Preoperative and Intraoperative care of

the surgical patient

 The patient should receive a
complete physical examination
followed by the appropriate
laboratory work-up.
 A thorough history helps
determine the extent of needed
physical and laboratory
examinations.
 Obtaining preoperative
information allows comparison
of the animal’s status before
and after surgery (eg.ability to
micturate after spinal surgery)
1.History Taking

 Thorough history from the owner

or caregiver is critical for accurate
evaluation of the underlying
disease process and
identification of other
abnormalities that might affect
the surgical outcome.
 The history should include:
 1.signalment
 2.diet
 3.exercise
 4.environment
5.past medical problems

6.recent treatment(especially anti-

inflammatory,antimicrobial,and potentially
nephrotoxic or hepatotoxic therapy)
7.evidence consistent with infection

Before a detailed chronology of endless detail

is obtained,the presenting complaint should
first be described from the standpoint of:
1.When did the current problem start?

2.What did the problem look like when it first

began?

3.Has the problem gotten better or worse

and if so,how much and associated with
what therapy?
Questions should be framed so as to avoid
vaque responses and obtain specific
information.
For example,”When was your dog last
vaccinated?”is a better question than “Is
your dog current on his vaccinations?”

Vomiting,diarrhea,altered
appetite,exposure to toxins or foreign
bodies,coughing,exercise intolerance and
other abnormalities should be noted.
Animals with a history of previous drug
reactions or siezures must be identified so
that potentially contraindicated drugs can
be avoided.
➢ 2.Physical
examination

 Animal should be systematically

evaluated during physical
examination and all body
systems should be included.
 Animal’s general condition
(body condition,attitude,and
mental status)should be noted.
 Traumatized animals should
have a neurologic examination
and an orthopedic examination
in addition to the evaluation of
the
respiratory,gastrointestinal,cardi
ovascular and urinary systems.
The completeness of the examination may
depend on the urgency of the situation.eg:

1.patients with life-threatening respiratory

distress or in shock require immediate
resuscitation,which may preclude certain
aspects of the initial physical examination.
Checklists have been used to prevent
oversights during the physical examination.
Checklists become part of the patient’s medical
record,are initially helpful when the initial physical
examination is performed by someone other than the
surgeon.

A thorough and systematic examination of the entire

patient is needed to detect possible problems that
may influence the outcome of the surgical
procedure.eg.that may lead to a disastrous situation
include the patient with a long bone fracture that
may have neurological deficit of the involved limb,a
ruptured urinary bladder,a diaphragmatic hernia,or
traumatic lung syndrome.
PE should provide an initial assessment of the patient’s
physical state, should help define potential organ system
problems that may need further:
1.radiographic

2.laboratory

3.electrophysiological

4.clinical evaluation
The following are essential for proper
patient evaluation:
Signalment

Nature and duration of the problem

Previous medical history

Systematic approach to the physical

examination
 Evaluation of the
preanesthetic physical
status is one of the
best determinants for
the likelihood of
cardiopulmonary
emergencies during or
after surgery.
 The more deteriorated
the physical status ,the
higher the risk of
anesthetic and
surgical complications
 The animal’s physical status and the procedure to be
performed dictate the extensiveness of the laboratory
work-up.

Young healthy animals undergoing elective

➢ 3.Laboratory procedures(e.g.OVH,declawing) and for healthy animals
with localized disease(e.g.patellar luxation) –
data determination of hematocrit and total protein(TP)

If the patient is older than 5 to 7 years,with systemic signs

(e.g. dyspnea,heart murmur,anemia,ruptured bladder,
gastric dilatation-volvulus,shock,hemorrhage) a complete
blood count (CBC),a comprehensive serum biochemistry
profile and urinalysis should be done.
The necessity for additional laboratory data is dictated
by the animal’s presenting signs and underlying disease.

Identification of associated or underlying disease

influences:

1.preoperative management

2.surgical procedure performed

3.prognosis

4.postoperative care
 Animals with neoplasia
should be evaluated for:
 1.metastasis (eg.thoracic
imaging
(radiographs,computed
tomography(CT) or positron
emission
tomography(PET/CT),abdo
minal ultrasound,lymph
node aspiration)
 2.cardiac disease – should
have thoracic
radiographs,cardiac
ultrasound scans,and/or
electrocardiogram
In endemic areas,the patient’s
heartworm status should be
checked before surgery.

A thorough preoperative
examination is cost-effective
because it often prevents or
predicts costly complications.
The extent of clinical laboratory depends on factors such as:

1.patient’s age

2.physical status

3.anticipated duration of the surgical procedure

4.availability of clinical laboratory tests

A surgical procedure is considered minor when the duration of surgery is

expected to be more than 30-45 minutes,the patient has a graded status of
1,2,or 3.
A surgical procedure is considered major –duration of surgery is more than 30-45
minutes or the patient has a guarded status of 4 or 5 regardless of the
anticipated duration of surgery.
 Pre-anesthetic diagnostic tests:
 What is considered the MDB(minimum data
base)for an elective surgical procedure on
a young ,healthy animal will be different
from the MDB for a procedure on a
geriatric patient with preexisting health
problems.
 MDB
 Minimum database for a young,healthy
surgical candidate should include:
1.Packed Cell Volume (PCV)

2.Total Solids

3.Blood Glucose

4.Blood Urea Nitrogen(BUN)

5.Alanine aminotransferase

These tests should be considered a starting point.

Other diagnostic tests should be performed if any of

these four basic parameters cause any concern.
Packed Cell
Packed Cell
volume(PCV)
Volume
or
(Hematocrit)
Hematocrit(H
CT) is the
percentage
Low PCVs are
1.decreased
2.decreased
of whole
found
RBC in
RBC
blood
cases life span
that
of: is
production
3.blood
(as
madewithup loss
some
of
(as in chronic
(secondary
red blood to
autoimmune
renal
diseasesfailure)
trauma,blood
cells (RBCs) and
-clotting
parasite
disorders
infections)or
 Increased PCV may indicate:
 1.dehydration(common)
 2.absolute polycythemia(rare)
 Normal range of PCV:
 1.canine – 37% to 54%
 2.feline – 27% to 48%
 Total solids(TS) or total proteins provide information on the animal’s plasma protein levels.
Total
Solids
There are three major plasma proteins:

or 1.albumin

Proteins 2globulin

3.fibrinogen

These levels have a direct effect on serum oncotic pressure

The lower the TP value,the lower the serum oncotic pressure.

