Most SA sx, linear incisions and dissection
Suture removal, piglet and lamb castration
Smaller than a 10, similar uses. LInear incisions or wider stab.
10 for LA, linear skin incision in thick-skinned
3 scalpel blade handle
4 scalpel blade handle
- Thick sturdy blades, for fascia or dense tissues
- approximately equal blades to handles.
- Straight or curved.
Delicate tissues, long handles in comparison to blade length. Straight or curved, variable size. Fine tissue dissection
- Very fine, very small, pointed tips.
- Small scissors with very fine tips
- Straight or curved.
- SA general surgery or ophthalmologist sx.
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.
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.
same size as Crile, jaws only go half way. Grasp small vessels for ligation or cautery
same size as Kelly, but teeth that go all the way. Grasp small vessels for ligation, cautery.
- Include Kelly, Crile, Halsted mosquito, Rochester Oschner, Rochester Carmault
- curved and straight
- differentiated by size and tips.
- Grasp vessels or vascular pedicles
Large sturdy forceps, cross striated (not like Carmault). Cross clamp vessels or pedicles, grasp masses or tissues.
- Forceps for large Pericles like canine OHE.
- Longitudinal, good for big, fatty pedicles. Atraumatic
Three parts, rather square. Self-retaining. Body wall retraction in abdominal sx.
2 parts, very square, looks like a tool. Self-retaining. Rib-spreader during thoracotomy.
like scissors with curved points on end, often orthopedic. Self-retaining, grip-lock ratchet.
Like scissors with combs on end. Self-retaining. Grip-lock ratchet.
- Thin hand-held retractor, comb/claw on one end and dull blade on other. Looks like a dental tool.
- retraction in small, shallow fields
- handheld, big with an eye in the middle of the handle, short hook on one side, longer on the other.
- general surgical procedures
- 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.
- 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
- atraumatic, long thin teeth on tip.
- Cardiovascular forceps. Narrower tips with two rows of non-aggressive teeth.
- Delicate tissues, esp vessels.
- 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.
Index on the top of the blade, cut with the belly of the blade.
Stab incisions or using the tip of the blade
- Monocryl (10ds)
- vicryl (3wks)
- PDS (6 wks)
- used for buried sutures or hollow organ closure, and for when sutures can't be removed.
- for skin closure or buried needing long-term strength like pexies, healing-impaired patients, Orthopedics, CV sx etc.
- Monocryl, PDS, Nylon, prolene
- less reactive, do not harbor or wick bacteria. Good for contaminated locations, but stiff and hard to tie.
- 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.
Edge to edge closure. Preferred for most.
Roll edges inward, good for hollow organs though appositional with oversew usually used (Lambert or Cushing)
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
Destroying all microorganisms. Disinfectant is similar agent but used on inanimate objects
Absense of pathogenic microbes/infection in living tissue. Antiseptic is applied to living tissue to achieve this
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
- 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
- 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.
- 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
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.
leaving some epididymis when castrating.
- band gun for castration, tail dock, dehorn?
- takes like a month to fall off but considered humane.
crushing only, no cutting, leave testicles in place to die.
banding gun for castrations. Tetanus a risk.
get it back in! Use a sling. Compression with bandages, hydrotherapy or ice, NSAIDs
- usu squamous cell carcinoma (most aggressive/invasive, can remove but it will probably come back.
- Most others don't metastasize.
- Phallectomy if necessary
phallectomy if penis and prepuce involved, obliterate cavernous tissue and stick urethra to skin to prevent skin scald
- 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.
- 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
- okay on a tiny uterus (or in castrations)
- use actual pedicle to tie a knot.
- 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.
- 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
- 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
- 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
- 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
- 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.
- 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
- 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
- tissue formation
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
- 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
- SURGICAL wound made under conditions of asepsis
- abx not required unless implants or extended six time, break in asepsis
- 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)
- >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
- 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)
- steroids (duration and dose dependent)
- 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
- 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
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
Adhesions! Normal function can be impeded
Blood supply compromised (venous obstruction = congestion + transplanted). SURGICAL EMERGENCY
- Congenital or heritable
- 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.
- 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
- 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.
- 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)
- 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)
- 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.