Basic Surgery

Dr.Ali Alhumood 2010 aliabh2006@hotmail.com

Forceps

Forceps
• Forceps: consist of two tines held together at one end with a spring device that holds the tines open. Forceps can be either tissue or dressing forceps. • Dressing forceps have smooth or smoothly serrated tips. • Tissue forceps have teeth to grip tissue. Many forceps bear the name of the originator of the design, such as Adson tissue forceps.

Rat Tooth: A Tissue Forceps
• Interdigitating teeth hold tissue without slipping. • Used to hold skin/dense tissue.

Adson Tissue Forceps
• Small serrated teeth on edge of tips. • The Adsons tissue forceps has delicate serrated tips designed for light, careful handling of tissue.

Allis: An Intestinal Tissue Forceps
• Interdigitating short teeth to grasp and hold bowel or tissue. • Slightly traumatic, use to hold intestine, fascia and skin.

Babcock: An Intestinal Tissue Forceps • More delicate that Allis, less directly traumatic. • Broad, flared ends with smooth tips. • Used to atraumatically hold viscera (bowel and bladder).

Sponge Forceps
• Sponge forceps can be straight or curved. • Sponge forceps can have smooth or serrated jaws. • Used to atraumatically hold viscera (bowel and bladder).

Towel clamps secure drapes to a patient's skin. They may also be used to hold tissue. Backhaus Towel Clamp • Locking forceps with curved, pointed tips.

Hemostatic forceps: Hinged (locking) Forceps. Many hemostatic forceps bear the name of the designer (Kelly, Holstead, Crile). They are used to clamp and hold blood vessels.

Classification by size and shape and size of tips

• Hemostatic forceps and hemostats may be curved or straight.

Kelly Hemostatic Forceps and Mosquito Hemostats
• Both are transversely serrated. • Mosquito hemostats (A) are more delicate than Kelly hemostatic forceps (B).

Comparison of Kelly and Mosquito tips
• Mosquito hemostats (A) have a smaller, finer tip.

Carmalt
• Heavier than Kelly. • Preferred for clamping of ovarian pedicals during an ovariohysterectomy surgery because the serrations run longitudinally.

Clamping an Artery Using a Kelly and a Carmalt Hemostat

intestinal forceps
Doyen Intestinal Forceps • Doyen intestinal forceps are non-crushing intestinal occluding forceps with longitudinal serrations. • Used to temporarily occlude lumen of bowel.

Payr Pylorus Clamps
• Payr pylorus clamp is a crushing intestinal instrument. • Used to occlude the end of bowel to be resected.

Self Retaining Retractor

Weitlaner
• Ends can be blunt or sharp. • Has rake tips. • Ratchet to hold tissue apart.

Gelpi
• Has single point tips. • Ratchet to hold tissue apart.

Handle Held Retractor

Senn
• Blades at each end. • Blades can be blunt (delicate) or sharp (more traumatic, used for fascia).

Hohman
• Levers tissue away from bone during orthopedic procedures.

Instrument Handling

Scissors and Hemostats:
• The thumb and ring finger are inserted into the rings of the scissors while the index and middle finger are used to guide the instrument. • The instrument should remain at the tips of the fingers for maximum control.

• This is the wrong way to hold the scissors. The ring finger should be inserted into the ring.

This is also the wrong way to hold the scissors. The tips of the scissors should be pointing upwards.

Thumb Forceps:
• Thumb forceps are held like a pencil.

• Thumb Forceps are not called 'tweezers'. • Thumb Forceps are not held like a knife.

Scalpels:
• The scalpel is held with thumb, middle and ring finger while the index finger is placed on the upper edge to help guide the scalpel. • Long gentle cutting strokes are less traumatic to tissue than short chopping motions.

• The scalpel should never be used in a "stabbing" motion.

Blades

#10 is the most commonly used scalpel blade. #15 is a smaller version of #10, and is used in for more delicate incisions.

• Blades #11 is pointed and is used in arthroscopic procedures (stab incisions). • Blade #12 is hooked and is used to remove sutures and declawing.

• Blade #22 and #23 are larger and used primarily in large animals

Selection of Appropriate Antiseptic

Isopropyl Alcohol (70%)
• ADVANTAGES:
1. Causes protein denaturation, cell lysis, and metabolic interruption. 2. Degreases the skin.