With a low oncotic pressure ,fluid tends to accumulate in the interstitium ,resulting in
edema.
High serum oncotic pressure ,fluid shifts out of the interstitium and back into the
vasculature(blood vessels)
 Elevated plasma protein values are associated
with:
 1.dehydration
 2.malignancies(e.g.lymphosarcoma)
 3.infections
 Decreased plasma protein values are associated
with:
 1.inadequate production (albumin is made in the
liver)
 2.inadequate intake(starvation)
 3.increased loss(renal disease,blood loss,parasites)
 4.inadequate absorption from the GIT (pancreatic
disease,inflammatory bowel disease)
 Plasma protein levels are important
because some
anesthetics(barbiturates)are highly bound
to proteins.
 If a patient is hypoproteinemic more free
drug(not bound to plasma proteins)will be
available to function as an
anesthetic,effectively increasing the dose.
 Animal’s protein level should be noted
when deciding which anesthetic to use.
 Normal range of total solids:
 Canine – 5.5 to 7.5 g/dl
 Feline – 6.5 to 8.2 g/dl
 Blood glucose- indicates CHO metabolism and
measure the endocrine function of the
pancreas.
 Eating raises BG levels,fasting lowers them.
 Stress will elevate BG in cats.
 In juvenile patients and diabetic patients,BG
values may need to be checked
intraoperatively and postoperatively if the
procedure is long.
 Normal range of BG
 Canine – 80 to 130mg/dl
 Feline – 70 to 180 mg/dk
 NOTE:for both canine and feline patients less
than 40mg/dl indicates hypoglycemia
Blood Urea Nitrogen
 Urea is a nitrogenous
compound that is a product of
amino acid breakdown in the
liver.
 Used to evaluate the kidney’s
ability to remove nitrogenous
waste(urea)from the blood.
 If the kidneys are not working
properly,an insufficient amount
of urea is removed from the
plasma,resulting in increased
BUN levels.
 Some anesthetics are primarily
metabolized by the kidneys,and if
there is any question of the patients
renal function,choosing a drug that is
not primarily metabolized by the
kidneys should be considered.
 Further diagnostic tests assessing
kidney function(e.g.urinalysis,should
be considered as well.
 Normal range of BUN
 Canine:5 to 35 mg/dl;feline: 5 to 35
mg/dl
 Alanine Aminotransferase

 (ALT) is an enzyme found in high concentration

in the liver cells of dogs,cats and primates.

 Damage to hepatocytes can elevate blood ALT

levels.

 Certain drugs such as anticonvulsant and

corticosteroids ,can also raise blood levels of
ALT.

 ALT,while not indicative of specific liver disease

,can be used as a general hepatic screen. U/L

 Normal range of ALT

 Canine: 8.2 to 109 U/L

 Feline:25-97 U/L
 Once the history,physical examination,and
laboratory tests have been completed ,the
surgical risk can be estimated and a prognosis is
given.

Determination Excellent prognosis – if the potential complications

is minimal ,high probability that the patient will
of surgical risk return to normal after surgery

Good prognosis – high probability of a good

outcome but some potential for complications
 Fair prognosis – if serious complications are
possible but uncommon,if recovery may be
prolonged,or if the animal ay not return to its
presurgical function
 Poor prognosis – if the underlying disease or
the surgical procedure is associated with
many or severe complications or both ,if
recovery is expected to be prolonged ,if the
likelihood of death during or after the
procedure is high, or if the animal is unlikely to
return to its presurgical function
 The risk of the surgical procedure outweigh its
potential benefits.example:removal of an
apparently benign skin mass may not be
warranted in an animal with hepatic or renal
dysfunction.
 Quality of life must be considered for
Veterinary patients;those with severe
debilitating,untreatable disease may not
benefit from surgery.
 However ,for some patients,surgery may
improve the quality of life,even if length of life
is limited.
Client
communication

 Communication with the

client is extremely
important to ensure the
owner’s satisfaction after
surgery.
 Owner’s should be
informed before surgery of
the diagnosis,surgical or
nonsurgical
options,potential
complications,postoperati
ve care,prognosis and
cost.
 Major factors that
influence the surgeon-
client relationship include:
 1.whether an elective or
nonelective procedures is
being considered
 2.whether the client is
seeking professional help
 3.if surgical treatment is
being initiated solely by
the surgeon
 The surgeon should discuss with the client the :

 1.reasons for the surgery

 2.it’s benefits
 3.degree of operative risk
 4.possible complications
 5.prognosis
 6.possible alternative courses of action
 7.pre-operative work-up
 8.operative and postoperative courses
 9.financial responsibilities of the client
 It shoud be
recognized that the
final surgical
recommendation
may not be possible
until radiographic or
clinical evaluations
are made
 Although cost cannot always be predicted
because of unanticipated
complications,owner’s should be kept
appraised of the animal’s status and of
procedures that may affect the initial cost
estimate.

If the disease is hereditary,neutering should

be recommended.A waiver signed by the
owner authorizing surgery and accepting
surgical risks,is mandatory and should be part
of the medical record.
 A signed estimate form,outlining anticipated
costs of diagnostics,preoperative care,surgery
and post operative care,should be included in
the record.
Patient
stabilization
 Patient should be stabilized
as thoroughly as possible
before surgery.
 Occasionally ,stabilization is
impossible and surgical
intervention must be done
rapidly;however,replacing
fluid deficits and correcting
acid-base and electrolyte
abnormalities before
induction of anesthesia
usually is justified.
 Intravenous fluids are indicated for
all animals undergoing general
anesthesia and surgery.including
healthy animals having elective
procedures.
 The need for perioperative
antibiotics is dictated by the
animals’s disease and the
procedure being performed.
 Patient history,clinical signs,physical
examination findings,electrolytes and total
carbon dioxide(CO2)are helpful in screening
for significant acid-base abnormalities.
 Blood pH,arterial Oxygen partial pressure
(PaO2),arterial carbon dioxide partial pressure
(PaCO2),and bicarbonate concentration may
be measured to evaluate for acid-base
problemsand to determine the extent of such
abnormalities.
 If the animal is acidemic(arterial pH<7.2),efforts
to optimize ventilation,and capillary perfusion
should be instituted.
 As a result of production and retention of CO2
in the tissue,correcting base deficits with
sodium bicarbonate without concurrent
ventilator and hemodynamic support may be
detrimental,most acidotic patient do not
require bicarbonate administration.
 Instead correcting
hypovolemia and
hypotension with fluid
therapy is more beneficial
and safer than giving
bicarbonate.
 The patient nutritional state
often is critical in chronically
diseased animals.
 Preoperative parenteral or
enteral hyperalimentation
sometimes is recommended
to improve nutritional status
before surgery.
 For example, in patients
with cleft
palate,cleaning
particulate matter from
the nasal
cavity,administering
appropriate
antibiotics,and
providing enteral
hyperalimentation for
several weeks before
surgery may reduce
infection and improve
wound healing.
 Traumatized patient must
be evaluated swiftly to
detect life-threatening
abnormalities.
 Cardiovascular and
respiratory systems should
be assessed by evaluating:
 1.pulse quality and rate
 2.respiratory rate and effort
 3.mucous membrane color
 4.capillary refill time
 The heart should be auscultated
for evidence of murmurs or an
arrhythmia,and the lungs should
be evaluated for crackles or
wheezes.
 Diminished heart or lung sounds
suggesting the presence of
space-occupying pleural
disease or a diaphragmatic
hernia should be noted.
 Oxygen therapy should be
given to animals that appear to
be in respiratory distress or that
have other signs of oxygen
deprivation.
 Initial assessment of the urogenital system should include palpation
of the bladder, to rule out obstruction and determination of the
animal’s ability to urinate.
 During the initial examination,the animal’s level of consciousness
and ability to ambulate should be noted.
 Needle thoracentesis should be
performed in severely dyspneic
animals suspected of having a
pleural space
disease(eg.pneumothorax,pleural
effusion)
 Tube thoracostomy and/or oxygen
supplementation by means of an
oxygen cage,nasal insufflation or
mask maybe necessary.
 Thoracic radiographs should be
taken after the condition of
severely dyspneic patients have
been stabilized.
Oxygen therapy – flow by oxygen
 1.blood volume

