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PRINCIPLES OF SURGERY
Admitting Orders
• Admit patient to ____ (room of choice, MSW)
• Consent for admission and management
• TPR q shift and record
• Input and Output
• Nursing orders

• Diet (DAT, NPO, etc.)

• IVF (PLR, D5LR, PNSS)
• Examinations (Labs, Imaging, Frozen section)
• Therapeutics (Pre-op antibiotics, anti-secretory, Blood)

• Plan (Operative or Non-operative)

• Notifications (Anesthesia, Residents,OR nurse)
• Refer accordingly
 Basic Surgical Instruments

Biopsy Techniques

Common Surgical Procedures

 KNIFE HANDLE
• Flat stainless steel instrument with one end narrower with a slot on either side
for attaching the scalpel blade
• A number is written on the handle (e.g., 3, 5, 7 and 4)
SURGICAL BLADES
Holding of the Scalpel
ILLUSTRATION DESRIPTION
Fiddle Bow Holding:!
In long, straight incisions, the scalpel is held like a fiddle
bow: the handle is gripped horizontally between the
thumb and middle fingers while the index finger is staying
above the handle!
!
Ring and little fingers are holding the end of the handle
Pencil Holding:!
In short or fine incisions, the scalpel is held like a pencil,
and the cutting is made mostly with the tip!
!
Best used for more precise cuts with smaller blades!
!
Scalpel is held with the tips of the first and second fingers
and the tip of the thumb
 SCISSORS
•Most often used to dissect and cut tissues, sutures and bandages

•Comes in different sizes, shapes and configurations (blade can be straight,

curved or angular)

•Tips of the blades can be blunt-blunt, blunt-sharp or sharp-sharp

•Cutting is usually made by portion of the blade which is close to its tip

•Also suitable for blunt dissection and preparation of the tissues

INSTRUMENT ILLUSTRATION REMARKS
Used for cutting sutures and bulky
Mayo connective tissues!
!
There are two types – straight and curved!
•Straight scissors are used when a straight
cut is desired, such as in sutures, nerves,
vessels.!
•Curved scissors are preferred for
dissecting, since they provide a better field
of vision for the areas to be cut

Used for cutting soft tissues !

Metzenbaum !
Should never be used for cutting sutures
Used for delicate tissue dissection
Iris (ophthalmic surgeries)!
!
Provided with two sharp points
Used to cut bandages, gauze or clothing!
Bandage !
One blade has blunt end to slide under
bandage without injuring the patient’s skin

Widely used to cut vessels (venotomy,

Potts or Kneed arteriotomy)!
Scissors !
Also used to cut fine, delicate tissue when
working in a tight space!
!
The blades of the scissors are angled at a
joint
Holding of the Scissors and All Ring-Ended Instruments
(1st - 4th rule of Holding the Instrument)

Thumb and the fourth digit are inserted into the

rings which are located at the handle!
!
2nd digit (index finger) is placed distally over the
handle to stabilize the scissors
Other Cutting Instruments
Other Cutting Instruments
DISSECTING INSTRUMENT
GRASPING INSTRUMENTS
• Used to grasp, pick up, and hold the tissues or organs during the operation

• Forceps, towel clamps, vascular clamps, needle holders, organ holders,

and sponge holding forceps belong to this category
NON-LOCKING GRASPING INSTRUMENTS
LOCKING GRASPING INSTRUMENTS
TISSUE GRASPING INSTRUMENTS
Hemostatic forceps (Hemostats)
Hemostatic forceps (Hemostats)
 RETRACTING INSTRUMENTS
• Used to hold tissues and organs aside in order to improve the
exposure and hence the visibility and accessibility of the surgical
field

• Hand-held retractors (e.g. skin hook, rake, Langenbeck, visceral

and abdominal wall retarctors) are held by an assistant and cause
minimal tissue damage because the assistant maintains tension
on tissues only as long as necessary

• Applied properly, self-retaining retractors (e.g.Weitlaner, Gosset

self-retaining retractor) are of great help, but care should be taken
not to damage the tissues when they are placed and removed
WOUND-CLOSING INSTRUMENTS
• The instruments (and materials) used to unite the
tissues

• The basic principles for wound healing are the

proper and tension-free approximation of tissues,
elimination of any dead space, as well as
preservation of its blood supply

• The number of stiches (or clips) should be

minimized
STAPLERS
CLIPS
SELF-ADHESIVE STRIPS and SURGICAL ADHESIVES
SURGICAL NEEDLES
Parts of a Surgical Needle
Conventional VS Atraumatic Needles
Needle Types Based on Sharp End and Cross Section
Needle Types Based on Shape
Sutures
Suture Information in a Foil Pack
 Non-absorbable Absorbable
• Not biodegradable and • Degraded via
permanent inflammatory response
– Nylon – Vicryl
– Prolene – Monocryl
– Stainless steel – PDS
– Silk (natural, can – Chromic
break down over – Cat gut (natural)
years)
 Natural Suture Synthetic
• Biological • Synthetic polymers
• Cause inflammatory • Do not cause
reaction inflammatory
– Catgut ( intestine of response
cow or sheep) – Nylon
– Silk (silkworm fibers) – Vicryl
– Chromic catgut – Monocryl
– PDS
– Prolene
Monofilament Multifilament (braided)
• Single strand of • Fibers are braided or
suture material twisted together
• Minimal tissue trauma • More tissue
resistance
• Smooth tying but
more knots needed • Easier to handle
• Examples: nylon, • Fewer knots needed
monocryl, prolene, • Examples: vicryl, silk,
PDS chromic
Suture Sizes
 Anesthetic Solutions

