Surgical Instruments Classification and Techniques"TITLE"Guide to Common Surgical Tools and Procedures" TITLE"Overview of Basic Surgical Procedures and Instrumentation

By
Guy Raveh
Basic Surgical Techniques Topic 2011, Guy Raveh
Topic List:
1. Surgical Deontology.
2. Informed consent.
3. Classification of surgical tool.
4. Cutting instruments.
5. Haemostatic instruments.
6. Grasping Instruments.
7. Retracting instruments.
8. Special instruments.
9. Suturing material.
10. Definitions of operation and reoperation.
11. Definitions of elective, urgent and emergency operation.
12. Indication and contradiction. Absolute and relative indications.
13. Tools' order on the big table.
14. Tools' order on the Sonnenburg table for venous cutdown technique.
15. Tools' order on the Sonnenburg table for skin and muscle incision and closure.
16. Tools' order on the Sonnenburg table for lapratomy.
17. Tools' order on the Sonnenburg table for closure of the abdominal wall.
18. Tools' order on the Sonnenburg table for tracheostomy.
19. Tools' order on the Sonnenburg table for vascular surgery.
20. Tools' order on the Sonnenburg table for intestinal surgery.
21. Surgical needles.
22. Surgical clips. Staplers and their application fields.
23. Absorbable suture materials (classification, fiber characteristic).
24. Non-absorbable suture materials (classification, fiber characteristic).
25. Properties of the ideal suture materials. Reaction index.
26. Suturing and knotting techniques. Techniques of suture removal.
27. Behavioral rules in the operating theatre.
28. Scubbing, Gowning and gloving.
29. Methods of sterilization.
30. Disinfection and isolation of the operative field.
31. Surgical hemostasis.
32. Injection techniques in general (tools, steps); intracutaneus, subcutaneous, intramuscular and
intravenous injections.
33. Technique of blood sampling (Tools, steps, vacutainer tubes).
34. Infusion solutions. Technique of infusion (tools, steps).
35. Steps and instrumentation of venous cutdown technique.
36. Classification of lapratomy (direction, relation to muscles).
37. Median lapratomy (anatomy, operative techniques).
38. paramedian lapratomy (anatomy, operative techniques).
39. Abdominal wound closure in two layers (surgical anatomy).
40. Abdominal wound closure in three layers (surgical anatomy).
41. Wound types and characterization.
42. Basic principles of wound treatment. Main steps of wound healing, wound dressing.
43. Catheter types; catheterization in general.
44. Preparation of venous catheter.
45. Urinary bladder catheterization.
46. Drain in general. Puncture of the abdominal wall and thoracic cavity.
47. Conicotomy (indication, surgical anatomy, operative techniques).
48. Tracheostomy (indication, surgical anatomy, operative techniques).
49. Early and late complications of tracheostomy.
50. Priorities in upper airway obstruction.
51. Basic principles of intestinal surgery.
52. Adhesion problem in abdominal surgery.
53. Basic principles of liver surgery (surgical anatomy, terminology, operative technique).
54. Basic principle of spleen surgery (surgical anatomy, operative technique possibilities of organ
saving surgery).
55. Basic principle of renal surgery (surgical anatomy, operative technique).
56. Basic principle of pancreatic surgery (surgical anatomy, operative technique).
57. Transplantation possibilities of the abdominal parenchymal organs. Historical data.
58. Bioplasts - Definition, types, application fields/
59. Surgical tissue adhesives.
60. Basic principles of vascular surgery.
61. Basic principles of venous and lymphatic surgery.
62. Anastomosis; intestinal and vascular sutures in general.
SurgicalOperative
Techniques
Topic 2011,
Ravehdiscoveries.
instruments.
techniques,
famousGuy
surgeons,
263. SurgicalBasic
64. Differences between lapratomy and laparoscopic interventions
Before you will start, I want to thank to Eran Kalmanovich and Assaf Persitz who
wrote topics in 2003, and I got a lot of help from their topics.
I tried to collect all the information that I thought that it relevant for this test. I know
that it looks a lot, but it is much less than it really seems.
Wish you lots of Good Luck!
Guy
1. Surgical Deontology
Definition: Deontology is the science of professional duties and etiquette.