2.fluid and electrolytes

Physiological
considerations
3.acid-base status

4.nutritional status
1.Blood
volume
 Normal blood volume of the
dog and cat- approximately 90
and 70ml/kg
 Acute hypovolemia and
anemia – most commonly
encountered blood volume
deficits requiring preoperative
management
 Treatment of acute
hypovolemia directed toward
establishing a circulating blood
volume that will produce the
arterial blood pressure needed
for adequate tissue perfusion.
 Clinical signs of hypoxia
include:
 1.dyspnea
 2.cyanosis
 3.tachycardia
 4.tachypnea
 5.postural changes
 6.anxiety
 7.and/or central nervous
system depression
 If clinical signs,arterial blood gases ,pulse
oxymetry or the patient’s disease suggests
hypoxia,supplemental oxygen may be
administered via:
 1.mask
 2.flow-by
 3.nasal catheter
 4.the animal may be placed in an oxygen
cage or tent.
 Flow by oxygen may be the easiest way to
provide supplemental oxygen in an emergency
situation.
 The oxygen line is placed within 1 to 3cm of the
patients’s nose and mouth,which creats a small
area where the fraction of the inspired air (F1O2) is
increased.
 It is not always practical or the best choice
because
 1.the procedure require a care provider to be
present to hold the oxygen line.
 2.the care provider make sure that the patient
does not move away from it
 3.because a high oxygen flow rate is required
 4.not nearly as effective as the other method
 Face mask delivery of
oxygen is a useful term
method for providing
supplemental oxygen.
 With an oxygen flow rate of
6 to 10 L/min and a well
fitted mask ,an F1O2 of 35%
to 55% may be achieved.
 Be aware that face masks
may not be tolerated and
are often difficult to fit well
to faces to the faces of cats
and brachycephalic dogs.
 An alternative is to use
an Elizabethan collar
covered with plastic
wrap to create an
oxygen rich
environment
 The end of the oxygen
tube should be fed up
through the collar and
secured.
 To allow elimination of
CO2 ,make a small
hole in the plasticwrap.
 Nasal catheter may be used when
more prolonged oxygen delivery is
desired than can be achieved
with flow by or face mask
techniques.
 Other advantages of nasal
catheter delivery of oxygen are
that it permits access to patient
without loss of the oxygen –rich
environment and it is well
tolerated in most patients.
 An oxygen cage provides
a sealed environment in
which F1O2 ambient
temperature and
humidity can be
controlled.
 The major disadvantage
of an oxygen cage is that
it isolates the patient from
the clinician because
each time the oxygen
door is opened,loss of the
oxygen-rich environment
occurs.
Title and content layout with list

 Add your first bullet point here

 Add your second bullet point here
 Add your third bullet point here
Title and content layout with chart

0
Category 1 Category 2 Category 3 Category 4
Series 1 Series 2 Series 3
Two content layout with table

 First bullet point here Class Group 1 Group 2

 Second bullet point here
Class 1 82 95
 Third bullet point here
Class 2 76 88

Class 3 84 90
Two content layout with SmartArt

 First bullet point here

 Second bullet point here
 Third bullet point here
Group
A

Group
C

Group Group
B D
Add a Slide Title - 1
Add a Slide Title - 2
Add a Slide Title - 3
Add a Slide Title - 4
Add a Slide Title - 5
Sterilization and
Disinfection
  Sterilization – destruction of all microorganisms
(bacteria,viruses,spores)on an item

Terminologies:  It usually refers to objects that come in contact

with tissue or enter the vascular
system(e.g.instruments,drapes,catheter
,needles)
 Disinfection – is the destruction of
most pathogenic microorganisms
on inanimate (non-living) objects
 Antisepsis – is the destruction of
most pathogenic microorganisms
on animate (living)objects.
 Antiseptics – are used to kill
microorganisms during patient
skin preparation and surgical
scrubbing however the skin is
not sterilized
 Cleaning – generally restricted
in meaning to the physical
removal of surface
contaminants,usually with
detergents or soap and
water,ultrasound or other
methods.
 Although cleaning does remove
soils,and bacteria,it does not kill
or inactivate viruses and
bacteria.
Disinfection

 Involves the use of liquid compounds

such as:
 1.phenol or its derivatives
 2.alcohols
 3.halides
 4.aldehydes
 5.quaternary ammonium compounds
 6.chloroform
 7.ethylene oxide(EtO)
 8.heavy metal ions
 9.dyes
Phenols
and its
derivatives
chloroform
Samples of
common
disinfectants
and
Antiseptics
 Samples of chemical
disinfectants
Selection of disinfectants depends on the desired
results

Some disinfectants,are effective at destroying a

limited number of microorganisms

Other disinfectant are effective at killing all

organisms,including spores
Sterilization

 Any equipment or supplies that come in contact with body tissues or

blood must be sterile.
 Methods of sterilizing surgical instruments or other equipments
include:
 1.steam
 2.chemicals
 3.plasma
 4.ionizing radiation
 The reliability of any sterilization method depends on:
 1.the number,type,and inherent resistance of microorganisms on the
items to be sterilized
 2.whether other materials(e.g. soil,oil) are present on the items that
may shield against or inactivate the sterilizing agent.
 Dry-heat sterilization has process
temperatures that cannot be tolerated by
most devices.

Recently ,low temperature sterilization

systems(e.g.hydrogen peroxide gas
plasma,peracetic acid
immersion,ozone)have been developed and
are being used to sterilized medical devices
 Advanced sterilization systems
that enable more rapid
Operating room personnel are
availability of wrapped,sterile
being asked to sterilize
devices,and instruments may
equipment more quickly and
result in rapid turnover of the
efficiently and at a lower cost.
OR suite and “down time”
between procedures.
 Swift and efficient sterilization of A low-temperature hydrogen
expensive heat and moisture peroxide gas plasma sterilization
sensitive medical and surgical system that provides terminal
devices is particularly sterilization of sophisticated
advantageous.(cameras,fiberoptic instruments in 5 minutes is useful for
cables,rigid endoscopes) such devices.
Steam sterilization

 Saturated steam under pressure – a practical and dependable

agent for sterilization of heat-tolerant medical supplies and
packaging.
 Steam rapidly destroys all known microorganisms by means of
coagulation and cellular protein denaturation .
To ensure the destruction of all living microorganisms,the
correct relationship between temperature,pressure and
exposure time is critical.

If steam is contained in a closed compartment and the

pressure is increased,the temperature also increases provided
the volume of the compartment remains the same.
 If items are exposed long enough to steam at a specified
temperature and pressure ,they become sterile.
 The unit used to create this high-temperature,pressurized steam is
called an autoclave.
Autoclave
 Commonly used sterilization
processes have a variety of
advantages and
disadvantages examples:
 1.steam autoclave,a 200-
year-old sterilization
technology is an effective
sterilization process,but its
high temperature and
moisture make it unusable for
many of today’s devices
Certain types of microorganisms have greater
inherent heat resistance than do other
microorganisms.

Spores of thermophilic aerobes and

anaerobes are the most resistant known
forms of life to moist.

Virus particles are much less tolerant to

steam sterilization than are spores.
Sterilization failure may occur if packs are
wrapped too tightly or are improperly loaded
in the autoclave or the gas sterilizer
container.

