This page intentionally left blank CHAPTER 4 Surgical instruments, materials, and skills 94 Scalpel handles Scalpel holders are numbered and accommodate a variety of sizes of scalpel blades. Care should be taken to mount and remove scalpel blades using an artery clip (Fig. 4.1). Needle holders Most needle holders are ratcheted and have a specially designed surface betw een the jaws to allow a firm grasp of the needle and prevent it twisting. They should be pl aced halfway along the needle to avoid dam- age to the needle point and the swage (which wo uld cause detachment from the suture). (Fig. 4.2) SCALPEL HANDLES1 95 Fig. 4.1 Scalpel holders no. 3, 4, and 5 Fig. 4.2 Mayo, Masson, and DeBlakey needle holders CHAPTER 4 Surgical instruments, materials, and skills 96 Scissors \200\224suture and dissecting Scissors are either straight or curved and used to c ut sutures or for dissection. Longer curved scissors are useful for dissection deep within body cavities. (Figs. 4.3 \200\2234.5) Fig. 4.3 Short and long McKindoe scissors SCISSORS \200\224SUTURE AND DISSECTING1 97 Fig. 4.4 Straight and curved Mayo scissors Fig. 4.5 30cm Metzenbaum/Nelson scissors CHAPTER 4 Surgical instruments, materials, and skills 98 Tissue dissecting forceps Dissecting forceps aid surgical dissection. Delicate structures s uch as bowel, arteries and veins etc. are handled with non-toothed forceps, while more robu st structures can be handled with toothed forceps, for example the skin or abdominal wall. The teeth can be used as a hook with avoidance of tissue damage. (Fig. 4.6) Tissue holding forceps Atraumatic tissue holding forceps, such as Duval and Babcock, can be used to manipulated bowel and visceral structures. Lane and Allis forceps cannot be used t his way as they are relatively traumatic and hence used to hold the skin and abdominal wall . Rampley sponge holders can also be used as tissue forceps such as retracting on the gallb ladder fundus during open cholecystectomy. (Fig. 4.7) TISSUE DISSECTING FORCEPS1 99 Fig. 4.6 Tissue dissecting forceps Fig. 4.7 From top: Rampley, Babcock, Littlewood, Duval, and Allis tissue holding forceps CHAPTER 4 Surgical instruments, materials, and skills 100 Artery forceps Artery forceps vary in size and are either straight or curved. They are used to clamp vascular structures prior to division and ligation. (Fig. 4.8) Fig. 4.8 From top: Mosquito, Criles, 7 inch Spencer Wells, Rochester-Penn, and Moynihan art ery forceps ARTERY FORCEPS1 101 Hand-held retractors Hand-held retractors are used by assistants during operative procedure s in order to provide the surgeon with a clear field of vision of the opera- tive field. (F igs. 4.9 \200\2234.11) Fig. 4.9 CHAPTER 4 Surgical instruments, materials, and skills 102 Fig. 4.10 Fig. 4.11 ARTERY FORCEPS1 103 Self-retaining retractors These allow assisting surgeons to be used for other tasks by retr acting open the surgical wound. (Figs. 4.12 \200\2234.17) Fig. 4.12 Travers self-retaining retractors CHAPTER 4 Surgical instruments, materials, and skills 104 Fig. 4.13 Jolles retractor (thyroid surgery) ARTERY FORCEPS1 105 Fig. 4.14 West retractor Fig. 4.15 Balfour set CHAPTER 4 Surgical instruments, materials, and skills 106 Fig. 4.16 Goligher set Fig. 4.17 Turner Warwick set ARTERY FORCEPS1 107 Bowel clamps Crushing bowel clamps are either curved or straight. Traumatic clamps occlude bowel that will be removed with the resection specimen. Non- crushing bowel clamps atraumat ically occlude bowel that is not resected to prevent spillage of bowel content prior to ana stomosis or stomal formation. (Figs. 4.18 \200\2234.21) Fig. 4.18 Hayes (top) Zachary-Cope (bottom) (closed) Fig. 4.19 Hayes (top) Zachary-Cope (bottom) (open) CHAPTER 4 Surgical instruments, materials, and skills 108 Fig. 4.20 Doyen bowel clamps (closed) Fig. 4.21 Doyen bowel clamps (open) ARTERY FORCEPS1 109 Vascular instruments Fig. 4.22 Satinsky (top) Fig. 4.23 O \200\231Shaughnessy (top) Lancy (bottom) CHAPTER 4 Surgical instruments, materials, and skills 110 Fig. 4.24 Ringed Bulldog (top) Debakey (bottom) ARTERY FORCEPS1 111 Suckers Fig. 4.25 Poole Sucker. Low pressure, internal/external sheath. CHAPTER 4 Surgical instruments, materials, and skills 112 Endoscopic equipment Gastroscopy set Components Light source Water bottle (air feed system) Mouth guard Biopsy forceps Gastroscope \200\224lens tip control air/suction buttons biopsy channel suction/air feed connectors. Light source Water bottle (air feed system) Mouth guard Tip control lens Air-feed connector Biopsy channel Air/suction Suction Biopsy forceps Fig. 4.26 Gastroscopy set ENDOSCOPIC EQUIPMENT1 113 Proctoscopy/sigmoidoscopy set Components Light source Light lead Bellows and eyepiece Biops y forceps Light attachment Proctoscopes (adult and pediatric) Sigmoidoscopes (rigid). Proctoscopes (adult) Light attachment Light source Pediatric Bellows Biopsy forceps Light lead Eyepiece (lens) Fig. 