SURGERY Guide to Procedures - PowerPoint Presentation

Slide1

SURGERY

Guide

to ProceduresSlide2

Topics

Patient prep

Debridement

Closure

Amputation

Fasciotomy

Slide3

Patient Prep

Emplace tourniquet but do not inflate. You can inflate it later if major bleeding occurs

Remove bandage

Wash wound and extremity

Chux

pads may be placed underneath pt. to collect excess fluids (remember to change them out after they get wet)

The wound and entire extremity needs to be thoroughly scrubbed (think of it as your hand and arm scrub before gowning)Slide4

Patient Prep

Wash wound and extremity

Dirty areas like the foot and perineum (axilla and hand for arms) should also be scrubbed even though they will be covered by drapes, because of the proximity to the sterile area

Once area is scrubbed, this is a good time to do the bulk of preoperative irrigation

This irrigation is mainly directed to the wound

Good retraction and gentle massage

We’re not worried about a little soap on the rest of the extremitySlide5

Patient Prep

Prepare for sterile procedure

Everyone in proper uniform

Hat, mask, clean shoes or shoe covers

Doors shut

Limit entrance into OR

Open only the outer wraps of sterile packs

Gown, gloves, surgical pack

Perform hand and arm (surgical) scrubSlide6

Patient Prep

Set up sterile fields

Gown and glove

Open and organize sterile fields

Exercise economy of motion, supplies and time

Get everything ready because your assistant will be unavailable when he will be supporting the extremity

It may be better to have the assistant open the individual sterile packets and allow the surgeon to grab and place the sterile items on the field than trusting the assistant to flip them onto the fields himselfSlide7

Patient Prep

Prepping the operative site

Painting the extremity should start with the wound and work outward to the peripheral extremity

It’s not a big issue if the assistant’s gloved hand touches a part of the painted extremity while it is wet

Remember that everything around you is unsterile

Be conscious of your surroundings and where your hands and gown areSlide8

Patient Prep

Prepping the operative site

Draping is then applied in order to accomplish 3 things, airtight from space below the draping, waterproof surrounding the operative area and a large enough work space for ease of the procedure

Airtight – 1 or 2 sterile hand towels placed tightly around the proximal thigh and clamp

Waterproof – 3 or 4 “

steri

drapes” placed over the hand towels

Working area – Bottom drape, top drape, splice in the sides and clamp

Distal drape - Sterile

Coban

, sterile towel or sterile gloveSlide9

Patient Prep

Prepping the operative site

Drapes should be placed deliberately and directly, not flipped or thrown into place

Once again, nothing is sterile around you

Be conscious of where your hands are

Prior to incising/excising, the wound should be irrigated again to flush out residual contaminants and antiseptic solutions (antiseptics are toxic to tissues as well as staining them, making assessment difficult)Slide10

Debridement

The wound is extended with a scalpel enough to expose the extent of the injury and allow for decompression of the wound

The skin edge surrounding the original wound (not the surgical incisions) is excised minimally with a scalpel

Dissecting scissors are not preferred for cutting skin

Undermining the skin is only necessary if the injury extends underneath itSlide11

Debridement

Subcutaneous fascia is incised with dissecting scissors to at least the same length of skin incision

Affected muscles should be bluntly separated from adjoining muscles, then inspected in their entirety

Use escalation of force while doing this

Be as gentle as possible

All necrotic, contused and contaminated tissues excised (4 “C”s)Slide12

Debridement

Any fat encountered excised generously

Work with a systematic approach

Address vessels as encountered

Transfix vessels with potential for moderate bleeding

Irrigate and inspect entire wound

Look in all nooks and crannies

Missed culture medium

For any bleeding and ensure all ligations are secureSlide13

Debridement

Final irrigation (1-3L or until it looks clean)

Dry, apply pressure

Dress with an abundance of gauze

Initial layer to have complete contact with tissues

Follow with some fluffed gauze

Continue antibiotic treatment for 5 days from injury or until closure (no more than 5 days)Slide14

Debridement

Dressing (advised for

caprine

model)