DISADVANTAGES:

1. Ineffective against bacterial spores and poorly effective against viruses and fungi.

Chlorhexidine Gluconate (Nolvasan)
• ADVANTAGES: - Rapid action. - Residual activity is enhanced by repeated use. - Less susceptible to organic inactivation than providone iodine. • DISADVANTAGES: - Occasional skin sensitivity. - Inactive against bacterial spores - Activity against viruses and fungi is variable and inconsistent

Iodophors: Iodine complexed with an organic substrate. • ADVANTAGES: - Bactericidal, viricidal, and fungicidal. • DISADVANTAGES: - Occasional skin sensitivity. - Partially inactivated by organic debris. - Less residual activity than chlorhexidine. - Poor sporicidal activity.

USES
• USES: - Supplies a film-forming solution of iodophor and isopropyl alcohol for a final skin prep. - Solution is contained within an applicator which speeds up the prep process. - Solution provides long-lasting, fast, broadspectrum antimicrobial activity.

Povidone Iodine - Betadine

DuraPrep

Hexachlorophene: a Phenol Derivative
• ACTION: Disrupts cell walls, precipitates cellular proteins. • DISADVANTAGES: - NOT USED: Neurotoxic. - Slow onset of action.
Phisohex

Antiseptics Handout

• Antiseptic -- Agent applied to living tissue • Disinfectant -- Agent applied to inanimate surface

A. Chlorhexidine Gluconate, 4% wv HibitaneR, SolvahexTM, Clenz 4 Chlorhexidine Acetate and Diacetate, 2% - Nolvasan: 1. Broadest spectrum. 2. Better residual activity than iodophors. 3. Occasional skin sensitivity (mucous membranes).

B. Iodophors BetadineR, DuraprepR

1. 2. 3. 4.

Excellent spectrum, contains iodine. Less residual activity than Chlorhexidine. Partially inactivated by organic debris. Occasional skin sensitivity.

C. Isopropyl Alcohol 70% (or Ethyl Alcohol 90%) 1. Protein coagulant 2. Degreases skin 3. Ineffective against spores

Hexachlorophene PhisohexR (no longer recommended) 1. Very potent against Gram positive bacteria (e.g., Staphylococcus). 2. Poor effect against enteric bacteria (Gram negative). 3. Inactivated by organic debris and alcohol 4. Long residual action.

Steam Sterilization: Autoclaving

Autoclave
• An autoclave is a self locking machine that sterilizes with steam under pressure. • Sterilization is achieved by the high temperature that steam under pressure can reach. • The high pressure also ensures saturation of wrapped surgical packs.

Autoclave Settings
General Wrapped Items

Temperature (F) Pressure (PSI)

)Time (min

250

20

30

Bottled Solutions

250

20

30

'Flashing'

270

30

4-7

Preparation for sterilization
• All instruments must be double wrapped in linen or special paper or placed in a special metal box equipped with a filter before sterilization. • 'Flashing' is when an instrument is autoclaved unwrapped for a shorter period of time. 'Flashing' is often used when a critical instrument is dropped.

Color Change Sterilization Indicators
• The white stripes on the tape change to black when the appropriate conditions (temperature) have been met. • Indicators should be on the inside and outside of equipment pack. • Expiration dates should be printed on all equipment packs.

• Color indicators are also included on the outside and inside of equipment sterilized in paper packages. • Biological sterilization indicators contain spores that are supplied in closed containers and are included with the instrument being autoclaved. Inability to culture the spores after autoclaving confirms adequate sterilization. Biological indicators are the most accurate sterilization indicators.

Ethylene Oxide Sterilization: ETO Gas
• Colorless gas, very toxic and flammable.Requires special equipmentOdor similar to ether. • Used for heat sensitive instruments: plastics, suture material, lenses and finely sharpened instruments. • Materials must be well aerated after sterilization. • Materials/instruments must be dry. • This specific type of EtO sterilizer is only found in larger veterinary hospitals

Large Two-Chamber EtO Sterilizer

Compact One-Chamber EtO Sterilizer
• Anprolene® is the most commonly used EtO sterilizer in veterinary practices. • Cartridges release 100% pure ethylene oxide • Kills all known viruses,bacteria (including spores), and fungi. • Annual safety inspections are recommended. • For more information on the Anprolene® system, go to the commercial vendors section.