In this topic you have to talk about what the surgeon MUST do before the operation,
during the operation, and after the operation.
In general there are two types of deontologists
1. Absolute deontologists They believe that some actions are wrong no matter
what consequences follow from them. For example by saying "I will lie",
then their action is wrong, even if some good consequences come out of it.
2. Non-Absolute deontologists They think that their actions are right due to
their consequences. In their case for example, lying might be actually the right
thing to do.
I do have to say that I think that as doctors lying is forbidden no matter what the consequences will be.
So in this case I think that a good example for the absolute\non-absolute deontologists can be given in
the case of Euthanasia (=mercy killing).
By the surgical deontology, the surgeon has to be in good condition both mentally and
physically to give the best treatment. Mentally means that the doctor isn't upset,
nervous etc; and physically means that the doctor is in good shape (e.g. his hands
doesn't shaking), got enough sleep etc.
It is also important to remember that the work of the surgeon doesn't limited to the
time of the operation. It start before the operation where she\he informs the patient
with all the relevant date, such as risks and benefits concerning his\her operation, and
continuing after the operation when the surgeon give the right information of "what
going to happen from now". (for more information please read the next topic about
consult form).
2. Informed consent
In this topic you have to talk about three things

A. What is the informed consent?
B. What does in contain.
C. Special points of it.
A. What is the informed consent?
The informed consent is a form that supplies the patient with the information about
what going on with him. It should be:
Fully informed.
Individual & Private.
Concerning about the state health of the patient.
Based on the last medical knowledge.
Continuous and precise.
Written Form.
When the form is given to the patient, it is important to pay attention to two things
1. His age in case the patient is too young, the form has to be given with
the presence of his legal guardians.
2. Mental state - in case the patient has a mental disability, or other diseases
which affect his memory \ ability to think \ remember (i.e. Alzheimer), it
shouldnt be given to the patient without the appropriate support.
B. What does in contain.
The form should contain the following information
Health state of the patient.
What the intervention type going to be.
The possible complications.
The consequences of refusing to the procedure.
If there is any alternative treatment.
Post-operative care and lifestyle.
C. Special points of the form.
The form has to be:
Objective the doctor shouldn't involve feeling while he\she writes the form.
Real it should give the patient the true information as it contains the medical
state of him, and also in case of a problem, this form can use as a future
document in case of suing against the hospital\doctor.
Detailed and Careful as doctors, we have to pay attention that we don't use
medical terms so it will be simple to the patient to understand his situation.
After the inform consent was given to the patient, he has to make his own decision,
and it is under the responsibility of the surgeon to check if the patient was informed
well before the operation takes place.
3. Classification of surgical tool
The surgical instruments are divided into 5 categorize 1. Cutting instruments. (Topic 4)
2. Haemostatic instruments. (Topic 5)
3. Grasping Instruments. (Topic 6)
4. Retracting instruments. (Topic 7)
5. Special instruments. (Topic 8)
The names of the different instrument can derive from
Their Function.
Their Inventor.
or sometimes "Just because they decided".
Topics 4-8 are talking about the different categories.
(I don't know where you can found them, but we took movies of the different
instruments. So just try to get them somehow)
4. Cutting instruments
We can divide it into two groups Scalpels & Scissors.

Scalpels: (Holding technique Pencil grip)
1. Conventional.
2. Changeable blade.
Scissors:
1. Cooper
2. Mayo
3. Knee
4. Peritoneal.
The Cooper, Mayo & Knee can be of different size and type (blunt/blunt,
Blunt/sharp, Sharp/sharp).
They also can be straight or curved.
5. Haemostatic instruments
Function Stopping of the bleeding.

Characteristic:
Traumatic.
Permanent.
Crushing.
We have 6 of them:
4 Haemostatic clamps:
1. Pean (smooth).
2. Kocher (toothed).
3. Lumnitzer (toothed) "mega Kocher". (remember also in grasping)
4. Mosquitoes.
And
5. Deschamps to go under blood vessels.
6. Diathermy (electro-surgical tools) can do both cutting & coagulation
function.
The Kocher was invited by Theodor Kocher (1841-1917), which gave him
the Nobel Prize.
The Pean & the Kocher can come in different sizes, where the biggest Kocher
actually is the Lumnitzer.
They also can be straight or curved.
6. Grasping Instruments
We can divide it into two groups Forceps & Clamps.

Forceps: (Holding technique Pencil grip)
1. Anatomical (Smooth).
2. Surgical (Toothed).
3. Special
a. Dental.
b. Bayonet-shape.
Clamps:
1. Towel clamps.
2. Backhouse.
3. Doyen.
4. Peritoneal.
5. Lumnitzer (remember also in haemostatic).
7. Retracting instruments
We have to divide it into two groups Manual retractors & Automatic retractors.
Manual retractors:
1. Langenbeck (1 prong).
2. Rake Retractors (2 8 prongs).
3. Deep surgery.
4. Spatula.
5. Skin Hook.
Both the Langenbeck and the Rake Retractors can have a sharp or blunt tip.
Automatic retractors:
1. Finochetto Chest retractor.
2. Gosset Abdominal retractor.
3. Mastoid retractor.
8. Special instruments
This topic is a bit messy. There are many special instruments (Read them all in page 18 in the book,
or under "Special Instruments if they will ever change it)
Vascular clamps:
1. Satinsky.
2. DeBakey.
3. Blalock.
4. Bulldog.
Characteristic (of the vascular clamps):