• Lidocaine (Xylocaine®) • Lidocaine (Xylocaine®) with

– Most commonly used epinephrine
– Rapid onset – Vasoconstriction
– Strength: 0.5%, 1.0%, & – Decreased bleeding
2.0% – Prolongs duration
– Maximum dose: – Strength: 0.5% & 1.0%
» 5 mg / kg, or – Maximum individual
» 300 mg dose:
• 1.0% lidocaine = 1 » 7mg/kg, or
g lidocaine / 100 cc » 500mg
= 1,000mg/100cc
• 300 mg = 0.03 liter
= 30 ml
LIDOCAINE PREPARATIONS
Local Anesthetics
Injection Techniques

• 25, 27, or 30-gauge • Aspirate

needle • Inject agent into
• 5 or 10 cc syringe tissue SLOWLY
• Check for allergies • Wait…
• Insert the needle at • After anesthesia has
the inner wound edge taken effect, suturing
may begin
 Wound Evaluation
• Time of incident
• Size of wound
• Depth of wound
• Tendon / nerve involvement
• Bleeding at site
 When to Refer

• Deep wounds of hands or feet, or unknown depth

of penetration
• Full thickness lacerations of eyelids, lips or ears
• Injuries involving nerves, larger arteries, bones,
joints or tendons
• Crush injuries
• Markedly contaminated wounds requiring drainage
• Concern about cosmesis
 Contraindications to Suturing

• Infection
• Fever
• Puncture wounds
• Animal bites
• Tendon, nerve, or vessel involvement
• Wound more than 12 hours old (body) and 24
hrs (face)
 Closure Types
• Primary closure (primary intention)
– Wound edges are brought together so that they are adjacent to each
other (re-approximated)
– Examples: well-repaired lacerations, well reduced bone fractures,
healing after flap surgery

• Secondary closure (secondary intention)

– Wound is left open and closes naturally (granulation)
– Examples: gingivectomy, gingivoplasty,tooth extraction sockets,
poorly reduced fractures

• Tertiary closure (delayed primary closure)

– Wound is left open for a number of days and then closed if it is
found to be clean
– Examples: healing of wounds by use of tissue grafts.
 Wound Preparation
• Most important step for reducing the risk of wound
infection.
• Remove all contaminants and devitalized tissue before
wound closure.
– IRRIGATE w/ NS or TAP WATER (AVOID H2O2,
POVIDONE-IODINE)
– CUT OUT DEAD, FRAGMENTED TISSUE
 Anesthetic Solutions
• CAUTIONS: due to its vasoconstriction
properties never use Lidocaine with
epinephrine on:
– Eyes, Ears, Nose
– Fingers, Toes
– Penis, Scrotum
Langer’s Lines
 Suture Techniques
• Simple interrupted
• Continous
• Blanket
• Retention
• Stapled
• Steristrips
 Suturing - finishing

• After sutures are placed, clean the site with

normal saline, or povidone iodine.
• May apply a small amount of topical antibiotic
or petroleum and cover with a sterile non-
adherent compression dressing or any other
dressing material.
 Suturing - before you go…

• Tell pt to return in one day for recheck,

- signs of infection (redness, heat, pain, pus)
- inadequate analgesia
- suture complications (suture strangulation or
knot failure with possible wound dehiscence)

It should be emphasized to patients that they

return at the appropriate time for suture removal
 Patient instructions and follow up care

• Wound care
– After the first 24-48 hours, patients should
gently wash the wound with soap and water,
dry it carefully, apply topical antibiotic
ointment, and replace the dressing/
bandages.
– Facial wounds generally only need topical
antibiotic ointment without bandaging.
– Eschar or scab formation should be avoided.
 Suture Removal
• Average time frame is 7 – 10 days
– FACE: 3 – 5 d
– NECK: 5 – 7 d
– SCALP: 7 – 12 days
– UPPER EXTREMITY, TRUNK: 10 – 14 days
– LOWER EXTREMITY: 14 – 28 days
– SOLES, PALMS, BACK OR OVER JOINTS: 10 days

• Any suture with pus or signs of infections should

be removed immediately
 Suture Removal

• Clean with hydrogen peroxide to remove any

crusting or dried blood
• Using the tweezers, grasp the knot and snip the
suture below the knot, close to the skin
• Pull the suture line through the tissue- in the
direction that keeps the wound closed - and place
on a 4x4. Count them.
• Most wounds have < 15% of final wound strength
after 2 wks, so steri-strips should be applied
afterwards
DESCRIBING PATIENT POSITIONS
IN THE OPERATING ROOM
POSITION DESCRIPTION COMMONLY USED FOR