Compact OneChamber EtO Sterilizer

Cold (Chemical) Sterilization:
• Instruments must be dry before immersion. • Glutaraldehyde (Cidex) is the most common disinfectant. • 3 hours exposure time is needed to destroy spores. • Glutaraldehyde is bactericidal, fungicidal, viricidal, and sporicidal.

Radiation Sterilization:
• High energy ionizing radiation destroys microorganisms and is used to sterilize prepacked surgical equipment. • Used for instruments that can't be sterilized by heat or chemicals. • Radiation sterilization is being promoted as an alternative to ETO sterilization. • Care needs to be taken because not all materials can be irradiated successfully • Currently used by manufacturers, but not used in veterinary hospitals • Common sources of radiation include electron beam and Cobalt-60 • For more information on specific sterilizers which utilize radiation, go to the commercial vendors section

Filter Sterilization:
• Filters are used for removal of microorganisms in fluids and gases. They come in a wide variety of types and sizes. • A 0.2 micron filter is required to remove bacteria from fluids. • The filter is placed in the IV line or on a syringe, so that the contaminated solution is sterilized before reaching the patient.

Gas Plasma:
• Based on a patented process involving the generation of a low-temperature hydrogen-peroxide gas plasma • Recently on the market, its efficiency in practice is still unproven • Requires only a 74 minute cycle time and leaves no toxic residues or emissions • Unlike EtO, it does not require special installation, ventilation, or aeration • Effectively sterilizes most heat- and moisture-sensitive medical devices and surgical instruments • For more information, go to STERRAD® in the commercial vendors section

Sterilization Methods Handout
A. Methods of Sterilization: 1. Physical Methods . 2. Chemical Methods. B. Sterilization Shelf Life of Packaged Supplies. C. Sterility Check List.

A. Methods of Sterilization:
1. b. Physical Methods: Steam Thermal – Autoclave: i. Definition -- a self-locking apparatus for the sterilization of material by means of steam under pressure. ii. Settings for general wrapped items: - Temp. - 250oF Pressure - 20 PSI - Time -- 30 min Setting -- Fast Exhaust & Dry

iii. Settings for bottled solutions: Always vent bottles to avoid bursting! - Temp. - 250oF Pressure - 20 PSI - Time -- 30 min Setting -- Slow Exhaust iv. Setting for "Flashing" an unwrapped instrument: - Temp. - 270oF Pressure - 30 PSI - Time -- 4-7 Min Setting -- Fast Exhaust v. Notes -- The above are general steam autoclave settings. Different models may operate with varying settings. Always refer to the appliance literature before operating a new piece of equipment.

b. Radiation: i. Use on materials that cannot be sterilized by heat or chemicals. ii. Radiant energy destroys microorganisms. iii. Filtration -- is a method utilizing filters capable of screening out microorganisms.

2. Chemical Methods:
a. Ethylene Oxide Gas: i. Colorless gas at room temperature. ii. Odor similar to ether . iii. Very toxic and irritating to skin and mucous membranes. iv. Microorganism destruction is caused by a chemical reaction. v. Materials sterilized need to be aerated in well ventilated room or placed in an aerator. Length of time required depends on items sterilized. vi. Effective sterilization is dependent on concentration of gas, exposure time, temperature, and relative humidity vii. Hazardous chemical, use great care .

a. Cold Sterilization: i. Instruments should be completely dry before soaking to prevent dilution. ii. Instrument soaking solution - 10-20 minute emersion only disinfects. iii. Incomplete destruction of spores, unless soak is for 10 hours. iv. Examples: Instrument Germicide (Phenol and Ethyl alcohol), CidexTM (Glutaraldehyde). v. Most require thorough rinsing before using instrument. vi. Contact time required varies with product used.

B. Sterilization Shelf Life of Packaged Supplies
1. The following wrapped items, if carefully maintained, are sterile for up to one (1) month: a. Double cloth wrapped instruments. b. Double paper wrapped instruments. c. Inexpensive peel pouches for gauze sponges. d. NalgeneR saline bottles.