Temporary.
Atraumatic.
Non-crushing.
Also:
1. Intestinal clamps (with or without rubber).
2. Thyroid clamps.
3. Tongue clamps.
4. Dissector.
5. Amputation saw.
6. Trachea canella \ Luer type.
7. Cartilage knifes.
8. Wire saw (Gigli saw)
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9. Suturing material
Consist of Needle holder, needles, suturing material and clip instruments.
Needles:
1. Skin - or 3/8; Triangular body, sharp tip.
2. Muscle or 5/8; Triangular body, sharp tip.
3. Serosal - ; Round body, sharp tip.
4. Parenchyma - Blunt tip.
Needle holders:
1. Mathieu (conventional).
2. Hegar (atraumatic).
3. Zweifel (atraumatic).
Suture material: (more info please read topics 23-24)

1. Absorbable.
2. Non absorbable.
Can be monofilament, polyfilament or pseudo-monofilament.
Clip instruments:
1. Clip applying forceps.
2. Clip removing forceps.
3. Michel clips.
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10. Definition of operation and reoperation

Operation: Diagnostic or therapeutic intervention with instruments in order to
break or reconstruct the continuity of different tissues.
Re-Operation: Repeated operation is needed soon in order to treat
complications. Multiple operations are possible.
11. Definition of elective, urgent and emergency operation

Elective operation:
The best time is elected in respect of the patient's will.
All rules must be kept.
Risks of the operation are low.
Relative indication (see next topic).
It can be both with medical importance (i.e. angioplasty widening of blood
vessels) and patients will (i.e. plastic surgery).
Urgent operation:
Having the diagnosis, for the safety of the patient, only the most important
preparations must be performed as soon as possible (24-48 hours).
Absolute indication (see next topic).
i.e. Kidney stones, Stomach ulcer, etc
Emergency operation:
The aim is to save the life of the patient.
The operation must be performed without any delay (fetal end is in direct ratio
to the passing time from the beginning of the problem till the end of the
operation!).
Some operative rules may be disregarded (i.e. history of the patient).
We have less information regards the patient.
Vital indication.
i.e. accident.
12. Indication and contradiction. Absolute and relative indications.

Indication - the cause \ reason of the operation (the illness indicates for the
operation).
Contraindication something that might prevent from the operation to take
place (for example a serious heart disease). The problem can be also
something else then a disease; it can be also a state of health or physical
condition. For example for an old patient or an obese patient there might be
some operations where the risk is too high
Absolute indication - if you don't do the operation, the patient will suffer
serious damage in his health, or he even might die.
Relative indication you have to sum up everything you have to look at
the benefit of the operation, the risks of it, and the health status of the patient,
and after doing that, you have to decide.
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13. Tools' order on the big table
13
14-20. Tools' order on the different Sonnenburg tables
First I would like to thank Yogev Hertz for the drawing!

Second, if you ask yourself how to work with this drawing so the white-painted
instruments are the "basic" instruments and by the different colors you can see the
additions that you have to make according to the different tables.
But still I have extra information for Topic 15 Muscle Closure use the muscle needle, Mathieu needle holder, Polyfilament
non-absorbable, or late-absorbable suture material. The diameter of the suture
material usually will be 1/0 - 3/0 and the stitches will be - simple interrupted stitches.
Do the knots on the middle, and cut the surgery material just above the knot.
Skin Closure use the skin needle, Mathieu needle holder, Polyfilament nonabsorbable suture material. The diameter of the suture material will be again 1/0 3/0, and the stitches can be simple interrupted or Donati stitches. This time do the
knots on the side and cut down the suturing material 1 cm above the knot (= Flag).
Topic17
(And I quote "I think that this question is a little bit stupid".)
Few examiners ask here to show the table for lapratomy, the others ask for a Mathieu,
2 surgical forceps and 3 Cooper scissors.
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21. Surgical needles
In general there are two types of needles