4.27 Proctoscopy/sigmoidoscopy set CHAPTER 4 Surgical instruments, materials, and skills 114 Flexible sigmoidoscopes Components Light source Light connection Suction valve Biopsy force ps Flexible sigmoidoscope \200\224tip control air/suction buttons biopsy channel. Light source Light connection Suction valve Tip control Flexible sigmoidoscope Suction Biopsy channel Air Biopsy forceps Fig. 4.28 Flexible sigmoidoscope ENDOSCOPIC EQUIPMENT1 115 Colonoscope Components Light source Light connection Colonoscope \200\224tip controls water/wash pipe suction valve light connection. Light source Light connection Tip controls Water wash Light connection Suction valve Fig. 4.29 Colonoscope CHAPTER 4 Surgical instruments, materials, and skills 116 Laparoscopic equipment Fig. 4.30 Laparoscope. Monitor (top), light source, Mavigraph (video printer), and VCR Fig. 4.31 Laparoscope. Light cable and camera Fig. 4.32 Camera LAPAROSCOPIC EQUIPMENT1 117 Fig. 4.33 Insulator Fig. 4.34 Endopath. Disposable surgical trochars Fig. 4.35 10mm trochar, Veress needle, Hasson trochar, and \200\230S \200\231 refractors CHAPTER 4 Surgical instruments, materials, and skills 118 Fig. 4.36 5mm instruments Fig. 4.37 5mm grasper Fig. 4.38 Laser fiber (top), laser scalpel, irrigator aspirator and Irrivac Fig. 4.39 Laparoscopic scissors. Designed as either curved, hooked, or straight, there is a variety available LAPAROSCOPIC EQUIPMENT1 119 Fig. 4.40 (a) 10mm claw grasper; (b) 10mm spoon forcep Fig. 4.41 Heater probe CHAPTER 4 Surgical instruments, materials, and skills 120 Anesthesia Video monitor Video monitor Video camera Laser Surgeon First assist Electrocautery Light source insuflator Camera driver Nurse Suction Ring basin stand Foot board Mayo stands ( \227 2) Fig. 4.42 Room set-up (appendicectomy) LAPAROSCOPIC EQUIPMENT1 121 Fig. 4.43 ENDOLOOP ligature with reducer (top), LIGACLIP endoscopic clip applier and clips Anesthesia Video monitor CO2 insulator Argon laser Surgeon 2nd circulator (laser safety officer) 1st circulator (R.N.) Instrument table Camera operator Monitor camera Light source VCR mavigraph Back table Mayo stand Fig. 4.44 Room set-up (cholecystectomy) CHAPTER 4 Surgical instruments, materials, and skills 122 Suture materials Suture materials in surgery can be categorized as absorbable and non- abso rbable and are composed of either natural or synthetic materials. The gauge or caliber are usually expressed using the US Pharmacopeia sizes (USP). USP Diameter (mm) 8/0 0.05 \200\2230.069 7/0 0.07 \200\2230.099 6/0 0.10 \200\2230.14 5/0 0.15 \200\2230.19 4/0 0.20 \200\2230.24 3/0 0.25 \200\2230.29 2/0 0.3 \200\2230.39 0 0.4 \200\2230.49 1 0.5 \200\2230.59 2 0.6 \200\2230.69 3 0.70 \200\2230.79 Absorbable sutures Natural Traditionally, catgut was popular \200\224derived from sheep or cow intestine. Its use has largely been abandoned given the theoretical risk of transmissio n of infections such as new variant Creutzfeld-Jacob disease (CJD) and its unpredictability has virtually excluded its current use. Synthetic Polyglactin (Vicryl), polydioxanone (PDS ) and polyglycolic acid (Dexon) are all absorbable suture materials, Vicryl and Dexon are b raided. They handle, tie and are stronger than catgut. Non-absorbable sutures Natural (silk , cotton) These braided sutures tie and handle well but perpetuate infection by the capilla ry action caused by the braiding. Only silk remains in popular use as synthetic sutures are superior but they do contribute to infection and are best avoided. Synthetic These may be monofilament or braided. Examples include polyproylene (Prolene), polyamide (Nylon), polyte trafluoroethylene (PTFE) and polyester (Dacron). They cause little tissue reaction but are a little more difficult to handle than silk. Their use is common for abdominal wall closure , hernia repair and skin closure. As they are not absorbed they retain their tensile streng th. Suture sinus formation, such as at the site of the knot in abdominal wall closure, are recognized complications of non-absorbable sutures. SUTURE MATERIALS1 123 Stainless steel wire This suture may be mono- or multi-filament, and may be used in cardiot horacic surgery for the closure of median sternotomy wounds. It is very strong but difficul t to handle and rarely leads to sinus formation. Needle types Needles are either straight or curved. Half-circle needles are most com- monly used. Deeper tissues require a larger circle arc. (cid:142)(cid:3) Straight or linear need les are for suturing easily accessible tissues such as skin. (cid:142)(cid:3) Cutting needles are triangular in cross section with the apex of the trian gle in the concavity of the needle. Reverse cutting needles have the apex on the convexity and are less traumatic. They are used for skin, tendons and scarred tissue. (cid:142)(cid:3) Round bodied needles (taper point) are oval or round in cross section. They are used for intestinal and vascular anastomosis