Instrument packs should be positioned

vertically and longitudinally in an autoclave.
Different
Surgical
Packs
 Heavy packs should
be placed at the
periphery,where
steam enters the
chamber.
 A small amount of air
space is allowed
between packs to
facilitate the flow of
steam (1 to 2 inches
between the packs
and away from the
surrounding walls)
 Linen packs are
loaded so that the
fabric layers are
oriented
vertically.These packs
are not stacked
because increased
thickness reduces
penetration of the
steam.
 Sterilization indicators
should be used.
 1.gravity displacement
sterilizer
Types of
steam 2.prevacuum sterilizer
sterilizers

3.flash sterilizer
1.gravity displacement sterilizer

 The most commonly used steam sterilizer

 Works on the principle that air is heavier
than steam
 Supplies to be sterilized are loaded into
the inner chamber.
Gravity displacement autoclave
 The minimum time and temperature standards
for a gravity displacement sterilizer are 10 to 25
minutes at 270 to 275 F or 15 to 30 minutes at
250 F.
  Relies on air being actively pulled out of the
inner chamber ,thereby creating a vacuum.

2.Prevacuum  Steam is injected to replace the air.

 Provides greater steam penetration in a shorter
sterilizer time than the gravity displacement.
 The minimum time and temperature standard is
3 to 4 miutes at 270 to 275F.
  Emergency or ‘flash’sterilization – performed
when an unwrapped ,nonsterile item must be
3.Flash sterilized quickly.
 The item is placed unwrapped in a perforated
sterilizer metal tray and is sterilized according to the
manufacturer’s time and temperature
recommendaations.
 It is difficult to deliver flash-sterilized devices
aseptically ,the tray is hot,wet and unwrapped
which means it collects dust,debris,and
microorganisms more readily.
 Should be used only in emergencies
Chemical (Gas)
Sterilization
 1.ethylene oxide –
flammable,explosive gas
that kill microorganisms by:
 A.altering their normal
cellular metabolism
 B.replication through
alkylation of
proteins,deoxyribonucleic
acid(DNA)and ribonucleic
acid(RNA)
ETO Sterilization
ETO
Sterization
Process
Advantage :

It can sterilize heat –or moisture –sensitive medical equipment without

deleterious effects on the material used in the medical devices.

Disadvantages :

Lengthy cycle time ,cost,potential hazards to patients and staff.

Eto sterilization cycle include five stages:

1.preconditioningand humidification

2.gas introduction

3.exposure

4.evacuation

5.air washes

It takes 2.5 hours excluding aeration

time.
Plasma
sterilization
 A low temperature
sterilization technique that
has become the method of
choice for sterilizing heat –
sensitive items.
 Inactivates microorganisms
primarily through the
combined use of hydrogen
peroxide gas and the
generation of free radicals
during the plasma phase of
the cycle.
Peracetic
sterilization
 Highly biocidal oxidizer that
maintains its efficacy in the
presence of organic material.
 It denatures protein
 It disrupts cell wall permeability
 Oxidizes sulfhydryl and sulfur bonds
in proteins and enzymes
Ionizing radiation – most equipment from the
manufacturers has been sterilized by ionizing radiation

Low-temperature sterilization process is restricted to

commercial use because of its expense.
 Items commonly used in the OR that are
sterilized with ionizing radiation include:
 1. suture material,sponges,disposable
items(gowns,drapes,table covers)
 2.powders
 3.petroleum goods
 Resterilization by other means may not be
possible for prepackaged sterilized items that
have been opened but not use,because an
alternate technique cauld damage the item
and create a health hazard.
 Cold chemical sterilization –
chemical used for sterilization
must be noncorrosive to the
items being sterilized.
 Glutaraldehyde is a
saturated dialdehyde that
has gained wide
acceptance as a high level
disinfectant and chemical
sterilant.
 Provides a means of sterilizing delicate lensed
Non-corrosive to metals,rubbers and plastics
instruments(eg.endoscopes,cystoscopies,bronchoscopes)
 Most equipment that is safe for
immersion in water is safe for
immersion in 2%glutaraldehyde

Items for sterilization should be

cleaned and dry,organic matter
(eg blood,saliva)may prevent
penetration into crevices or joints.
 Complex instruments should be disassembled
before immersion

After the appropriate immersion

period,instruments should be rinsed thoroughly
with sterile water and dried with sterile towels to
prevent damage to the patient’s tissues.
 Major problem with
glutaraldehyde is that
it is a known
respiratory and
dermal irritant and
adverse health effects
may occur in exposed
workers.It may cause
pancreatitis,chemical
colitis and mucosal
damage in human
patients
Sterilization indicators

Allow monitoring of the effectiveness of

sterilization

Chemical indicators - available for

steam gas,and plasma sterilization consist
of paper strips or tape impregnated with
materials that changes color when a
certain temperature is reached.
 Chemical indicators
do not indicate
sterility –only that
certain conditions for
sterility have been
met.
 The indicators are
placed in the center
of each pack and on
the outside of the item
to be sterilized.
Principles of
Hospital
Asepsis
Minimization of infection in a surgery practice involves applying
principles of aseptic technique throughout the hospital.

Goals:

1.to minimize sources of contamination

2.to block transmission of microorganisms

Sterile
Technique

All surgical procedures

are ideally performed
under sterile conditions.

Designed to prevent
the transmission of
microorganisms into the
body during surgery or
other invasive
procedures.
General principles of aseptic
technique should be familiar to all
personnel working in and around
the surgical environment.

These principles include:

1.use only sterile items within a

sterile field.
 3.sterile personnel operate
within a sterile field(sterile
2.sterile(scrubbed)personnel personnel touch only sterile
are gowned and gloved items or areas,unsterile
personnel touch only
unsterile items or areas)
 4.sterile drapes are used to create a
sterile field.

5.all items used in a sterile field must be

sterile.

6.all items introduced onto a sterile field

should be opened,dispensed,and
transferred by methods that maintain
sterility and integrity.
7.a sterile field should be
maintained and monitored
constantly

8.all surgical staff should be

trained to recognize when they
have broken technique and
should know how to remedy the
situations.
 NOTE:know what If contamination
equipment and occurs,remedy the
supplies are sterile contamination
and what are not immediately.
sterile and keep the
two apart.
 Have been defined to describe
appropriate preparation for items
depending upon their purpose and
Levels of bodily contact.

