coordination.

 Training can be as simple as transporting beads
from one container to another or threading needles
through fixed eyelets. For the exercise, a 30° lapa-
roscope (diameter 5-10 mm and length 15-30 cm)
is used because this ensures an optimal view with a
wider field of vision after it is turned to another po-
sition.

 The student’s practical training starts with eye-hand
coordination exercises to pass needles and suture
materials through metal rings.

 The precision intracorporal suturing applied in en-
doscopic surgery was developed by Alexis Car-
rel (1873–1944) and Charles Claude Guthrie (1880–
1963) for vascular and microvascular surgery. The
intracorporal tissue-suturing procedures allow for
the reconstruction of fine tissue structures, because
of the higher surgical accuracy. Today, much bet-
ter results can be achieved with this technique than
with conventional surgical interventions.

 Suturing exercises begin with the suturing of a latex
glove that has two rows of dots marked on it. A cut
made through it facilitates the acquisition of skill in
needle handling, precision entrance-exit bites, su-
turing, and the knot-tying sequence. It is particu-
larly important that a good technique, such as tar-
geting entrance and exit points, should be practised
early on in training.

1 2

ADVANCED MEDICAL SKILLS 119

IX. BASICS OF MINIMALLY INVASIVE SURGERY

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5

6

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ADVANCED MEDICAL SKILLS120

IX. BASICS OF MINIMALLY INVASIVE SURGERY

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