and suturing muscle and peri toneum. (cid:142)(cid:3) Round bodied J-shaped needles are useful for closing defects in the abdominal wall such as those created during laparoscopic procedures or inserting synthetic mesh for incisional hernias. The \200\230heel \200\231 of the needle pushes deeper structu res, such as bowel, away to allow safer suturing of the abdomen. (cid:142)(cid:3) Blunt needles are popular as they decrease the risk of needle-stick injuri es. They are commonly used for mass closure of the abdomen. They are, however, more difficu lt to used than sharp needles. CHAPTER 4 Surgical instruments, materials, and skills 124 Knot tying Safe knot tying is fundamental to good surgical practice and one of the first ch allenges faced by the basic surgical trainee. There are a number of ways in which the surgi cal trainee can acquire competence. Exposure to surgical procedures allows the observation of knot tying and initial prac- tice. Local anesthetic minor operation lists are often an e xcellent place to develop basic skills. All of the Royal Colleges of Surgery offer widely a vailable Basic Surgical Skills courses. They are a recognized mandatory part of basic surgi cal training and should be attended as soon as possible during the training program. Principles of knot tying (cid:142)(cid:3) Tie knot firmly so it does not slip. (cid:142)(ci d:3) Carry the knot down to the tissues with the tip of the index fingers and make sure that the strands of the ligature are flat by drawing then in opposite directi ons. This prevents twisting and the knot slipping. (cid:142)(cid:3) Do not use undue force otherwise the knot will cut through the tissue or fracture. (cid:142)(cid:3) Tie knots in anticipation of postoperative tissue swelling to prevent necrosis. (cid:142)(cid:3) Do not clamp the knot to complete your tie. This will weaken the suture, particularly monofilament sutures. (cid:142)(cid:3) Avoid friction or sawing between strands when tying as the suture may weaken. (cid:142)(cid:3) The knot should be as small as possible to exclude foreign material. (cid: 142)(cid:3) Do not add extra knots \200\230to make sure \200\231. Basic knotting techniques Basic surgical trainees should be familiar with the following kno ts: (cid:142)(cid:3) The one-handed reef knot (cid:142)(cid:3) Instrument tying (cid:142)(c id:3) The surgeon \200\231s knot (cid:142)(cid:3) The slip or granny knot (cid:142)(cid:3) The Aberdeen knot. Guidelines for obtaining a fine scar Try to place the incision in Langer \200\231s contour lines. Use atraumatic techniques and avoid tension. Non-absorbable sutures may be removed a s follows: (cid:142)(cid:3) Face and neck: 2 \200\2234 days (cid:142)(cid:3) Scalp: 5 \200 \2237 days (cid:142)(cid:3) Abdomen and chest: 7 \200\22314 days (cid:142)(cid:3) Limbs: 5 \200\22310 days (cid:142)(cid:3) Feet: 10 \200\22314 days. Sutures can be removed earlier t han these times for cosmetic reasons. If removed early additional support to the wound can be facilitated with Steri-strip adhesive skin strips. These may also be used as an alternat ive to skin sutures, particularly in children. Skin clips are an alternative to skin suture s. They have low infection rates and similar cosmetic results. How- ever they are more expe nsive. KNOT TYING1 125 Fig. 4.45(a) With the palms up and the strands running over the index fingers, hold the str ands against your palms with the fourth and fifth fingers. Perform all manipulations with t he thumb, index and third fingers Fig. 4.45(b) Bring the right-hand strand over to make a loop around the left index finger Fig. 4.45(c) Form a pinch with the left thumb and index finger Fig. 4.45(d) Push the left-hand pinch through the loop with the thumb Fig. 4.45(e) Bring the right-hand strand over and grasp it with the pinch Fig. 4.45(f) Push your pinch with the strand through the loop with index finger and grasp t he strand on your side with the right thumb and index fingers CHAPTER 4 Surgical instruments, materials, and skills 126 Fig. 4.45(g) Draw the strands in opposite directions with right hand, crossing over the lef t side Fig. 4.46(a) Hook left thumb pushing the left strand up over the thumb Fig. 4.46(b) Form a loop around the left thumb by bringing the right-hand strand from left side to the right, over the left thumb and left-hand strand Fig. 4.46(c) Form a pinch with the left thumb and index finger Fig. 4.46(d) Push the pinch through the loop with the index finger and grasp the right-hand strand with the pinch KNOT TYING1 127 Fig. 4.46(e) This time, push the pinch with strand through the loop with the left thumb Fig. 4.46(f) Again grasp the strand with the right thumb and third finger and carry the kno t down with the index fingers to complete the square knot Fig 4.47(a) Swing the right-hand strand behind and around the clamp Fig 4.47(b) Grasp the right-hand strand with the left thumb and index finger Fig. 4.47(c) Catch the