-
10 blade
Most SA sx, linear incisions and dissection
-
-
12 blade
Suture removal, piglet and lamb castration
-
15 blade
Smaller than a 10, similar uses. LInear incisions or wider stab.
-
22 blade
10 for LA, linear skin incision in thick-skinned
-
3 scalpel blade handle
SA sx
-
4 scalpel blade handle
LA sx
-
Mayo scissors
- Thick sturdy blades, for fascia or dense tissues
- approximately equal blades to handles.
- Straight or curved.
-
Metzembaum scissors
Delicate tissues, long handles in comparison to blade length. Straight or curved, variable size. Fine tissue dissection
-
Tentotomy scissors
- Very fine, very small, pointed tips.
- Small scissors with very fine tips
- Straight or curved.
- SA general surgery or ophthalmologist sx.
-
Suture scissors
Straight scissors with similar handle to blade length, each tip blunt or sharp. Cutting sutures.
-
Lister bandage scissors
Very strong bandage scissors, tip against skin is blunted. Cutting bandage material or removing bandages.
-
Utility scissors
For cutting suture etc. SCISSORS ARE NEVER FOR SKIN
-
Halsted mosquito forceps
Small locking forcep with fine tips. "Mosquito" or "snap". Grasp small vessels for ligation or cautery.
-
Kelly forceps
same size as Crile, jaws only go half way. Grasp small vessels for ligation or cautery
-
Crile forceps
same size as Kelly, but teeth that go all the way. Grasp small vessels for ligation, cautery.
-
Hemostatic forceps
- Include Kelly, Crile, Halsted mosquito, Rochester Oschner, Rochester Carmault
- curved and straight
- differentiated by size and tips.
- Grasp vessels or vascular pedicles
-
Rochester Oschner
Large sturdy forceps, cross striated (not like Carmault). Cross clamp vessels or pedicles, grasp masses or tissues.
-
Rochester Carmault
- Forceps for large Pericles like canine OHE.
- Longitudinal, good for big, fatty pedicles. Atraumatic
-
Balfour retractors
Three parts, rather square. Self-retaining. Body wall retraction in abdominal sx.
-
Finochietto retractor
2 parts, very square, looks like a tool. Self-retaining. Rib-spreader during thoracotomy.
-
Gelpi retractor
like scissors with curved points on end, often orthopedic. Self-retaining, grip-lock ratchet.
-
Weitlaner retractor
Like scissors with combs on end. Self-retaining. Grip-lock ratchet.
-
Senn retractor
- Thin hand-held retractor, comb/claw on one end and dull blade on other. Looks like a dental tool.
- retraction in small, shallow fields
-
Army-Navy retractor
- handheld, big with an eye in the middle of the handle, short hook on one side, longer on the other.
- general surgical procedures
-
Malleable/ribbon retractor
- hand-held, looks like a nail file, just a strip. Bends to custom shape.
- General surgery.
-
Poole suction tip
Perforated sleeve, straight cover with fenestrations. Good for abdomen, large volume
-
Frazier suction tip
Small straight angle, good for local, orthopedic or fine.
-
Yankauer suction tip
Bulb handle, curve with shower head tip. Good for chest, large volume.
-
Allis tissue forceps
- Closure like a cracked Easter egg, interlocking teeth.
- Crushing instrument for tissue, or secure cautery tips or suction tubing.
-
Layhey traction forceps
- Scissors with claws/combs on ends.
- grasp and manipulate tissues
-
Babcock intestinal forceps
- Closed "Y"s on each end of scissor, flat edges meet.
- Atraumatic.
- Grasp bowel or other hollow organs, non-crushing.
-
Backhaus towel clamps
Penetrating, use to hold bottom layer to skin, can also hold wounds closed during suture
-
non-penetrating towel clamps
Top layer, hold towel to towel, NOT TO DOG
-
Rat-toothed thumb tissue forceps
- Tissue spring forceps, longer than adson, taper not as dramatic, variable number of teeth.
- Traumatic, handling fibrous tissues. NOT hollow organs or vessels.
-
Adson thumb forceps
- interlocking teeth at VERY END
- delicate spring forceps with fine tip.