Sterility and
1.critical – equipments or implants
Disinfection entering the body beneath the skin
or mucous membranes – require
sterilization and are handled using
sterile technique
 2.Semi-critical –
equipments that
contacts the skin or
mucous membranes
only for surgical
purposes without
penetration of the
body must be cleaned
and disinfected to
reduced the level of
microorganisms,but
sterility is not
required.eg.vaginosco
pe
 3.Noncritical –
instruments that
contact the mucous
membranes or intact
skin not directly
associated with surgery
should be terminally
cleaned and
disinfected but do not
require specific
handling between
patients.eg.larnyngosc
ope
Preparation of the
Surgical Site
 Endogenous microbial flora (particularly Staphylococcus aureus and
Streptococcus spp. ) are the most common source of surgical site
infection(SSI).
 The term SSI is more appropriate than “surgical wound contaminant”
because it includes infection that directly results from surgical procedures
that involve other areas as well such as organs or internal spaces that are
manipulated during the operation.
 Surgical site infections are
classified by the Centers for
Disease Control and
Prevention (CDC)as:
 1.incisional – infection of
the actual site of the
surgical incision
 2.organ/space – infection
of an anatomic part that
was manipulated during
the operation
 Incisional SSI are further classified
as:
 1.superficial – involving the skin
and subcutaneous tissue
 2. deep – involving deep soft
tissue layers such as incisional
fascia and muscle.of
 To be considered an SSI,an
infection ,must occur within 30
days of the surgical procedure,or
within 1 year if it is associated
with a surgical implant and the
infection appears to be related
to the operation.
 Normal or resident organisms living in the skin’s
superficial cornified layers and the outer hair
follicles of dogs include:
 1.Staphylococcus epidermidis
 2.Corynebacterium spp.
 3.Pityrosporum spp.
 4.S.aureus
 5.Staphylococcus intermedius
 6.E.coli
 7.Streptococcus spp.
 8.Enterobacter spp.
 9.Clostridium spp are transient pathogen
 Eliminating exposure to this flora is extremely
important during surgery.
 Although it is impossible to sterilize skin without
impairing its natural protective function and
interfering with wound infection,pre-operative
preparation reduces the number of bacteria and
likelihood of infection.
 Antisepsis is the prevention of sepsis by preventing
or inhibiting the growth of resident and transient
microbes.
 An antiseptic – is a product with anti-microbial
activity that formerly may have referred to as an
antimicrobial agent.
 An antiseptic agent is an agent capable of
producing antisepsis.
 The prevalence of SSI is a major concern because
of the associated increased incidence of morbidity
and mortality,length of hospitalization,and cost of
care for postoperative patients.
 Preventive preoperative measures that can reduce
the risk of SSI include administration of antimicrobial
prophylaxis and proper utilization of skin antiseptic
agents for the surgical team and the patient.
 Thus it is imperative that Veterinarians and their
staff be proactive in preventing infection during
surgery by using proper techniques and solutions to
prepare the skin for surgery.
Dietary
restrictions
 In adult animals,food intake
generally is restricted 6 to 12
hours before induction of
anesthesia to avoid intraopretive
or post operative emesis and
aspiration pneumonia.
 Access to water generally is not
curtailed
 Operations of the large intestines
often require specialized
preparations (eg.dietary
restrictions for 48 hours)or enteric
antibiotics(eg.oral
kanamycin,neomycin,penicillin
G,metronidazole)or both
 Food should not be
withheld from young
animals for longer than 4 to
6 hours because
hypoglycemia may occur.
Excretions

 Animals should be allowed to defecate

and urinate shortly before induction of
anesthesia.
 Colonic surgeries may require enemas
 An empty urinary bladder often
facilitates abdominal procedures.
 If the urine is not evacuated naturally,
the bladder may be manually expressed
with the animal under general
anesthesia,or a sterile urethral catheter
may be passed into the bladder.
Treatment of hair

 Before a patient is prepared for

surgery,the patient’s identity,surgical
procedure to be performed,and surgical
site should be verified.
 In some cases,bathing the animal the
day before surgery to remove loose
hair,debris, and external parasites may
be warranted.
 Whenever possible,infection remote to
the surgical site should be identified and
treated before an elective preparation is
performed.
 These procedures should be postponed
until the infection is resolved.
 Hair should be removed as close to the
time of surgery as possible,and hair
removal should always occur outside the
room where the surgical procedure will
be performed(eg.in the prep room)
 Removal of hair the night before the surgery is
associated with a significantly higher superficial skin
infection rate than removing the hair immediately
before surgery.
 The surgical site should be identified and hair
should be liberally clipped around the proposed
incision site,so that the incision should can be
extended within a sterile field.
 The prepared area should
be large enough to
accommodate extension of
the incision,additional
incisions (if needed)and all
possible drain sites.
 It also must be large
enough that inadvertent
wound contamination is
avoided if the drapes move
during the procedure.
 A general guideline is to
clip at least 20 cm on each
side of the incision.
 The hair can be removed
most effectively with an
electric clipper and a No.
40 clipper blade.
 Patients with dense hair
coats may be clipped first
with a coarser blade
(No.10),the higher the
blade number ,the shorter
the remaining hair.
 Clippers should be held in a
‘pencil grip’and initial
clipping should be done with
the hair growth pattern.
 Subsequent clipping should
be done against the pattern
of hair growth to obtain a
closer clip.
 Depilatory creams are less
traumatic than other hair
removal methods ,but they
induce a mild dermal
lymphocytic reaction.
 They are most useful in
irregular areas where
adequate hair removal is
difficult .
 Razors occasionally are used
for hair removal (around the
eyes) but can cause
microlacerations in skin that
may increase irritation and
promote infection.
 After hair removal is
complete;loose hair is
removed with a vacuum.
 Before the animal is transported to the surgical
suite,the incision site is given a general cleansing
scrub,and ophthalmic antibiotics or lubricants are
placed on the cornea and conjunctiva.
 Lesions,eruptions,abrasions,irritations,rashes,dermati
tis,burns,denuded or traumatized areas or other
similar medical conditions that cauld provide a
portal of entry for pathogen should not be present.
 In male dogs undergoing
abdominal procedures,the
prepuce should be flushed
with an antiseptic solution.
 The skin is scrubbed with a
germicidal soaps to remove
debris and reduce bacterial
populations.The area is
lathered well until all dirt
and oils have been
removed.
 Commonly used scrubbing solutions include:
 1.iodophors
 2.chlorhexidine
 3.alcohols
 4.hexachlorophene
 5.quaternary ammonium salts
 Alcohol is not effective
against spores but
produces a fast kill of
bacteria and acts as a
defatting agent.
 Using alcohol by itself is not
recommended,but it is
commonly used in
conjunction with
chlorhexidine or povidone-
iodine.
 Hexachlorophene and
quaternary ammonium salts
are less effective than other
available agents and no
longer recommended for
preoperative skin
preparations
 It is important to avoid
abrading the skin by
excessive scrubbing with
gauze sponges.
Positioning
Sterile skin preparation
The purposes of the preoperative skin preparations
are:
1.to remove soil and transient microorganisms from
the skin
2.to reduce the resident microbial count to
subpathogenic levels in a short time and with at
least amount of tissue irritation
3.to inhibit rapid rebound growth of
microorganisms.
Coverage for the final exams:

1.Chapter 4 – preoperative and

intraoperative care of the surgical patient
2.Chapter 5 – preparations of the
operative site
3.Chapter 9 – Surgical infections and
Antibiotic Selection
4.Surgical complications by Slatter
Basic Parts of
Surgical
Instruments
Basic
components
of a surgical
instruments
Must know the basic parts of surgical instruments
to use,clean,and inspect them appropriately.

Jaws or tip – 1.can be traumatic or atraumatic

in design

2.straight or curved

3.jaw or tip can have serrations,teeth or flat

surfaces.
 Serrations can be
horizontal,vertical,or a
combination eg.Rochester
Carmalt hemostatic forceps
 Arrangement of the teeth –
1x2,2x3 and so on.
 Tips with a 1x2 configuration have
one tooth on one side of the tip
and two teeth on the opposite
side
 The teeth can also be arranged in rows
eg.Adson Brown thumb tissue forceps
 Box lock – present only on instruments
with ring handles.
 Joint or hinge of the instruments
 Absorbs great stress when the instruments
is in use .
 Shank also referred to as the “
shaft”or body of the instrument.
 Longest area and determines overall
 length .
 May range from 3 to 12 inches in total
length of the shank.
 Rachet – found only on instruments
with ring handles
 Device with interlocking teeth that will
lock an instruments jaw in closed
position.
Orthopedic Surgery
Instruments