right-hand strand (black) again with right hand. Now the right-hand strand is crossing over the left-hand strand Fig. 4.47(d) Push the left-hand strand with the left thumb, the tip riding over the left-ha nd strand CHAPTER 4 Surgical instruments, materials, and skills 128 Fig. 4.47(e) Make a loop by bringing the right-hand strand over the thumb, crossing over th e left-hand strand Fig. 4.47(f) Make a pinch with the left index finger and the thumb Fig.4.47(g) Push the pinch through the loop with the index finger and then grasp the right- hand strand with the pinch Fig. 4.47(h) Push the pinch and the strands through the loop with the thumb Fig. 4.47(i) Regrasp the right-hand strand with the right hand and carry down the knot with the index fingers KNOT TYING1 129 Fig. 4.48(a) Make a loop around the left index finger Fig. 4.48(b) Make a pinch with thumb and index finger Fig. 4.48(c) Push the pinch through the loop with the thumb Fig. 4.48(d) Grasp the right-hand strand by the pinch Fig. 4.48(e) Push the pinch with the strand through the loop Fig. 4.48(f) Regrasp the right-hand strand and carry the knot down, with the right hand cro ssing over the left hand CHAPTER 4 Surgical instruments, materials, and skills 130 Fig. 4.49(a) With the right-hand strand rossing under the left, hold the strands with the t humb and index finger. Tie around clamps, with the right-hand strand grasped from under the left Fig. 4.49(b) Place the right third and fourth fingers over the right-hand strand and loop t he left-hand strand around them. After mastering this, you need use only the third finger Fig. 4.49(c) Flex the distal phalanx of the right third finger over the black left strand o f the loop Fig. 4.49(d) Swing the white right strand through the loop with the back of the third finge r Fig. 4.49(e) Pull the white strand through the loop with the right third and fourth fingers Fig. 4.49(f) Carry the knot down with the index fingers and lay the knot flat KNOT TYING1 131 Fig. 4.50(a) Push the right-hand strand up and over the right index finger and bring it ove r to form a loop over the left-hand strand Fig. 4.50(b) Flex the right index finger around the left black strand of the loop Fig. 4.50(c) Swing the right-hand strand with the back of the right index finger and pull i t through the loop with the help of the third finger Fig. 4.50(d) Cross the left-hand strand up and over to the right while right hand pulls tow ards the left Fig. 4.50(e) Carry the knot down with the index fingers and lay it flat CHAPTER 4 Surgical instruments, materials, and skills 132 Surgeon \200\231s or friction knot This knot is used as a tension tie, usually in repairing tendons or approximating the fascial planes. It can also be used when closing skin incisio ns. The steps are described in the illustrations. Fig. 4.51(a) A loop is formed around the left index-thumb pinch Fig. 4.51(b) The pinch is put through the loop and the right-hand strand is grasped by the pinch and pushed through with the left index finger Fig. 4.51(c) The index-thumb pinch is once again put through the loop and the right-hand st rand is again grasped by the pinch and pushed through the loop with the index finger for th e second time KNOT TYING1 133 Fig. 4.51(d) The knot is carried down by the index fingers and kept flat. The knot can be c ompleted with the second half of the two-hand tie The instrument tie This is frequently used when closing skin incisions and also during GI o r vascular anastomosis. Fig. 4.52(a) With the needleholder in the right hand, hold one end of the string with the l eft hand Fig. 4.52(b) Form the first loop around the needleholder by passing it over and then under the left strand Fig. 4.52(c) Pick up the free end with the needleholder and pull it throuth the loop CHAPTER 4 Surgical instruments, materials, and skills 134 Fig. 4.52(d) Lay the knot flat by crossing the left hand over the right Fig. 4.52(e) Make a loop around the needleholder, this time, by pushing it under and then o ver the left-hand strand Fig. 4.52(f) Pick up the free end with the needleholder and pull it through the loop. Lay t he knot flat by pulling on the strands in opposite directions KNOT TYING1 135 Surgical drains The use of surgical drains has always been controversial and opinions vary considerably. Postoperative drainage may be indicated to aid evacua- tion of pus, blood, bi le, or fluid and help abolish dead space or remove anticipated collections. Most drains con sist of latex based material or polyvinylchloride (PVC), silastic and polyurethane polymers . Types Active drains employ suction devices Closed systems These comprise either reusable or disposable systems. The reusable systems provides high pressure suction with a reservoir c apacity but are less commonly use than disposable drains. Disposable drains provide low pre ssure suction (100mmHg) by way of a compressi- ble bottle. The system can be charged and re charged by