2. Two (2) packaging methods are sterile for up to six (6) months: a. MonarchR Instrument Canisters -- Special box system with single use filters for use in steam autoclaves. b. Sterility Maintenance Covers -- Sealable plastic covers to place over freshly autoclaved and cooled packs to extend shelf life by diminishing air penetration. c. Heat sealed packages commercially prepared in tube or peel pouch form may be considered sterile for up to one (1) year.

C. Sterility Check List
Before assuming a pack is sterile, always evaluate the following before opening the pack: 1. Expiration or sterilization date. 2. Indicator color change. 3. General condition of wrapper and how it had been stored. 4. Always check for holes or moisture damage.

Chromic Surgical Gut
• Advantages: - monofilamentous • Disadvantages: - inflammatory reaction - rapid loss of tensile strength (2-3 weeks)

Disposable Gown, Hair Cap & Boot.

Disposable Paper Gown
• ADVANTAGES: - Paper gowns are resistant to wetting so they are less permeable to bacteria. They are preferred for wet bloody surgery (equine abdominal surgery). - Donning a new gown for each surgery and disposing of it at the end ensures sterility. • DISADVANTAGES: - Paper is less ecologically sound because it is not reusable.

Linen (cloth) Gowns
• ADVANTAGES: - Linen gowns are both comfortable and reusable. - Previously worn gowns can be autoclaved to regain sterility. • DISADVANTAGES: - Linen is a woven material so that when it becomes wet, bacteria can permeate through its interstices. - Linen is not the gown material of choice for wet, bloody surgical procedures.

Plastic Gowns
• ADVANTAGES: - Plastic is superior in its resistance to wetting and bacterial penetration. Plastic can be used to reinforce paper gowns during wet surgery (plastic sleeves for abdominal surgery). • DISADVANTAGES: - Plastic is extremely uncomfortable to wear because of the inability to shed heat and perspiration.

Beard Cover

Short Hair Cap with a duck-billed mask

Long Hair Cap with a pleated mask

Boots used in small animal surgery

Boots used in large animal surgery

Preparing The Equipment For Surgery

Folding of a Gown for Sterilization
• Hold the gown so that the outside is facing away from you. Place the outside right and left ties into the white tab.

• Fold the gown in half lengthwise twice making sure that the inside of the gown is showing.

• Lie the gown on a table and fold in half lengthwise again. Then fold end to end twice. The gown is folded in such a way that the top of the inside of the gown is presented when the sterile pack is unwrapped. This is the area grasped by the surgeon to begin donning the gown.

SCRUB TECHNIQUE

1) Trimming and Cleaning Nails
• Trim fingernails and clean with disposable nail file.

2) Initial Wash and Scrubbing Fingers
• Wash for 30-60 seconds with surgical scrub. • Scrub fingers with a sterile scrub brush • Make sure to scrub all sides of each finger, including the area between fingers.

3) Scrubbing Hands and Forearms
• Scrub hands and arms with a sterile scrub brush. • Make sure to scrub each surface of each hand and arm. • An accepted contact time is 10 brush strokes per surfac

4)Rinse
• Rinse hands and rescrub as in step 3. During scrubbing, rinsing and drying, hands are held above elbows. This is done so that water will not be dripping from upper arms onto lower arms and hands.After both scrubs and rinses, total contact time should be 5 minutes.Some surgeons do not rinse off the chlorhexidine in order to enhance residual activity.

Surgical Scrub

Disposable Brushes (Hibiclens):
- Packaged with antiseptic already contained within the brush. - Antiseptic can be chlorhexidine or iodophor based surgical scrubs.

Non-disposable Brushes
• Can be resterilized before each use. • Can be used with chlorhexidine or iodophor based surgical scrubs.

Surgical Prep of the Large Animal Patient

• During orthopedic procedures a stockinette is used to cover the distal part of the limb. The entire circumference of the distal limb is covered so that the surgeon can grasp and manipulate the limb. Proximal to the proposed incision site, a 'V' shaped drape is folded over the limb so that the entire circumference is covered and can be manipulated. In addition to the limb, the entire horse is covered with drapes.

• Step 1: Clipping: Generously clip area around the proposed incision with #40 surgical clipper blade. Isopropyl alcohol poured on site will facilitate clipping. Vacuum or brush and dispose of clipped hair and debris.

• Step 2: Gross Preparation: Use a surgical scrub product (Chlorhexidine [Nolvasan®], or Providone-iodine [Betadine®]) and tap water. Scrub and rinse until area is free of debris and water beads as it flushes across skin. Rinse with tap water.

