SURGERY Guide to Procedures Topics Patient prep
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SURGERY Guide to Procedures Topics Patient prep Debridement Closure Amputation Fasciotomy Patient Prep Emplace tourniquet but do not inflate. You can inflate it later if major bleeding occurs Remove bandage Wash wound and extremity Chux
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01
SURGERY Guide to Procedures<br>
02
Topics Patient prep
Debridement
Closure
Amputation
Fasciotomy<br>
Debridement
Closure
Amputation
Fasciotomy<br>
03
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)<br>
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)<br>
04
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 extremity<br>
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 extremity<br>
05
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) scrub<br>
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) scrub<br>
06
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 himself<br>
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 himself<br>
07
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 are<br>
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 are<br>
08
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 glove<br>
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 glove<br>
09
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)<br>
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)<br>
10
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 it<br>
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 it<br>
11
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)<br>
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)<br>
12
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 secure<br>
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 secure<br>
13
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)<br>
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)<br>
14
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 coban<br>
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 coban<br>
15
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 closed<br>
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 closed<br>
16
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 out<br>
Any sign of infection, the wound should not be closed
When is doubt, leave sutures out<br>
17
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 dried<br>
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 dried<br>
18
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 dermis<br>
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 dermis<br>
19
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 substantial<br>
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 substantial<br>
20
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.<br>
21
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)<br>
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)<br>
22
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 extremity<br>
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 extremity<br>
23
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 muscles<br>
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 muscles<br>
24
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 sectioned<br>
Reflect this muscle proximally, slightly past the point of where the bone is to be sectioned<br>
25
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 distally<br>
Reflect the sectioned muscles proximally, slightly past the point where the bone is to be sectioned
Do not strip periosteum proximally or distally<br>
26
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 bleeding<br>
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 bleeding<br>
27
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 it<br>
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 it<br>
28
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 drainage<br>
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 drainage<br>
29
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 dressing<br>
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 dressing<br>
30
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<br>
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<br>
31
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)<br>
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)<br>
32
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/irrigation<br>
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/irrigation<br>
33
Fasciotomy Prepare extremity as usual if time permits
May need to be performed STAT
Make as sterile as possible
S/Sx will dictate urgency<br>
May need to be performed STAT
Make as sterile as possible
S/Sx will dictate urgency<br>
34
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)<br>
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)<br>
35
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 septum<br>
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 septum<br>
36
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 tributaries<br>
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 tributaries<br>
37
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 compartment<br>
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 compartment<br>
38
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 space<br>
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 space<br>
39
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 aponeurosis<br>
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 aponeurosis<br>
40
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<br>
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<br>