V-shape stack of 4x8s (thick enough to collect fluid for wound size)

Suture proximally with 4-6 sutures of 0 silk

Place

webril

over 4x8s and entire leg for both absorption and padding for splint

Place elastic stocking over

webril

and staple proximally

Place and form splint and affix with

cobanSlide15

Closure

4 - 6 Days after Debridement

Prep

and drape as usual

Inspect for necrotic tissue, adhesions, signs of infection (thorough inspection)

If only a small amount of necrotic tissue is present, it may be removed

If there were no signs of infection, the wound may be closedSlide16

Closure

Collagen (if present) can be scraped off with gauze or the back end of tissue or Adson forceps

Any sign of infection, the wound should not be closed

When is doubt, leave sutures outSlide17

Closure

Skin excision should be limited only to areas which will create defects

Determine wound approximation and undermine prn

In

areas of tension, undermining no more than 5 cm from wound edge can be

helpful

Wound irrigated, inspected, final irrigation and driedSlide18

Closure

Wound can be closed with wound edges approximated and everted with

forceps

Under no circumstance will the wound be closed under tension (use ROM to determine differences of tension)

If undermining will not suffice, the use of MRSI can be used

Not over undermined area

Depth of incision through entirety of dermisSlide19

Closure

Roll the wound to express any residual fluids and help with apposition

Dress with gauze and suture (0 silk) on its proximal end (

caprine

model)

Cover with elastic stocking stapled proximally (

caprine

model)

If a drain is placed it should be removed within 24 hrs if not draining substantial exudates

>20ml in 24hr period is substantialSlide20

Closure

Dressings – the idea is not necessarily that the same dressing stays in place until suture removal, but that the wound remain protected by a dressing until suture removal. Of course, the dressing should be changed if the dressing becomes saturated and/or soiled. A little dirt on the exterior of the elastic stocking does not indicate that underneath the dressing is soiled. Slide21

Closure

Secondary intent

Dressing changes and gentle washing Q4-5D

Use of vessel loops/sterile rubber bands (Jacobs ladder) help to keep skin from retraction

In cases of infection:

Daily sugar or honey dressings and copious washing until infection subsides

Institute antibiotic regimen

Re-excise as needed

Switch to infrequent dressing changes once infection is under control (Q4-5D)Slide22

Amputation

If it is a partial amputation which has a significant amount of tissues attaching the distal extremity, it should be scrubbed in

If it is basically a complete amputation and only hanging on by 1 or 2 tendons or just a small amount of skin, then it can be removed prior to preparation

Once scrubbed in, the focus is on performing the amputation and not on the non-viable distal extremitySlide23

Amputation

Tourniquet placed and inflated

Document time and order time hacks

Extremity prepared and draped as usual

First step is to assess level of amputation

Next, create skin flaps by incising all the way through the dermis and deep fascia

Only reflect skin flaps proximally if needed to allow access/exposure

Do not de-glove entire stump

Incise fascia over musclesSlide24

Amputation

Blunt dissect to mobilize the

whole (unaffected)

muscle to be used as the

myoplasty

and section at distal attachment

Reflect this muscle proximally, slightly past the point of where the bone is to be sectionedSlide25

Amputation

Section all other muscles at the point or slightly distal to where the bone is to be sectioned.

Reflect the sectioned muscles proximally, slightly past the point where the bone is to be sectioned

Do not strip periosteum proximally or distallySlide26

Amputation

Score periosteum (to include bevel on tibia for BKA) and section bone

Keep

gigli

saw blade between a 90 - 180 degree angle

Let the saw blade do the work

Have assistant hold good tissue out of the way

File or rasp sharp corners (bevel the edges)

Always rasp toward the medullary canal

Locate vessels and address them

Transfix all vessels that have the potential for moderate bleedingSlide27

Amputation

Remove tourniquet and check for hemorrhage control

Performed right after vessel ligations - 90 minute tourniquet time!