emptying the bottle, compressing, and reconnecting the drainage tube. Non-return valves should be used to prevent reflux and inward migration of bacteria. Colonization of the reservoir contents can occur. Open systems Sump drains contain an air inlet lumen which prevents blockage by soft tissue. Although more efficient than closed suction systems, the y have the disadvantage of requiring a non-portable suction system and may permit the entry of bacteria although this can be re- duced by filters. Passive drains work by siphonage or gravity. These may also be open or closed. Closed systems drain into a bag by low pressure suction working on the siphon principle. Open systems drain by capillary action or gravity into dressing or stoma bags. Therefore their efficiency depends on the position of the pat ient and the volume and site of the collection. If a fistulous track is necessary to provide a long period of drainage, such as bilary drai nage after exploration of the common bile duct latex drains are preferable as fibrosis is s timulated. Complications (cid:142)(cid:3) Secondary infection (more common with open drains) \200\224t his can be reduced by the presence of non-return valves. (cid:142)(cid:3) Primary hemorrhage at the site of insertion of the drain and secondary hemorrhage if internal vascular structures are damaged via suction or on removal. (cid:142)(cid:3) Pressure or suction necrosis of bowel leading to injury, anastomotic dehiscence, and intra-abdominal sepsis. (cid:142)(cid:3) Migration within or without the body cavity. (cid:142)(cid:3) Blockage is common and can distract from covert hemorrhage or body space fluid collection. The timing of drain removal is not readily definable. In principle they should be removed w hen their purpose is fulfilled. (cid:142)(cid:3) Low daily output \200\224when draining for bile and serous collections. (cid:142)(cid:3) Draining for blood should depreciate, as goo d operative technique will minimize postoperative hemorrhage. However in situations when a drain is placed after bleeding, the change from a bloody fluid to haemoserous with cardiova scular stability should encourage removal. CHAPTER 4 Surgical instruments, materials, and skills 136 (cid:142)(cid:3) The toleration of oral intake, absence of distension, return of bowel sounds, passage of flatus, and bowel motion are indications for removal of drains placed ad jacent to an intestinal anastomosis. (cid:142)(cid:3) Thoracostomy tubes can be removed from the chest when daily out- put is lo w, when there is no further air leak on coughing and a non- swinging fluid level in the clo sed underwater drainage system when treating a pneumothorax, haemothorax or pleural effusio n. KNOT TYING1 137 Preparations for surgery Scrub-up technique The aim of preoperative scrub up is to remove s urface organisms from the hands and the forearms. The technique does not remove deeper orga nisms from the hair follicles or sweat glands, and recolonisation usually occurs within 20 \200\22330min. However modern washing agents such as povidone iodine (Betadine) and chlorhe xidine (Hibiscrub) will kill organ- isms for up to 2 hours after scrubbing. There is no adv antage to exces- sive or lengthy scrubbing, and only nails need scrubbing. Hand and wrist j ewelry should be removed. Three minutes is adequate for the first scrub of the day. Between cases hands can be washed with a spirit solu- tion or rewashed for 1 \200\2232min. Staff w ith an infective lesion of the skin should not be in theater until recovery is complete. (c id:142)(cid:3) Adjust the temperature of the water until acceptable. Lightly wash the hands and forearms. Take a sterile brush, apply washing agent and clean fingernails. (cid:142)(cid:3) Wash hands and forearms for about 2min allowing water to run downward towards the elbows. (cid:142)(cid:3) Dry each hand and forearm separately with disposable towels pro- vided, dry from wrist to forearm. (cid:142)(cid:3) Put on your gown first and then glove your non-dominant hand fol- lowed by dominant. This can be achieved by picking up the inner sleeve of the glove with the finger s of the opposite hand, directly or through the sleeve of the gown, ensuring that the outer (patient side) of the glove is not touched. Punctured gloves Gloves are punctured regularly during surgical procedures, this should be borne in mind particularly for prolonged and contaminated cases and replaced when recognize d. Soiled gowns should likewise be replaced. Shaving Shaving should only occur directly before surgery, ideally on the operat- ing table by an appropriate person. Shaving before this time can cause damage to the epidermis and f olliculitis increasing the risk of infection. Skin preparation Prepare the skin with either Betadine or Chlorhexidine in alcohol. Two app lications are usually made. Operating on mucous membranes should involve removal or debris first then cleaning with normal