 Basics orthopedic
instruments:
 1.Bone Holders – designed to
hold bone fragments
together until permanent
fixation can be achieved
 Have pointed tips,toothed
tips,or serrated tips.
 Available in a variety of sizes
and styles
Periosteal Elevators
 Used to prepare the fractured bone for permanent fixation.
 The intended use is to elevate the periosteum from the bone so that implants can be replaced.
 Available in many shapes and sizes.
 The most popular style – Freer elevator or Synthes elevator
Bone
Rongeurs
 Have cupped tips with
sharp edges,work with a
squeezing action of the
handles.
 Used to break up bits and
pieces of bone for grafting
purposes
 Pieces of bone too small to
reattach to the animal are
broken into small pieces
and packed around the
fracture lines to encourage
new osteoblast formation
and promote healing
 Can also be used to
remove pieces of
unnecessary bone.
Bone cutters

 Have handles with squeezing and

spring action,similar to those of
rongeurs
 Have cutting-edged tops
designed to cut through bone
and to remove small pieces of
bone
 Single-handed
instruments that have a
cupped tip surrounded
by sharp edges.
 Used to collect
(“harvest”)bone graft
material or to shape and
scrapes bony surfaces.
‘
 Hand Chuck(Jacob’s
Chunk
 Designed to hold and
drive intramedullary pins
for repair of a fracture or
for other orthopedic
procedures requiring the
use o pins.
 Hand chuck is a manual
drill.
 Can hold wires with sizes
from 0.035 inch and up to
3/16 inch
 SURGICAL
INSTRUMENTATIONS
 Instruments
categories
• Each type of surgical
instruments is designed for a
particular use and should be
used only for that purpose
• Using instruments for
procedures for which they are
not designed may dull or break
them.
• 1.scalpels
• 2.scissors
• 3.needle holders
• 4.tissue forceps(thumb)
• 5.hemostat forceps
• 6.tissue forceps
• 7.retractors
• Miscellaneous instruments
Scalpels
• Primary cutting instruments used
to incise tissue.
• Reusable scalpel handles (NO.3
and 4)with detachable blades are
most commonly used in Veterinary
Medicine,disposable handles and
blades are available.
• Disposable scalpels with a
locking retractable shield are
designed to minimize the risk
of surgical blade injuries while
passing blades between
procedural steps and during
disposal.(BD Bard-
Parker,Franklin Lakes,NJ)
• Blades are available in various
sizes and shapes depending on
the intended task.
• No. 10 blade is most commonly
used in small animal surgery
for incision and excision of
tissues.
•
• No.15 is a smaller
version of a No.10
and is used for
precise incisions in
smaller tissues.
• No 11 blade is
ideal for stab
incisions into fluid
– filled structures
or organs.
• The curved angle of the
No.12 blade limits its
applicability ,but it is most
often used in cats for
elective dissection
onychectomy(declawing)
• Scalpels are used in a
“slide cutting” fashion
which means that the
direction of pressure
applied to the knife blade
is at a right angle to the
direction of scalpel
pressure.
• When incising skin,the
scalpel blade should be
kept perpendicular to the
skin surface.
• Scalpels can be held with:
• 1.a pencil grip
• 2.a fingertip grip
• 3.a palmed grip
• The pencil grip allows
shorter,finer and more
precise incisions than the
other grips because the
scalpel is at a 30 – to 40
degree greater angle to
the tissue
• This grip is less useful in long incisions.
• The finger tip grip offers the best accuracy and stability for long incisions.
• The palmed grip is the strongest hold on the scalpel and allows exertion
of great pressure on the tissue ,but this is often unnecessary in surgical
situations.
 Scissors
• Come in a variety
of
shapes,sizes,and
weights,generally
classified
according to:
• 1.type of point –
blunt-
blunt,sharp-
sharp,sharp-blunt
• 2.the blade shape
– straight or
curved
• 3.the cutting edge – plain,serrated
• Curved scissors offer greater
maneuverability mechanical and
visibility
• Straight scissors provide the
greatest mechanical advantage
when cutting tough or thick tissue.
• Metzenbaum – also called
Metz,Nelson,delicate or
tissue scissors and Mayo
scissors are most commonly
used in small animal
surgery.
• Metzenbaum scissors are
more delicate than Mayo
scissors –designed for sharp
and blunt dissection or
incision of finer tissues
• Mayo scissor are used for
cutting dense,heavy tissue
such as fascia
• Suture scissors used in
the OR are different
from suture removal
scissors.
• The suture scissors have
a concavity on one
blade to gently hook the
suture away from the
skin and facilitate easy
removal
• Delicate scissors – tenotomy
scissors,iris scissors – are often used
in ophthalmic procedures and other
meticulous surgeries such as perineal
urethrostomy that require fine,precise
cuts.
Iris
scissors
• Bandage scissors
have a blunt
tip,which reduces
the risk of cutting
skin when the
scissors are
introduced under
the bandage
• Scissors should be
utilized only for
their specific
purpose and
should be
regularly
maintained.
• Scissors may
be used for
sharp cutting or
blunt dissection
• Wide-based
tripod grip –
scissors are
held with the
tips of the
thumb and ring
finger through
the finger rings
and with the
index finger
resting on the
shanks near
the fulcrum.
• Scissors should not be completely
closed if the incision is to be
continued because the result is a
ragged incision:scissors should be
nearly closed,advanced and nearly
closed again.
• Blunt dissection – (separation of tissue by
inserting the points and opening the handle)may
be used to separate loosely bound tissues such
as muscle or fat or to undermine skin edges for
wound closure.
• Blunt dissection should not be used in tougher
tissue or where precise cuts are possible.
Tissue forceps
Tissue (thumb) forceps are tweezer -
like,nonlocking instruments used to grasp
tissue.The proximal ends are bonded together
to allow the grasping ends to spring open or
be squeezed shut.
They are available in various shapes and
sizes;tips (grasping ends)maybe:
1.Pointed

2.Flat

3.round

4.Smooth

5.Serrated with small or large teeth

 Tissue forceps with large teeth should not
be used to handle tissue that is easily
traumatized.
 Tissue forceps with smooth tips such as
DeBakey forceps are recommended for
manipulation of delicate tissue such as
viscera or blood vessels.
 The most commonly used tissue forceps
(i.e.Brown-Adson forceps)have small
serrations on the tips that minimize trauma
but facilitate holding tissue securely.
 Tissue forceps generally
are used in the
nondominant hand.
 Tissue forceps are used
to stabilize and/or
expose tissue layers
during suturing
Title and Content Layout with List
 Click to edit Master text styles
 Second level
 Third level
 Fourth level

 Fifth level
Title and Content Layout with Chart
6

0
Category 1 Category 2 Category 3 Category 4
Series 1 Series 2 Series 3
Two Content Layout with Table

Class Group A Group B  First bullet point here

 Second bullet point here
Class 1 82 85
 Third bullet point here
Class 2 76 88

Class 3 84 90
Two Content Layout with SmartArt
 First bullet point here
Group A
 Second bullet point here
• Task 1
 Third bullet point here • Task 2