- Small, narrow tip, teeth at only very tip
- SQ tissues or thin skin. Too traumatic for viscera
-
DeBakey's forceps
- atraumatic, long thin teeth on tip.
- Cardiovascular forceps. Narrower tips with two rows of non-aggressive teeth.
- Delicate tissues, esp vessels.
-
Russian forceps
- LA GI sx, teeth in a circle at tips (Bear paw)
- nontraumatic, used for viscera or somatic tissues other than skin.
-
Brown Adson thumb forceps
Between Adson and DeBakey, teeth with a little height (7 rows). Closure of SQ tissues or thin skin. Less traumatic than Adson, good for hollow organs.
-
three-point grip
Index on the top of the blade, cut with the belly of the blade.
-
pencil grip
Stab incisions or using the tip of the blade
-
Absorbable sutures
- Monocryl (10ds)
- vicryl (3wks)
- PDS (6 wks)
- used for buried sutures or hollow organ closure, and for when sutures can't be removed.
-
non-absorbable sutures
- Nylon
- prolene
- supramid
- for skin closure or buried needing long-term strength like pexies, healing-impaired patients, Orthopedics, CV sx etc.
-
monofilament
- Monocryl, PDS, Nylon, prolene
- less reactive, do not harbor or wick bacteria. Good for contaminated locations, but stiff and hard to tie.
-
Multifilament
- vicryl, supramid
- softer, better knot security but wicks/holds bacteria. General closure, ligation, oral sx.
-
Interrupted suture pattern
- Adjustment of tension, good for irregularly shaped wounds, doesn't interfere with blood supply. Failure of one knot inconsequential.
- But takes more time and more suture, more knots = more foreign material in wound.
-
Continuous suture pattern
- Faster, tension evenly distributed, better seal, less foreign material in wound.
- Less precise control, compromise blood supply, failure of one knot disrupts entire line.
-
Apposition
Edge to edge closure. Preferred for most.
-
Inversion
Roll edges inward, good for hollow organs though appositional with oversew usually used (Lambert or Cushing)
-
Eversion
Rolling edges outward, closure of skin (rare)
-
Surgical infection and SSI
- Infection at operative site within 30 days of surgery. Implant is up to a year
- Surgical Site Infection
-
sterilization
Destroying all microorganisms. Disinfectant is similar agent but used on inanimate objects
-
asepsis
Absense of pathogenic microbes/infection in living tissue. Antiseptic is applied to living tissue to achieve this
-
Joseph Lister
Scottish surgeon washed hands in carbolic acid, mortality went from 45.7% to 15%
-
For every hour of surgical time
Infection rate approximately doubles.
-
Type of procedure in relation to surgical infections
- Clean: 2.5-6% (not near dirty area of body
- clean-contaminated: 2.5-9% (spay, neuter, REALLY clean GI sx)
- Contaminated: 5.5-28% (GI, etc)
- Dirty: 18-25% (picking gravel out of wound)
-
ventral midline approach to abdomen in SA (female vs male difference)
- Remove hair, scrub. Length of incision dep on sx (xyphoid to umbilicus to pubis), between nipples.
- 10 or 15 blade, one line, don't raise scalpel. Sharply incise SQ to expose linea alba.
- stab incision through linea alba by holding up and stabbing. Palpate for adhesions, lengthen. Remove falciform ligament as needed
- For male, prepucial flush, towel clamp prepuce to one side under drape, skin incision around prepuse. Make sure you re-attach ligament!
-
holding layer of SA abdomen
External rectus sheath
-
anatomy of linea alba and how it relates to secure closure
3 layer closure, linea alba is first closure. Fascia is strong, muscle and fat are weak. Don't get fat in between linea alba structures!! Use simple continuous absorbable, avoid including muscle
-
describe routine closure of SA abdomen
- Simple continuous through rectus sheath/linea alba
- simple continuous through SQ
- close skin with non-absorbable (if you want). REPAIR PREPUCIAL LIGAMENT IN MALE DOGS. ALso, don't mistake this for linea alba. Cover incision while in hospital, check twice daily. REmove sutures at 10-14 days
-
hernia
- Protrusion of an organ or tissue though a natural or traumatic opening. Includes defect, content and sometimes a sac
- can be internal (not abdominal wall) or external (defect in abdominal wall)
-
classification of hernias by status
- Reducible: can be returned, organs healthy, not emergency
- irreducible/incarcerated: can't be reduced, but vascularity of content still okay
- strangulated: content undergoing strangulation due to compromise of blood supply
-
classification of hernias by etiology
- Congenital: most common, at or just after birth, possibly inherited
- acquired
- iatrogenic: incisional, postcastration
-
treatment for umbilical hernia
- Manual reduction: for less than 2 fingers with no infection, once or twice a day, may close spontaneously in 2nd to 3rd month.