saline. The eyes should be closed with adhesive tapes for h ead and neck surgery. Drapes The operative field is draped with disposable or non-disposable drapes prior to comm encement of surgery. Disposable drapes are preferable as they are waterproof and avoid the use of towel clips; however they are expensive. CHAPTER 4 Surgical instruments, materials, and skills 138 Abdominal incisions Abdominal incisions should be large enough to permit the intended proce dure to be performed safely and efficiently. Vertical incisions Upper midline This permits access to the stomach, duodenum, gallblad- de r, liver, spleen and transverse colon. The incision may extend from the xiphisternum to the umbilicus and can be extended distally if necessary. It is continued through the skin, sub cutaneous tissue and linea alba to the peritoneum. This is held between artery forceps away from the abdominal contents and then incised with a scalpel. Two fingers are then inserted to allow safe division of the peritoneum and abdominal wall upwards and downwards with sca lpel, point diathermy or dissecting scissors. Lower midline The incision extends from the u mbilicus to the symphysis pubis. This permits access to the infra-colic compartment and pel vis. The bladder should be catheterised prior to incision to avoid injury when full given i ts close relationship to the anterior abdominal wall. Full length midline This incision ext ends from the xiphisternum to the symphysis pubis and is useful for aortic and complex colo rectal procedures. Mass closure This is the technique of choice for closing midline wounds. All layers of the abdominal wall are taken except skin and subcutaneous fat. One or more single or loop sutur es are used with an over and over technique taking at least 1cm bites of abdominal wall 1cm apart, with a ratio of suture to incision length of 1:4 or more. This allows tension free closure and accommodates postoperative tissue oedema. Absorbable sutures such as PDS or non -absorbable such as Prolene or Nylon can be used with blunt needles to avoid needle-stick i njury. The subcutaneous tissue may or may not be closed and skin closed with absorbable or non- absorbable suture or skin clips as for any other abdominal incision. Paramedian incision This incision is in the upper or lower abdomen parallel to and 2cm from the midline. It permits access to the organs of each quadrant of the ab- domen according t o its site but tends to have been replaced by the fast open-close midline. The anterior rec tus sheath is divided and the muscle dissected laterally to expose the posterior sheath. Th is is divided verti- cally, together with the transversalis fascia and peritoneum. The peri to- neum and posterior rectus sheath are closed together in one layer of non-absorbable sut ures followed by the anterior sheath and skin. There is a lower risk of wound dehiscence or incisional hernia if the lateral paramedian approach is used because of the overlying rect us muscle when the wound is closed. ABDOMINAL INCISIONS1 139 Oblique incisions Kocher \200\231s (subcostal) incision This allows access to the contents of the right and left upper quadrants and is particularly indicated for operations on the g all bladder and spleen in patients with a wide costal angle. The incision may extend from t he midline to the lateral edge of the rectus into the oblique muscles. It lies parallel to and about 2 \200\2232.5cm below the costal margin. All tissues are divided in the line of t he incision. Closure is by the mass technique or in layers in the following order: peritone um and posterior sheath together and then anterior sheath (with non- absorbable or delayed absorption sutures, e.g. Prolene, Nylon, or PDS) and skin closure. Rooftop incision This ex posure allows access to the upper abdomen incorporating bilateral subcostal incisions conti nuous below the xiphis- ternum to permit access to the stomach, pancreas, spleen and adrena l glands. Either masse closure or closure in layers of the anterior and posterior rectus sh eath with Prolene, PDS, or Nylon is acceptable. The wound is associated with a sound scar a nd less postoperative pain. Thoracoabdominal incision A left thoracoabdominal incision invo lves the patient positioned on their right side and the use of a double- lumened endotrache al tube. An oblique abdominal incision is extended alone the line of the 8th or 9th rib div iding the intercostals muscles and pleura. This is used for access to the distal esophagus, cardia of the stomach and diaphragm. Closure of the abdomen is as for other oblique incisi ons. The chest is closed by approximating the ribs with strong inter- rupted Prolene suture s over a chest drain. Rutherford-Morrison incision This allows access to the lower ureter, the colon and the iliac arteries. The approach can be trans- or extraperi- toneal. The inci sion extends laterally from just above the anterior supe- rior iliac spine