PRINCIPLES OF SURGERY

MALIHA MALIKROLL NO. 1007

CONTENTS

DEVELOPING A SURGICAL DIAGNOSIS BASIC NECESSITIES FOR SURGERY ASEPTIC TECHNIQUE INCISIONS FLAP DESIGN• Prevention of flap necrosis• Prevention of flap dehiscence• Prevention of flap tearing TISSUE HANDLING HEMOSTASIS• Means of promoting wound hemostasis• Dead space management DECONTAMINATION AND DEBRIDEMENT EDEMA CONTROL PATIENT GENERAL HEALTH AND NUTRITION

PRINCIPLES OF SURGERY

Human tissues ,due to their innate properties ,react to injury fairly predictably. So ,with experience certain set principles are evolved for optimal healing.These are called as BASIC PRINCIPLES OF SURGERY.

DEVELOPING A SURGICAL DIAGNOSIS

Important decisions regarding surgery are made from :Identifying signs and symptoms by1. Complete and thorough history2. Physical examinationRadiographic findingsLaboratory investigationsRecord keeping/data in an organized form Differential diagnosis

BASIC NECESSITIES FOR SURGERY

1. Adequate visibility is based on

Adequate access- mouth opening, surgical exposure, retraction

Adequate light Surgical field free of

excess blood and other fluids.

2. Assistance

ASEPTIC TECHNIQUE

It includes minimizing wound contamination by pathogenic microbes through:

Medical asepsis Surgical asepsis

ASEPTIC TECHNIQUE(CONTD..)

Universal precautions are applied to prevent sepsis and efforts fall under the following headings.

1. Instrument sterilization.2. Operatory disinfection.3. Surgical staff preparation. Hand and arm preparation. Clean technique. Sterile technique.

INCISIONS

Incisions are necessary for many OMFS procedures. The following principles apply.

Use a sharp blade of proper size .

Use firm continuous strokes. Avoid cutting vital structures. Incise perpendicular to the

epithelial surface. Intraoral incisions should be

properly placed.

FLAP DESIGN

Principles of flap design help to prevent:1. Flap necrosis.2. Flap dehiscence3. Flap tearing.

1.Preventing flap necrosis

1. The tip should never be wider than the base unless a major artery is present at the base.

2. The length of a flap should be no more than twice the width. In the oral cavity, the length should never exceed the width.

3. When possible, include an axial blood supply in the base.

4. The base should not be twisted, stretched or grabbed with instruments that can interrupt or destroy the blood supply feeding and draining the flap.

2.Preventing flap dehiscence

Dehiscence (separation) is avoided by approximate the edges over healthy bone, handling the edges gently and minimizing tension.

Dehiscence exposes underlying bone leading to pain,bone loss, infection and scarring.

3.Preventing flap tearing

Make incisions long enough to give adequate access.

Make more than one releasing incision if more access is needed.

TISSUE HANDLING

Apart from careful flap design and incision technique, the careful handling of the tissues is also necessary for optimal and uncomplicated healing.

Excessive crushing, pulling, extremes of temperature, desiccation and harsh chemicals damage tissues and these should be avoided.

Toothed forceps and skin hooks are preferred to forceps that crush the wound edges.

TISSUE HANDLING(CONTD..)

Avoid excessive pulling forces to retract tissue. Use copious irrigation when drilling or cutting bone to

decrease bone damage from heat. Protect soft tissue when drilling from frictional heat

and direct trauma. Wounds should never be allowed to desicate. Only physiologic substances should come in contact

with the living tissue.

HEMOSTASIS

Prevention of excessive blood loss is important for :Preserving patient’s oxygen-carrying capacityIncreased visibilityTo prevent formation of hematomas

HEMOSTASIS(CONTD..)

MEANS OF PROMOTING WOUND . HEMOSTASIS1.Assist natural clotting processes by applying pressure on a bleeding vessel or a hemostat.2.Use of heat(thermal coagulation).3.Suture ligation.4.Use of vasoconstrictive substances(epinephrine)5.By applying procoagulants(commercial thrombin & collagen)

HEMOSTASIS(CONTD..) DEAD SPACE MANAGEMENT Dead space is an area that remains

devoid of tissue after wound closure. It is created by removing tissue in the

depths of the wound or by not reapproximating all tissue planes during closure.

These are usually filled with blood (hematoma) which delays healing and predisposes to infection.

HEMOSTASIS(CONTD..)

DEAD SPACE MANAGEMENT Can be managed in 4 ways:1. Suture all tissue planes.2. Pressure dressing.3. Packing(with an antibacterial

medication).4. Use of drains.

DECONTAMINATION AND DEBRIDEMENT

DECONTAMINATION AND DEBRIDEMENT(CONTD..)

Debridement with copious irrigation of wound with sterile saline during surgery and after closure.(large volumes of fluid under pressure) To remove debris . To reduce the bacteria count and minimizes the likelihood of infection.To remove necrotic, foreign and devitalized tissue .

EDEMA CONTROL

Results from the collection of serum(fluid)in the interstitial spaces due to the transudation from damaged vessels and lymphatics obstruction by fibrin.

Variables help determining the degree of postsurgical edema:

1. Tissue injury2. Loose connective tissue

EDEMA CONTROL(CONTD..)

• Post-surgical edema is minimized by:

1. Careful and gentle tissue handling2. Short term steroids(prior to surgery)3. Use of ice packs(controversial)4. Head kept elevated above the rest of the body for few

postoperative days

PATIENT GENERAL HEALTH AND NUTRITION

PROPER WOUND HEALING

PATIENT GENERAL HEALTH AND NUTRITION(CONTD..)

1. Diseases inducing catabolic metabolic state

• Poorly controlled IDDM• End-stage renal or hepatic

disease• Malignant diseases

2. Conditions interfering with delivery of oxygen and nutrients to wounded tissue

• Severe COPD• Poorly compensated

congestive heart failure• Drug addictions (ethanolism)

3. Drugs or physical agents that interfere with immunologic or wound healing cells

• Autoimmune diseases (long-term corticosteroid therapy)

• Malignancies (cytotoxic agents & radiation therapy)

• Medical conditions impairing patient’s ability to resist infection and wound healing :

PATIENT GENERAL HEALTH AND NUTRITION(CONTD..)

SURGEON’S ROLE :Increased chances of normal healing of an elective surgical wound by evaluating and optimizing the patient’s general health status before surgery.For malnourished patients, improving nutritional status so that the patient is in a positive nitrogen balance and an anabolic metabolic state.

Thank you for the PATIENT LISTENING