- Corset: bandage it in. Works in calves but not foals.
- Strangulation: use devices to induce necrosis and sloughing for <5cm and non-infected. More risk.
- Surgical: large reducible, small that don't respond, mandatory for strangulated or irreducible.
-
Inguinal/scrotal hernia
- Can occur in female. Scrotal means dropped farther than inguinal.
- Indirect: large vaginal ring, goes through into inguinal canal. Rings are normal, contained in common tunic. Almost all congenital
- direct: passes through body wall (internal oblique) but still into inguinal canal, outside common tunic.
-
postcastration hernias in horses
- Herniation of bowel or omentum following castration
- any breed but esp Standardbreds and drafts
- usu strangulate, so acute colic.
-
before surgery, horses need
tetanus!!
-
Emasculator
crush and cut, nut to nut. LA castrations
-
types of equine castrations (4)
- open: vaginal tunic incised
- closed: vaginal tunic not incised
- combination: vaginal tunic incised but held on to and emasculated
- primary closure castration: aseptic conditions, incision closed primarily (like a dog) for fly season, Standardbreds, etc. Normally heal by second intention
-
stretching incisions in LA castrations
exactly what it sounds like, stretch it out so it drains and allow to heal from inside out
-
complications of LA castrations
- scrotal edema: common, NBD. NSAIDs and stretching.
- Herniated omentum: ligated and emasculated, monitor for bowel herniation.
- Eventration: organ herniation, life-threatening, requires surgery in a hospital, usu have to resect.
-
proud cut
leaving some epididymis when castrating.
-
Callicrate bander
- band gun for castration, tail dock, dehorn?
- takes like a month to fall off but considered humane.
-
emasculatome
crushing only, no cutting, leave testicles in place to die.
-
elastrator bands
banding gun for castrations. Tetanus a risk.
-
penile injury
get it back in! Use a sling. Compression with bandages, hydrotherapy or ice, NSAIDs
-
Penile neoplasia
- usu squamous cell carcinoma (most aggressive/invasive, can remove but it will probably come back.
- Most others don't metastasize.
- Phallectomy if necessary
-
Dole's Procedure
phallectomy if penis and prepuce involved, obliterate cavernous tissue and stick urethra to skin to prevent skin scald
-
Reefing procedure
- equine preputial resection and anastamosis
- Put sutures at the 4 quadrants and then fill in with interrupted
-
Biggest concern of C-section + spay
blood loss--there's lots in the uterus.
-
OHE
- skin incision, dissect SQ fascia
- pick up linea, cut through in UPWARDS motion
- Find the uterus (under the bladder, above the bowel)
- suspensory ligament: medial leaf to kidney, lateral leaf to body wall. TEAR the lateral leaf to exteriorize
- triple-clamp ovarian pedicle, ligate. Repeat on other ovary to remove.
- transect or tear mesovarium
- triple-clamp uterine body, double ligate
- simple continuous linea closure
- SQ closure?
- intra-dermals or cruciates
-
pedicle tie
- okay on a tiny uterus (or in castrations)
- use actual pedicle to tie a knot.
-
pyometra
- 4-10 weeks post-estrus, due to endometrial hyperplasia and secondary infection
- depression, anorexia, vomiting, PUPD, vaginal discharge
- Tx with OHE! Recurs at next heat unless bred.
-
closed canine castration
single prescrotal incision, move testicles toward and through then ligate.
-
canine scrotal castration
- faster and don't cause the self-trauma we thought they did. Some post-op drainage.
- clip but DON'T DAMAGE skin, incise just lateral to raphe.
- have to incise septum to exteriorize second testicle
- Single interrupted absorbable suture in spermatic fascia. Invert incision with fingers. Scrotal hat while in the hospital.