Locate all named nerves and address them

By sharp dissection, proximally as possible

No need to crush or inject them

Look for any tissues under fascial tension and relieve itSlide28

Amputation

Irrigate, final look and ensure hemostasis

All nooks and crannies, ligations

Final Irrigation, dry and dress

Do not suspend skin flaps (do not place gauze between skin flaps and underlying tissue)

Lots of

absorbant

bulk needed for stump dressing

Need to account for an extreme amount of

serosanguinous

drainageSlide29

Amputation

Post op

Splinted in extension

Stump elevated and rested first 48

hrs

Mobility started ASAP

Gentle ROM directed at extension of the joint(s) above after the rest period

Both passive and active

Should not harm the wound or

dressingSlide30

Amputation

Closure

Prepared as usual

Suture whole muscle over bone by anchoring to periosteum and muscles (whatever you have)

You are suturing this muscle to stay in place, not just placing a few tack sutures

Place

drain

Close skin flaps incorporating deep fascia

Combination of vertical mattress and simple interrupted Slide31

Amputation

Post-Op care

Same as previous until suture removal

Drain removed at 48 hours or when drainage is < 20ml in a 24hr period

After suture removal, physical therapy progresses and elastic stump bandaging can be applied (figure 8 wrap using 50% stretch of the elastic) Slide32

Amputation

Secondary Closure

Either complete secondary closure or partial secondary closure:

Use of vessel loops or sterile rubber bands (Jacob's ladder) can be used to prevent skin retraction

Infrequent dressing changes every 4-5 days with a gentle wash/irrigationSlide33

Fasciotomy

Prepare extremity as usual if time permits

May need to be performed STAT

Make as sterile as possible

S/

Sx

will dictate urgencySlide34

Fasciotomy

Lower Leg Procedure (anterior and lateral)

Incise laterally through dermis one finger in front of fibula, from three finger breadth distal to fibular head to 3 finger breadth proximal from lateral malleolus

Locate intermuscular septum between anterior and lateral compartments

Make "H" incision, first by incising (with scalpel) across the septum to ensure it is the septum (be cautious of superficial peroneal nerve)Slide35

Fasciotomy

Lower Leg Procedure

Make the legs of the "H" proximally and distally by incising (with dissecting scissors) over both the anterior and lateral compartments

Lift the fascial up from the underlying tissue by running the closed scissors underneath the fascia prior to incising

Incise by pushing through the fascia with slightly open scissors

Do not use clipping action

Keep scissor curve pointed away from septumSlide36

Fasciotomy

Lower Leg Procedure (superficial and deep posterior)

Incise medially through dermis one thumb breadth posterior to the

tibial

border, from three finger breadth distal to

tibial

plateau to 3 finger breadth proximal from medial malleolus

Exercise caution to avoid cutting the saphenous vein

Incise fascia over superficial compartment

Avoid saphenous vein

Be prepared to ligate saphenous tributariesSlide37

Fasciotomy

Lower Leg Procedure (superficial and deep posterior)

Locate soleus muscle and remove its attachment to the tibia by blunt or sharp dissection

You should be able to visualize the Posterior

Tibial

neurovascular bundle between the superficial and deep posterior compartments

Incise fascia overlying the deep posterior compartmentSlide38

Fasciotomy

Forearm

Incision through the skin will start either on the medial or lateral side of the upper arm heading distally

At the elbow, the incision should be obliquely across the crease

Caution with cephalic vein

It should then be carried out to the wrist, where once again continued obliquely (v-shaped) to the

Thenar

spaceSlide39

Fasciotomy

Forearm

Fascial incisions to open the superficial volar, deep volar and mobile wad can be accomplished with this skin incision

The

bicepital

aponeurosis

(

lacertus

fibrosis

) also needs

to be released

Caution with brachial artery

and median nerve

Bicepital

aponeurosisSlide40

Fasciotomy

Forearm

A skin incision over the extensor muscles on the posterior aspect of the forearm will provide access to the dorsal compartment

Irrigate, final inspection and final irrigation

Dry and dress

No constriction

Keep extremity at the level of heart

Delayed Primary Closure or Secondary Intent