Group B

• Task 1
• Task 2

Group C

• Task 1
• Task 2
Tissue
Forceps,Retractors
 Tissue forceps are used to grasp or clamp
tissue,varying the degree of tissue trauma that is
created.
 Allis tissue forceps have interlocking sharp teeth,this
instrument is used to firmly grasp tissue that is going to
be removed from the body.
 Babcock tissue forceps have broad,flared,and blunt
grasping tips that are more delicate than allis tissue
forceps and can be used carefully on tissue
remaining in the body.
 Doyen intestinal forceps are noncrushing,occluding
forceps with shallow longitudinal striations that are
used to temporarily occlude the lumen of the bowel.
Retractors- used to retract tissue and
improve visualization
 1.Hand-held retractors
 2.Self-retaining retractors
 The ends of hand-held
retractors maybe
hooked,curved,spatula-
shaped (i.e. Hohmann)or
toothed.
 Some hand-held retractors
(e.g. malleable or ribbon
retractors)may be bent by the
surgeon to conform to the
structure or area of the body
being retracted.
 Senn (rake) retractors are small,double
ended retractors with three small,fingerlike
projections on one end and a flat,curved
blade on the other.
 Army-Navy retractors are larger with
blunt,broad blades on each end for
retraction of large amount of tissue.
 Self-retaining retractors – e.g.Gelpi
and Weitlaner – maintain tension
on tissue and are held open with a
boxlock or another device (e.g.a
set screw,such as in Balfour and
Finochietto retractors)
 Balfour retractors are used to
retract the abdominal wall
 Finochietto retractors are
commonly used in
thoracotomies.(surgical incision
into the chest wall)
Self-
Retaining
Retractors
 Hand Held
Retractors
Malleable or ribbon
retractors
Senn or rake retractors
Balfour
Retractor
Title and Content Layout with List

 Add your first bullet point here

 Add your second bullet point here
 Add your third bullet point here
Title and Content Layout with Chart

0
Category 1 Category 2 Category 3 Category 4
Series 1 Series 2 Series 3
Two Content Layout with Table

 First bullet point here Group 1 Group 2

 Second bullet point here
Class 1 82 95
 Third bullet point here
Class 2 76 88

Class 3 84 90
Title and Content Layout with
SmartArt

Step
Step 3 4 Title
Title
Step 2
Title
Step
1 Title
Surgical needles
• Many sizes and shapes of surgical needles are available.
• Needle point,needle body and the needle eye are considered
 Needle Point

• Helps to determine the type of tissue in which the

needle should be used.
• 1.taper point needle – sharp point that pierces and
penetrates tissues without leaving small cuts
because the cross section is rounded
Needle Holders
• Round needle body associated with the taper point
is best used in tissue when a sealed suture line is
needed.eg.suturing intestine or hollow organs
• Any tissue that should not be traumatized or is not
difficult to pass a needle through will tolerate a
taper needle.
• 2.taper-cut needle – combination of a
round,tapered body and a reverse cutting point.
• Used with tough fibrous tissues and some
cardiovascular procedures.
• 3.reverse cutting needle – has three cutting edges
on the point-the cross section is triangular with one
of the cutting edges being the outside of the curve.
• 4.cutting- edge needle-has three cutting edges on
the point and body ,but the third cutting edge is on
the inside of the curve.
• Most traumatic because the cutting edge on the
inside of the curve cuts towards the edges of the
wound,,compromising the strength of the tissue.
 Needle body

• Needles can be straight, circular,or curved.

• 1.straight needles- sometimes referred to as Keith
needles,are available,have limited application in
Veterinary Medicine
• One procedure made easier by the use of Keith needle
is the placement of a purse string suture in the anus.
Keith surgical needle
• Curved needles can either be:
• 1.full curved
• 2.half curved
• 3.double curved
• Double curved needles – have both ends curved in
opposite directions
• Reserved for use in large animal surgery especially
bovine surgical sutures
• Half-curved needles –only half the body of the
needle is curved.
• Rarely used in Veterinary Medicine
• Full-curved needles –have the entire body of the needle
involved in the curve.
• Varying degrees of curvature can be found,based on the
portion of a full circle that is involved.eg.a 3/8 –circle
needle means that if a full circle were divided into eight
equal parts ,the continuous curve of three of those
parts would be this shape.
• Half-circle needle –would mean that four continuous
parts((or half the circle) would be the shape of the
needle.
• Other common circular needles shapes are:
• 1.1/4-circle
• 2.5/8-circle
 Suture Attachment End

• Final portion of the needle

• Some needles have eyes,which can be single or
French style
• Single eyed needles –must have the suture material
passed the needle eye.
• Suture is threaded through the eye from the inside
of the curve to the outside.
• The threading of the needle results in a bulky
portion of the suture that pass through the
tissue,creating excessive tissue drag and damage.
• French-eyed needle – one complete eye and one
split eye
• Suture is passed through the complete eye and then
pushed down through the split eye ,which securely
grips the suture.
 Swaged needle or eyeless needle
• Most atraumatic ,most common method of suture
attachment
• When the suture is manufactured ,the needle and suture
are attached to each other.
• Tissues undergo minimal damage because the point and
diameter of the needle create the hole,and the suture
simply follows along without causing further trauma.
The ease of use and limited trauma of the eyeless needle
makes it the first choice of almost all veterinary surgeons.
Needle Holders
 Needle holders grasp and manipulate
curved needles .
 Size and type of needle holder are
determined by:
 1.characteristics of the needle to be
held
 2.location of tissue to be sutured
 Large needles require wider,heavier
jawed needle holders.
 If needle holders are used to hold
suture,the jaws should be finely serrated
or smooth to prevent damaging the
suture by fraying or cutting it.
 Long needle holders facilitate
working in deep wounds.
 High quality needle holders
are made of non-
corrosive,high strength alloy
and have a glare – free finish.
 Most needle holders have a
rachet lock just distal to the
thumb,but some have a
spring or latch mechanisms
for locking ,example is the
Castroviejo type.
Mayo-hegar-
commonly used
in Veterinary
Medicine for
manipulating
medium coarse
needles
Olsen hegar
needle holder-
have scissor
blades that
allow suture to
be tied
The disadvantage of
Olsen-Hegar needle
holder is that
expertise is required
to prevent cutting
the suture during
knot tying.
Mathieu needle holder
have a ratchet lock at
the proximal end of
the handles which
permits locking and
unlocking simply by
progressively
squeezing the handles
together.
Mathieu
needle
holder
 Needles generally should be placed
perpendicular to the needle holder
because this allows greatest
maneuverability.
 A needle generally is grasped near its
center to allow it to be advanced
through the tissue with greater force
and less risk of breakage.
 When the needle is grasped near the
eye or swage,maximum needle length is
available for suturing and risk of needle
slippage is reduced;however the
needle is more likely to bend or break
unless delicate tissue is being sutured.
 Small in length,used with small animals ,with special species and in
extraocular ophthalmic procedures(considered too large for intraocular
surgery)
 Similar to the Mayo-Hegar needle
holder,Crile-Wood needle holder
has a finer,more delicate jaws
 Holding the needle near the
pointed end allows the greatest
driving force when suturing tough
tissue ,but extracting the needle is
difficult.
 Needle holders may be held using:
 1.a palmed grip – no fingers are
placed in the rings ,and the upper
ring rests against the ball of the
thumb.
 2.thenar grip – the upper ring rests
on the ball of the thumb,and the
ring finger is inserted through the
lower ring.
 3.a thumb – ring finger grip – thumb is
placed through the upper ring and the
ring finger through the lower ring.
 4.a pencil grip – index finger and thumb
rests on the shafts of the needle holder
which is used with Castroviejo needle
holder.
 The palmed grip is most advantageous for suturing tough tissue that
requires a strong needle-driving force,however the needle cannot
be easily released and regrasped after a stitch without changing to
another grip,making suturing less precise.
 The thenar grip allows the needle to be released and regrasped for
extraction without changing grips.
 The greatest advantage of a thumb-ring finger grip is that it allows
precision when releasing a needle.Preferred when tissue is delicate
or when precise suturing is required.
Agenda

 Overview
 Brainstorming objectives
 Rules
 Brainstorming activities
 Summarize
 Next steps
Overview

 Quick overview of what this meeting is all about:

 Agenda
 What to expect
Brainstorming Objectives

 Describe the objective(s) of the exercise.