-
feline castration
- pluck hair
- incise scrotum lateral to raphe
- ligate or cord tie
- could also do open and tie ductus around testicular vessels, three throws.
- skin heals by second intention.
-
canine chemical sterilization
- zeuterin: arginine buffered zinc gluconate.
- Injected into testicle. Blocks spermatogenesis and causes fibrosis. No longer available
- Calcium chloride: insanely cheap. Causes inflammation/mineralization/fibrosis. Initial swelling then slow shrinkage.
-
Primary (first intention) wound healing
- immediate closure by suture (within a few hours)
- optimal cosmetic and functional outcome, most rapid return to work
- good for when there is no tissue loss, little risk of wound infection. Time since wound is not as important as local tissue defenses/blood supply/contamination
- success depends on perfusion, minimal exudate, ability to remove foreign material, absense of necrosis, tension.
- Only for clean, clean-contaminated and MANAGEABLE contaminated
-
second intention
- No surgical intervention. Healing as an open wound via contraction and epithelialization
- good for upper limbs and body in horses, not lower limbs
- healing by epithelialization, very slow with ugly, hairless scar and poor mechanical durability
-
delayed primary closure
- left open at first but closed within 3-5 days, before granulation appears.
- traumatic wounds, at risk of infection and dehiscence. Leaving open for 1-4d reduces risk of infection. Any time before fibroplasia (4-5days) has same effect as primary
- Outcome is like primary
- Clean wound, abx, antimicrobial dressing and pressure bandage changed 1-2days. Clean and debride as necessary.
- Close when limb edema minimal, tissue appears healthy, small amounts of serous discharge
-
secondary closure
- Type of delayed closure, suture after granulation tissue has formed (delayed primary in integumentary lecture)
- Considered tertiary (third intention) healing.
- best where wound viability is questionable, may necrose.
- for neglected wounds (too late) or dehisced wounds
-
preparing wound bed
- pack with KY jelly or sponges
- clip with #40 blade
- shave margins (straight razor or scalpel blade)
- scrub around wound, avoid detergent on wound edges
- lavage (low or high pressure), complete wound excision, simple debridement
-
wound lavage
- Warm, sterile isotonic fluid, good at removing bacteria or foreign material. Can add stuff like surfactant (biofilms), abx, iodine, chlorhex, questionable.
- Low pressure: for anything you plan to close. Gravity flow.
- High pressure: great at removing particles but not for wounds you want to close
-
complete wound excision (en bloc debridement)
- Most effective cleaning for traumatic wound
- surgical excision of entire wound bed (not skin edges), makes "surgically clean"
- contraindicated in infected
-
simple debridement
- Surgical removal of grossly visible foreign material and damaged tissue, used when complete excision not an option.
- ALWAYS combine with wound lavage, ineffective at removing bacteria and particles.
-
Ways to manage dead space
- Penrose or fenestrated suction drain
- counterpressure for limb wounds
- suture obliteration of dead space
-
sutures to dissipate tension
- Add vertical mattress tension sutures widely around wound then simple interrupted along incision
- quill or button sutures - place tubing or button under the bars of a mattress suture to dissipate tension - careful or skin can slough underneath
-
indications for not closing wounds
- Significant tissue loss
- existing infection
- high risk of infection (severe local trauma, marked contamination)
-
closing wounds vs not in horses
- Healing by contraction/epithelialization very effective in head, trunk and upper limbs.
- Poor on lower limbs, especially if tissue has been lost. Happens through migration of epithelial cells, hairless weak scar.
-
Exuberant granulation tissue
- Failure of normal balance between collagen production and lysis at end of fibroplastic phase of healing (~3 weeks)
- only ON or BELOW carpus/tarsus. More in high motion areas and larger horses
- counterpressure, immobilization, topical corticosteroids, silicone dressings.
- Treatment: sharp surgical removal, skin grafting.
-
Pinch grafting
- Take 3-4mm "pinches" of skin and place 1cm apart in pockets in tissue
- bed must be well vascularized, not infected, flush with skin margins
-
penniculus muscle
- Muscle under skin of dog and cat with much blood supply.
- Undermine UNDER this muscle to stretch skin for closure.