• Step 3: White Glove Test: Soak 10-15 white 4x4 gauze sponges with isopropyl alcohol (70%). Wipe the scrubbed skin (always work from proposed incision site to the periphery) and check for remaining dirt and debris. Discard gauze if you pick up debris. Once you reach the periphery, discard gauze and start again at the proposed incision site with a new gauze sponge.

• Step 4: Final Skin Preparation: Saturate 10-15 gauze sponges with antiseptic solution (2% Nolvasan® Betadine®). Add ten milliliters of Nolvasan® or Betadine® surgical scrub to the top sponges. Scrub in a circular motion starting at the surgical site and moving toward the periphery. Never scrub in the direction of the periphery towards the proposed incision site. Total contact time should be 5 minutes.

• When picking up the sponges to begin scrubbing, fold and hold the corners of the sponge so that you do not touch the surface of the sponges that will be in contact with the surgical site.

• Starting with 1 to 3 sponges, scrub in circular motion starting at the proposed incision site and moving towards the periphery. Discard sponges as you reach the periphery (do not move peripheral debris toward the central incision site). Repeat for a total of five minutes.

• Step 5: Rinse: Rinse with sterile saline or 70% isopropyl alcohol. Continue rinsing until the area is free of fat and/or surgical scrub residue (rinsing solution will bead as it is flushed across skin. Rinsing solution should always flow from central (clean) to periphery (contaminated).

• Step 6: Final Antiseptic Preparation: Apply 70% Isopropyl alcohol to skin and let dry. Finish by applying an even coating of 2% Nolvasan® or Betadine® solution with spray bottle.

Preparing The Patient For Surgery

Draping Technique for the Small Animal Patient
Four Corner Draping: The function of draping is to separate the sterile surgical site from contaminated areas of the patient.

Unfolding the Drape
• The drape is unfolded and an edge folded under towards the patient. Wrap the corners of the drape around hands.

Placement of Drapes:
• The drape should be floated above the patient and placed in the appropriate position (i.e. do not drag the sterile drape along the patient's contaminated body). When applying the drapes make sure the sterile drape is in between the surgeon's sterile gown and the unsterile (undraped) surgical table. The drape should only be adjusted minimally once it has been laid onto the patient. If the drape needs to be adjusted it should only be moved in a direction AWAY from the sterile surgical site and NEVER towards the sterile site.

Securing the Drapes:
• Drapes are secured to each other and to the patient's skin with Backhaus towel clamps.The towel clamps are tucked underneath the drapes, making sure that they are not lying on the patient's skin.

Step by Step Photo Series of Surgical Prep of the Small Animal Patient

Step 1: Clipping:
• • • Clip operative site (wide borders) and remove all hair (central vacuum). Wipe skin with clean moist 4x4 gauze sponge to remove all hair and debris. Hair is removed in order reduce contamination of the surgical site by bacteria on the patient's skin and in the patient's hair follicles. Shaving is a less acceptable method of removing hair because shaving damages the skin to a greater degree than clipping. Any method of hair removal damages the patient's skin. Inflammation increases the risk of bacterial colonization. In order to reduce this risk, hair is removed immediately prior to surgery. For orthopedic procedures on long bones, the entire limb must be clipped to dorsal midline. Wounds within the surgical site must be coated with a water soluble jelly so that they do not collect hair and debris during the process of clipping.

• •

Step 2:Initial Scrub
• Soak scrub brush with tap water and 2% Chlorhexidine Gluconate (Nolvasan®).Using foam side of brush, apply mixture to entire clipped area.Collect and remove any loose hairs and debris.

Step 3: Scrub Incision Site
• With a new brush, scrub at the incision site for 2 full minutes. • Do not stray from the incision site.

Step 4: Periphery Scrub
• Soak a new scrub brush with tap water and Chlorhexidine Gluconate scrub.

Step 5: Rinse

Step 6: Final Antiseptic Spray
• The entire scrubbed area is then sprayed with a final preparation solution of 0.5% Chlorhexidine Diacetate in 70% isopropyl alcohol. This spray solution is made by diluting 1 part Nolvasan® (2% Chlorhexidine Diacetate) in 3 parts 70% isopropyl alcohol.