 New product or service ideas?
 New feature ideas?
 Feature/product naming?
 Promotion ideas?
 New process for doing something?
 Define top requirements or restrictions.
Rules

 No idea is a bad idea.

 Be creative.
 Take risks.
 No criticism allowed.
Brainstorming Activity

 Generate ideas.
 Use games and exercises to “warm up” your creative thinking.
 When ideas slow down, try another exercise to generate fresh ideas.
 Breaking into smaller groups may be helpful.
 Use a computer to capture every comment/idea.
Summarize

 Review ideas.
 Vote on top candidates and consolidate.
 Check requirements and restrictions.
 Trim list to top 5-10 ideas.
Next Steps

 Describe what happens next:

 Research the ideas generated?
 Follow up with larger group?
 Generate action items for follow-up:
 Start turning ideas into reality.
Suture
materials
Suture material

 Hold together wound edges

until the wound can
withstand the stress of
healing without additional
support
 Some examples of tissue
instability that would require
suture material are an:
 1.intentional surgical incision
2.ligated vessels and ligament,tendon, or
muscle repair

Suture material is available in many

forms,sizes and colors.

Characteristics of suture materials:

1.tensile strength-the amount of force in psi

that the suture can withstand (as an untied
fiber)before it breaks.
 2.memory – ability or tendency of the suture to
return to its original packaged form.
 3.flexibility – is the ease with which the suture is
manipulated,either by the surgeon or in the
tissue.
 Determined by the size(diameter) and the
material used to make the suture. example:silk
has better flexibility than stainless steel.
 4.absorbability- suture can be
classified as either:
 1.nonabsorbable – is not broken
down by the body and remain
intact in the body for at least 2
years
 2.absorbable – can be broken
down by the body through different
processes.
 A.phagocytosis – leukocytes ,usually
neutrophils are released and travel
to the site of concern(incision) to
ingest and destroy the microbes or
in the case of suture material ,the
foreign suture material.
 2.hydrolysis – the chemical
compound in the suture is
decomposed as it is exposed to
water.
 Absorption of suture may begin as
soon as 7 days after placement
 Complete absorption may take 60
days to 2 years
 5.Capillarity – ability of the suture to
allow microbes to “wick”(be carried)
to the interior of the suture strand.
 This action can be curtailed if the
manufacturer coats the suture
production to reduce the “wicking”
action .
 Polytetraflouroethylene
(Teflon)wax,paraffin,silicone,and
calcium stearate are substances
used to coat suture
 Generally ,multifilament sutures are
treated more often for capillary than
monofilament.
 6.Structure
 There are two basic types of suture:
 1.multifilament suture called braided
suture
 Has two or more strands braided
together to form a single strand of suture
 2.monofilament suture are single ,solid
strand of suture material
 Tends to have less “tissue drag”or friction
when its being pulled through the tissues
than multifilament suture material
 7.knot security – the ability of
suture to hold the knots the
surgeon has placed is imperative.
 Some types of suture materials
hold knots better than other types.
 Braided material has less knot
slippage than monofilament
suture.
 Once knots have been formed
with the suture,they must stay
secure.
 The slippage of a knot that was
around a major vessel slips,and
the animal bleeds to death.
 8.color – some sutures are dyed during
manufacturing process for easier
identification after placement in the
tissues.
 Available in dyed and undyed styles.
 Suture color should be considered in
some cases.example:if the patient is a
black Labrador and both black nylon
and blue polypropylene are available for
skin sutures,the blue sutures will be much
easier to identify at suture removal in ten
days.
Origin of material

 Suture material is also classified by the origin

of the material from which it is made:
 1.natural suture material –product made
from fibers found in nature.examples:
cotton,silk,and catgut(now made from
sheep intestinal mucosa)
 2.synthetic suture material – produced with
the use of manufactured
products.examples:nylon,polyglactin 910
3.Metallic suture – limited to surgical stainless
steel suture which includes suture wires and
staples.
 Ideal suture material(Physical
characteristics)
 1.have no knot slippage
 2.have high tensile strength
 3.absorbable
 4.cause no tissue reactivity
 5.easy to handle
 6.inexpensive
 In addition to the physical characteristics of the
suture material,the surgeon must also consider
the following criteria when selecting the suture
type and size.
 1.patient size
 2.area (tissue) of placement(skin vs.hollow
organ
 3.strength required
 4.healing potential of the tissue
 5.importance of cosmetic appearance
 6.cost
sizing

 Suture material is classified by size

according to the United States
Pharmacopeia(USP)
 USP uses a numeric scale to denote size
from fine to coarse.
 Hypodermic needles are classified by
gauge – which indicates the diameter size
of the needle
 Intramedullary pins are classified by
fractions of an inch to identify their size in
diameter (eg.1/8,5/32,1/4)
 Suture is classified by the term ought
 When sizing suture,the numeral “0”is used to
represent “ought” or “zero”
 The more zeros in a size,the smaller is the
suture
 For example,”0000”(pronounced “four-
ought”) is the same as 4-0 (also pronounced
“four-ought”)
 Similarly “00”is the same as 2-0,which some
refer to as “double ought”
 Size 5-0 suture material is smaller in diameter
(finer)than 3-0 suture.
 Whole numbers alone can also be used to
identify the size of the
suture(e.g.No.1,No.2,No.3)
 In the sizing of suture material ,whole
numbers used alone,that is,without any
“oughts”,increase in size with an increase in
number;the larger the number,the larger
the suture
 Suture is manufactured in a wide range of
sizes,from 11-0 to No.5.
 Smaller patients and more delicate
tissue(ophthalmology or cardiovascular
procedures) tend to use the small
sizes,whereas the larger sizes are primarily
used in large animal surgery.
 Packaging
 Packaged as single-use items sterilized at
the factory by the use of gamma radiation
 Suture packaged and sterilized in this
manner has a long shelf life,which is
indicated by an expiration date on the box.
 Individual suture packs are opened on an
as-needed basis,aseptically,onto the
surgical field.
 Exposed but unused suture should not be
resterilized but rather saved for use in
nonsterile procedures(e.g.necropsy closure)
 Ifthe inner suture pack was unopened and
unused on the sterile field ,resterilizing the
package may be possible.
 Under no circumstances should suture be
steam-sterilized.
 Any sterilization should be accomplished by
the use of an ethylene oxide (EtO sterilizer)
 Another packaging option is to have long
lengths (50-100m)of suture placed on a reel
or “cassette” by the manufacturer.
 This method of storing suture material has a
greater potential for contamination.
 A knot in the middle of the reel of suture is a
common risk and can prove to be a difficult
obstacle in removing suture from the
cassette.
Staples

 Internal and external staples are available

for use in veterinary surgery,differ
dramatically in cost,ease of use,and
applicability.
 1.external staples – skin(external)staples are
stainless steel staples placed
perpendicularly to an incision to close the
wound.
internal staples
➢ May be most advantageous in certain
thoracic cases(example:pulmonary
resection,excision of tumors in certain
location)
➢ thoracoabdominal(TA)staples are designed
to place multiple rows of staples in tissues
➢ Special staples are also used with
gastrointestinal procedures such as
gastrointestinal anastomosis and end to end
anastomosis
➢ Although expensive ,these staples can save
time in critical cases
➢ Benefit must be weighed against the cost so
that these staples are used judiciously.