- Incisions need to be STRAIGHT and NOT JAGGED--don't pick up your blade, and only cut once
-
Three phases of wound healing
- Inflammation
- tissue formation
- remodeling
-
phases of inflammation (3)
- Vasoconstriction (seconds to minutes)
- Vasodilation (start coagulation)
- fibrin clot
- 1-24h = neutrophil migration, NETS (why you remove every spec of necrosis), clean-up
- 48h = macrophages = HEALING
-
tissue formation
- 2wks-6months - basal cells, epithelial cells. Wound contraction by myofibroblasts.
- granulation tissue looks like wet velvet, wet does not mean infected, just no tight junctions to hold in albumin yet. DO NOT CULTURE, WILL be +, no correlation between infection.
-
Absense of granulation tissue by ___________ is a problem
- 3-5d in dogs
- 5-6d in cats
- excess necrotic tissue, contamination, poor perfusion, infection, poor patient health
-
Clean wound
- SURGICAL wound made under conditions of asepsis
- abx not required unless implants or extended six time, break in asepsis
-
contaminated wound
- Open traumatic wound
- made with a major break in sterile technique like spillage of GI contents.
- Abx prophylaxis required (too early for infection, so prophylactic)
-
dirty/infected wound
- >10^5 bacteria per gram of tissue
- clinically exhibits signs of inflammation (heat, pain, swelling, redness, discharge)
- Therapeutic abx required
- purulent necrotic wound or established peritonitis
-
clean-contaminated wound
- Surgical wound under conditions of asepsis, but when entering a hollow organ in six (resp, urinary, alimentary tract entered)
- abx prophylaxis required
-
PATIENT reasons a wound won't heal
- Diabetes mellitus (impaired macrophages)
- hyperadrenocorticism
- FIV
- steroids (duration and dose dependent)
- chemotherapy
- severe anemia
- poor nutritional status (cachexia)
- hypotension or hypothermia or a long time under general anesthesia
- being a cat
-
WOUND factors that inhibit healing
- Tension = poor perfusion
- high mobility in area
- pressure points (point of elbow, etc)
- radiation site
- highly productive wound
- excessive suture material in wound bed
- foreign or necrotic tissue
-
Steps of basic wound management (7)
- wear gloves
- apply sterile water-soluble gel to wound surface
- clip and KEEP clipped
- lavage - get gel and hair out of wound. Can use tap water
- debride - sharp excision of necrotic tissue
- forage exposed bony surfaces (drill into medullary cavity to make mushrooms and promote granulation)
- Primary closure vs open wound management (for delayed primary or second intention)
-
layers that make up a bandage and their purposes
- contact layer: closest to wound, could be debriding (contaminated wound before granulation tissue) or non-debriding (post-granulation to support incision)
- absorptive layer: wick away fluid and even out pressure of outer layer
- outer layer: keep bandage in place
-
reduce risks of bandage management
- insufficient padding
- too long between changes
- bandage became wet
- too tight
- toes left out, blood flow occluded
- no allowance made for flexion of limb
- poor owner communication - WRITTEN instructions
- don't use Ehmer sling unless P is staying in the hospital
- if a P is DESPERATE to get it off, take a look!
-
contact layer options and considerations
- debridement: contaminated wound prior to granulation tissue formation. Honey-soaked sterile gauze, saline-soaked lap sponges (wet-to-dry), sugar under lap sponges.
- non-debridement: post-formation of granulation tissue, to support a surgical incision. Hydrocolloid/hydrogel under a non-adherent semi-occlusive dressing, mepilex, NOT Telfa alone on an open wound, dessicates and becomes debriding.