to a point about 2.5cm above the pubic tubercle medially. All tissues are divided in the same line and the inferior epigastric vessels are ligated. The peritoneum can then be reflected anteriorly to access retroperitoneal structures such as the ureter, inferior vena cava, iliac vessels or lumbar sympathetic chain. Gridiron incision This is the traditional appendicectomy incisio n extend- ing obliquely from a point two-thirds of the way along the imaginary line drawn f rom the anterior superior iliac spine to the umbilicus. The incision is made at right angle s to this line. Skin, subcutaneous fat, and fascia are divided in the same line, the extern al oblique, internal oblique, and trans- verses abdominis are either split in the line of t heir fibers or cut to ex- pose the peritoneum, which is then opened between artery forceps. Closure is in layers, with Vicryl to peritoneum and muscular layers. Any doubt over diagnosis is an indication for diagnostic laparoscopy, however, occasionally the preoperative diagnosis of appendicitis is wrong. In this situation the incision can be extended medially and laterally if disease of the terminal ileum or right colon requires r esection. Alterna- tively or for pathologies of the left or upper abdomen the incision shou ld be closed and midline incision performed. CHAPTER 4 Surgical instruments, materials, and skills 140 Transverse incisions Transverse skin crease incisions can be made in Langer \200\231s lines in the upper or lower abdomen. They can be used to approach the gall bladder, stomach, duo denum, aorta, kidneys, right colon, or for defunctioning loop stomas etc. Exposure and drai nage are better. Chest complications (particularly in patients with pre-existing respirator y disease) and postop- erative pain are less common and incisional hernias unusual. Lanz incision This is a right lower-quadrant transverse skin crease incision which gives be tter cosmetic results. It is similar to the gridiron. Pfannenstiel incision This suprapubic transverse incision allows access to the pelvic cavit y predominantly for gynecological purposes. The incision is 8 \200\22312cm long superior to the pubis. It divides skin, fat, external oblique, internal oblique, and transversalis fas cia from one inferior epigastric artery to the other. The rectus abdominis muscles are spli t vertically in the midline for several centimeters to expose the peritoneum, which is then opened between artery forceps. If greater access is required, the rectus may also be divid ed transversely and retracted cranially. ABDOMINAL INCISIONS1 141 Fig. 4.53 Abdominal incisions CHAPTER 4 Surgical instruments, materials, and skills 142 Upper gastrointestinal endoscopy Check list 1 Ensure that the patient is fully prepared, ha s received an adequate explanation, and has given consent. 2 Ensure that the endoscope is working properly. 3 Ensure that the endoscope has been clean ed. Insertion technique Wear gloves during the procedure. Insert a butterfly needle or small ve nflon into a vein on the dorsum of the hand. Spray the fauces with anesthetic. Ask the pati ent to lie in the left lateral position. Insert a mouth guard and administer oxygen with pu lse oximetry with nursing supervision. If requested give the patient sedation with reversal agents readily available. This varies according to preference but midazolam in 1 \200\2232 mg increments usually up to 5 \200\22310mg is appropriate. Hold the instru- ment controls i n the left hand. Insert the tip of the endoscope with the right hand into the mouth. Gently advance the endoscope passing it over the tongue with the tip flexed. When the laryngx and vocal cords are visualized anteriorly the endoscope is directed posteriorly, and ask the p atient to swallow. Do not force the instrument. Inspection of upper GI tract Esophagus Look for webs or carcinoma in the upper third. Gentl y inflate after clearing mucus by suction. The gullet usually distends so that a clear view can be obtained. Look for landmarks like the cardiac impulse. In the lower esophagus check the mucosal folds for inflammation due to oesophagitis and note the distance from the inci sor teeth. Check also for hiatus hernia. Deep inspiration by the patient is helps to identi fy the position of the diaphragm. If there is an obvious lesion pass the biopsy forceps dow n the biopsy channel and take a specimen for histology (preferably brushings for cytology, which is safer). Stomach Follow the lumen at all times. Inflate as required. On entry note obvious abnormalities like abnormal folds, tumors, blood, bile, retained fluids or foods. A spirate excessive fluid to prevent inhalation. Now in- spect the whole lumen, the greater a nd lesser curves, the incisura and roof of the pyloric antrum. The fundus can be visualized at this point by flexing the tip of the instrument by 180(cid:13) (J maneuver). Alternativ ely this can be done after examination of the