• Most common with the least amount of harm Laparotomies

Supine • Placed on back with legs extended and uncrossed Hernia repairs
at the ankles Cholecystectomies
• Arms either on arm boards abducted with palms
up or tucked
• Head in line with the spine and the face is upward
• Hips are parallel to the spine
• Safety belt placed above the knees

• Face down, resting on the abdomen and chest Spine surgery

Prone • Chest rolls placed lengthwise under the axilla and Laminectomies
along the sides of the chest from the clavicle to iliac
crests (to raise the weight of the body off of the
abdomen and thorax)
• Another roll is placed at the iliac or pelvic level
• Arms lie at the sides or over head on arm boards
• Head is face down and turned to one side with
accessible airway
• Female breasts and male genitalia must be free
from pressure and torsion
• Safety belt placed above knees
DESCRIBING PATIENT POSITIONS
IN THE OPERATING ROOM
POSITION DESCRIPTION COMMONLY USED FOR

• Shoulder & hips turned simultaneously to prevent Renal and adrenal

Lateral decubitus torsion of the spine & great vessels surgeries
• Lower leg is flexed at the hip; upper leg is straight
• Head must be in alignment with the spine
• Breasts and genitalia to be free from pressure
• Axillary roll placed to the axillary area of the
downside arm (to protect brachial plexus)
• Padding placed under lower leg, to ankle and foot
of upper leg, and to lower arm (palm up) and upper
arm
• Pillow placed lengthwise between legs and
between arms

• With patient in the supine position, the legs are Perineal surgeries (vagina,
Lithotomy raised and abducted to expose the perineal region abdomino-perineal
• Arms are placed on padded arm boards, tucked at resection)
the sides, or placed across the abdomen
• Legs and feet are placed in stirrups that support
the lower extremities
• Adequate padding and support for the legs/feet
should eliminate pressure on joints and nerves
• The perineum should be in line with the
longitudinal axis of the OR bed
DESCRIBING PATIENT POSITIONS
IN THE OPERATING ROOM
POSITION DESCRIPTION COMMONLY USED FOR

• Patient is placed in the supine position while the Procedures in the lower
Trendelenburg OR bed is modified to a head-down tilt of 35-45 abdomen or pelvis
degrees resulting in the head being lower than the
pelvis
• Arms are either at the side or on bilateral arm
boards
• Foot of the OR bed is lowered to a desired angle

• The entire OR bed is tilted so the head is higher Head and neck procedures
ReverseTrendelenburg than the feet (thyroidectomy, neck
• Facilitates exposure, aids in breathing and dissections)
decreases blood supply to the area Upper gastrointestinal
surgeries (bariatric surgery)
DESCRIBING PATIENT POSITIONS
IN THE OPERATING ROOM
POSITION DESCRIPTION COMMONLY USED FOR

• Patient begins in the supine position Surgeries of the posterior

Fowler • Foot of OR bed is lowered slightly, flexing the cranial fossa and shoulder
knees, while the body section is raised to 35-45
degrees, thereby becoming a backrest
• Entire OR bed is tilted slightly with the head end
downward (preventing the patient from sliding)
• Feet rest against a padded footboard
• Arms are crossed loosely over the abdomen and
taped or placed on
• For cranial procedures, the head is supported in a
head rest and/or with sterile tongs

• Modification of the prone position Anorectal surgeries

Jack knife • Patient is placed in the prone position on the OR (fistulotomies,
bed and then inverted in a V position hemorrhoidectomies)
• The hips are over the center break of the OR bed
between the body and leg sections
• Arms are extended on angled arm boards with the
elbows flexed and the palms down
• A pillow is placed under the ankles to free the feet
and toes of pressure
• The OR bed leg section is lowered, and the OR
bed is flexed at a 90 degree angle so that the hips
are elevated above the rest of the body
Biopsy Techniques
Aspiration Biopsy:
▪involves the aspiration of cells and
tissue fragments through a needle
that has been guided into the
suspected tissue
Core-Needle biopsy
▪a core of tissue is obtained
through a specifically designed
needle introduced into the
suspected tissue.
Incisional biopsy
▪removal of a small wedge
of tissue from a larger tumor
mass
Excisional biopsy
▪ removal of entire tumor
with or w/o normal
surrounding tissues
Principle in performing all surgical biopsies

1. Needle tracts or scars should be placed so that they can

be conveniently removed as part of subsequent definitive
surgical procedure.
Transverse
incisions are drains if necessary,
contraindicated port of entry has to
because they be in proximity and
require a wider continuation with
soft-tissue the skin incision, not
resection to its sides
Principle in performing all surgical biopsies

2. Care must be taken to avoid contaminating

new tissue planes during biopsy procedure.

3. Adequate tissue samples must be obtained to

meet the needs of the pathologist.
Principle in performing all surgical biopsies

4. When orientation of the biopsy specimen is important for

subsequent treatment, it is important to mark distinctive
areas of the tumor to facilitate subsequent orientation of
the specimen by the pathologist
COMMON SURGICAL
PROCEDURES
INCISION AND DRAINAGE
UNGIECTOMY
Circumcission
Chest Tube Thoracostomy
THANK YOU