-
bandage factors that cause delayed wound healing
- excess pressure = insufficient padding (prevents epithelial cells from moving)
- too long between bandage changes (cytokine-rich fluid pooling on surface)
- Traumatic contact layer (tug off each time)
- excess tension (poor availability of surrounding tissues that limits contraction)
- Poor wound vascularity (bony surfaces)
-
Hasted's principles (7)
- strict aseptic technique
- gentle tissue handling
- meticulous hemostasis
- preservation of blood supply
- obliteration of dead space
- accurate apposition of tissue planes
- minimization of tension on tissues
-
Options for closing a tension-free wound
- primary closure
- delayed primary closure
- second intention
-
options for closing a wound with tension
- undermining
- walking sutures: suture through dermal layer and deep fascia of muscle, pull edges closer together to distribute tension away from appositional margin
- multiple releasing incisions for distal extremity wounds
-
options for closing a wound with a large defect or lots of tension, where tension-relieving techniques alone are insufficient
Local flaps, axial pattern flaps or free graft
-
biological difference between local flaps and axial pattern flaps (with examples of each)
- Local flaps: From anywhere to anywhere, rely on skin to survive. Advancement (pull down over), rotational (edge bordered wound), transposition (90degrees), flank/elbow fold flap (advancement from the flank or elbow)
- axial: anatomically KNOWN direct cutaneous vessels. Can't reach distal to elbow/hock. caudal epigastric.
-
what is meant by a free graft? What are the 4 steps of graft take
- take skin
- "de-fat" - remove fat from back
- "mesh - cut holes for drainage
- lay over GRANULATION bed and suture on
- Plasmatic imbibition, inossculation, revascularization
-
risks/benefits of active and passive drains
- eliminate dead space when placed in healthy wounds at surgical closure, remove excess fluid.
- foreign material in wounds increases risk of dehiscence, causes potential site of ascending bacterial infection, drain material could be retained in wound.
- Jackson Pratt = active suction, can be used in abdomen, more sterile.
- Passive, penrose, relies on gravity so must be placed properly and covered.
-
common errors in clinician decision making that result in wound dehiscence
- excess tension
- wound closed prematurely
- inappropriate surgical technique
- RARELY infection
-
Hernia definition
A hole where there shouldn't be, stuff sitting where it shouldn't
-
-
loss of domain (hernia)
Takes away physical space from another areas - diaphragmatic removes space from lungs
-
incarceration (hernia)
Adhesions! Normal function can be impeded
-
strangulation (hernia)
Blood supply compromised (venous obstruction = congestion + transplanted). SURGICAL EMERGENCY
-
umbilical hernias
- Congenital or heritable
- common
- could also be concurrent cardiac defects, incomplete caudal eternal fusion, cryptorchidism, PPDH.
- May spontaneously resolve by 6 months.
- risk of bowel entrapment, otherwise elective surgery.
-
Inguinal hernias
- 70-90% female, often caused by estrus and risk factors, L>R
- Proceed as soon as dx, emergency if organ entrapment
- best reduced by caudal midline laparotomy.
- CHECK OTHER SIDE
-
scrotal hernias
- Variant of inguinal hernia
- viscera pass through entire inguinal canal
- often concurrent strangulation.
- Rare, often in brachycephalic and chondrodystrophoids.
- Can rarely push back in from outside (prescrotal incision if reducible? Close external ring). Caudal midline for non-reducible.
-
Abdominal/thoracic wall rupture
- Many different kinds, often polytrauma/comorbidity - rule out!
- Rads! Midline approach, may have to drill holes in pubis if periosteum not substantial enough
- There may be NO EXTERNAL PUNCTURES, be prepared.
-
diaphragm rupture
- Know which holes should be there and what goes through them, don't mess with it!
- May see VQ mismatch, increased CO2 (no neg pressure in pleural space. Dyspnea, decreased lung sounds, asynchronous respiratory pattern (thoracic wall out and abdomen in on inspiration)
- could be incarceration or strangulation, watch for liver lobes, intestine or stomach in thoracic cavity
- gastric herniation TRUE EMERGENCY
- Place a chest tube through thoracic wall before you close it (for suction)
-
gastric herniation
- EMERGENCY
- stomach in pleural cavity. Will start to build up gas when outflow obstructed
-
liver lobe or splenic torsion or strangulation
- Diaphragmatic hernia
- high volume pleural effusion, SO MUCH FLUID puts into hypovolemic shock.
- Thoracocentesis, ridiculously high volume.
-
peritoneopericardial diaphragmatic hernia (PPDH)
- congenital
- pericardial sac connects with abdominal cavity.
- Often asyptomatic.
- Often concurrent with umbilical hernia, caudal eternal defect - xiphoid absent, ID at spay.
- Tx - just pull it in and suture up.
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