duodenum if access was convenient earlier. Ca rry out biopsy or CLO test if indicated. Now advance the endoscope to inspect the pylorus. Note its mobility and the presence of deformity or inflammation. Duodenum Enter the duodenu m by keeping the pylorus in the center of your view. The \200\230up-and-down \200\231 cont rol with the left hand assists ad- vancement. Once inside the duodenal cap carry out a full inspection, withdrawing the tip and depressing it to achieve this. To examine the remainde r of the duodenum the endoscope usually has to be rotated 90 to the right using the up-an d-down control to see the lumen. UPPER GASTROINTESTINAL ENDOSCOPY1 143 Withdrawal Re-inspect the lumina of the duodenum, stomach and oe- sophagus on withdrawal by rotating the tip. Aspirate excessive air from each area once you are satisfied with the ex amination. Ensure the patient has appropriate instructions and prescriptions after the proc edure. CHAPTER 4 Surgical instruments, materials, and skills 144 Examination of the anus and rectum Tell the patient what you intend to do. Ask them to lie on their left side with their knees drawn up towards their abdomen and their buttocks at th e edge of the bed. Stand with your left side next to the patient \200\231s back. Action Separate the buttocks and inspect the anus. Note whether there are changes of excori ation, erythema, moistness, or soiling of the perianal skin and underwear. Identify anal ta gs, prolapsed hemorrhoids or peri- anal warts. Digital examination Wear rubber gloves and apply lubricating jelly to the tip of the right index finger. Place the pad of your index finger on the anal orifice poste- riorly and appl y enough pressure to permit entry. At this stage the pa- tient may complain of pain and dis comfort and you may note spasm of the sphincter. This suggests an anal fissure. Do not pers ist with the digital rectal examination. Note if there is a sentinel at the lower end of th e fissure, usually situated posteriorly. Lubrication of the finger with ligno- caine gel ma y permit digital examination. However if there is spasm and pain it is better to examine th e patient under anesthetic. Once the finger is in the anus, change its direction so that the tip \200\230points \200 \231 into the rectum. With the pad of the finger feel the posterior and lateral walls. Are there any abnormalities \200\224mass, ulcer, polyp? Now bend your knees and rotate the finger so that you can feel the anterior rectal wall. Is there a mucosal abnormality? Can you feel the prostate anteriorly in a male patient? Note its consistency. In female patients you can feel the cervix through the anterior wall as a knob-like projection. Note whether movement of the cervix leads to pain or dis- comfort. Proctoscopy The proctoscope is a short instrument consisting of an obturator en- closed in a viewing barrel with a handle and a light source. Action Apply lubricating jelly to the tip of the obturator and press it on to the anal orif ice until it has penetrated. Once the instrument has been com- pletely inserted, remove the obturator, attach the light source and gently but slowly withdraw the instrument. Note the state of the rectal mucosa. Is it pink (normal)? Does it bleed easily? Does it completely fill the barrel (prolapse)? As you withdraw the instrument note whether there are hemorrhoi ds. They can appear as purple projections at the 3, 7, and 11 positions or circumferentiall y. Band or inject them if indicated. Note also whether there are polyps or an anal fissure anteriorly or posteriorly (proctoscopy is usually painful in the presence of a fissure but it may be made possible by applying lubricating jelly containing a local anesthetic.) EXAMINATION OF THE ANUS AND RECTUM1 145 Sigmoidoscopy The sigmoidoscope is a rigid steel or plastic hollow tube about 25 \200\22330 cm in length and up to 2cm in diameter. It comprises an outer hollow tube, an obturator, wh ich is withdrawn after the instrument has been inserted, and a light source, which is fiber -optic in modern instruments. There is an attachment on the lens piece for the insufflation of air to open up the lumen ahead of the instrument. Preparation of patient The patient should have the procedure explained fully and give conse nt. Preparation of the bowel is often unnecessary. A disposable enema may help in cases of difficulty, but sometimes may have the reverse effect. Position The patient lies in the left lateral position with the hips flexed and the buttock s raised. Procedure (cid:142)(cid:3) Carry out a digital examination of the rectum. If it is loaded, defer sigmoidoscopy until the bowel has been prepared with a disposable enema. (cid:142)(cid:3) Lubricate the sigmoidoscope. Disposable plastic sigmoidoscopes are lubricated under running warm tap water. With the obturator in place, introduce the sigmoid oscope gently through the sphincter to about 5cm by pointing it towards the umbilicus.