Traumatic the sutering material and the needle are not connected (the
ratio beteen the needle and the material isn't 1:1,). Cause higher damage
to the tisse.
Atraumatic the sutering material and the needle are connected (the
ratio beteen the needle and the material is 1:1,). Cause less damage to
the tisse. In this category we also have the double armamentarium,
which has two needles on both of the sides of the sutering material. (use
for vascular surgery).
The niddles have 3 parts Shaft\eye, body and a tip.
The Shaft\eye:
We are talking about shaft when we are talking about atraumatic needle. In this
case the suturing material continues with the needle itself.
We are talking about eye when we are talking about Traumatic needle (also known
as conventional needle). In this case the suturing material doesn't continue with the
needle itself, but it goes into at hole (=eye) in the end of the needle.
The body:
The bodies are the middle portion of the needle (Different body shape
use).
Round (serosa).
Triangular (skin\muscles).
Spatula.
Lancet.
Diamond.
The tip:
It can be
Sharp - to get thru the tissue.
Blunt to avoid hurting the tissue & friable organ (i.e. liver).
The names come from the shape of the needles
Taper Round body, and become sharp towards the tip.
Spatula use mainly for eye sugary (
).
Regular cutting triangular body, cutting edges on the inside.
Reverse cutting triangular body, cutting edges on the outside.
Lastly, the needle can be
Straight.
circle.
5
Skin
/8 circle.
circle.
Muscle
3
/8 circle.
curved.
J shaped.
Holding: 2/3 from the tip (or 1/3 from the shaft\eye).
15
different
22. Surgical clips. Staplers and their application fields.

In the clips we have 2 instruments (for pictures look at topic 9) I.
Clip applying forceps.
II.
Clip removing forceps.
We use the Michel-clips.
The staples can be (invited by Petz Aladar - Hungarian)
Straight.
Curved.
Circular (use in End-to-End anastomosis).
Type of clips
1. For ligation a. Absorbable:
i. Lactomer 9-1.
ii. Polydioxanone.
b. Non Absorbable:
i. Stainless steel.
ii. Titanium.
2. For surgical staplers
a. Surgical staplers.
b. Polysorb stapler.
c. Poly surgiclip.
Use:
Closure of wounds (internal\skin).
Connects pars of lung\intestine.
Side effects:
May interfere with MRI.
16
23-24. Absorbable & non Absorbable suture materials (classification,

fiber characteristic)
Absorbable:
A. Natural
1. Cat gut (animal origin).
2. Collagen (animal origin).
B. Synthetic
1. Polyglycolic acid.
2. Polyglactin 910.
3. Polydiaxanone.
4. Polyglyconate.
5. Lactomer 9-1.
6. Glycomer 631.
7. Glyconate.
8. Polyglecaprone 25.
9. Polyglytone 6211.
10. L-lactid\glycolid.
It dissociates \ abbsorbs by hydrolysis or by proteolyric enzymes.
Time: 10 days to 8 weeks
It uses for internal organs and peritenium.
Complications can cause inflamation.
Non Absorbable:
A. Natural
1. Silk (animal origin).
2. Linen (plant origin).
3. Steel (mineral origin).
B. Synthetic
1. Polyamide.
2. Polyester.
3. Polypropylene.
4. Polytetrafluoroethylen.
5. Polybuteser.
Used in places with constant pressure like heart\bladder, and also in the
skin\vascular surgery.
Cause to a lesser immune response, which means less scaring.
The advantage of synthetic over natural is that the synthetic contains more disinfectant.
Fiber Characteristics:
It can be Monofilament.
Polyfilament:
o Twisted.
o Braided.
Pseudo-Monofilament (It has a polyfilament with a "coat").
17
Advantage of the Pseudo-Monofilament\Monofilament over the Polyfilament material is that they

don't have "drainage effect" when liquid drain from one side to the other, along the material and
increase the risk to inflammation.
It comes in different sizes:

Metric size (use in Europe) 1-0.01 mm (=0.1 metric-10 metric).
USP\British size (use in USA) - 1-0.01 mm (=11/0 USP 6 USP).
The material is kept in a package with the following information:
Brand.
Type.
Color.
Material.
Width.
Length.
Sterilization mode (EO=Ethylene Oxide, Y=gamma).
Date.
Code #.
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25. Properties of the ideal suture materials. Reaction index.

When we are talking about the "ideal suture material" we have to look of it from 3
different points
Physical point:
High tensile strength.
High breaking strength.
Good tying capability.
Good knotting holding security.
High flexibility.
Monofilament.
Surface smoothness.
No cutting or serrating effect.
Easy to sterilize.
Biological point:
Doesn't cause edema.
Doesn't cause allergic reaction.
Not Toxic.
Doesn't have carcinogenic effect.
Minimal drainage effect.
Minimal tissue reaction (R1 ~1) (see next).
Minimal tissue effect.
Minimal adhesion effect.
Chemical point:
Resistance to:
Acids.
Alkalis.
Bacteria.
Enzymes.
Reaction index:
The reaction index is the ratio of the suture material and reaction area (the area which
shows any reaction to the suture material). The lower the value of this ration, the
higher the reaction higher inflammation.
Ri = D
X
Ri Reaction index.
D Diameter of the suture material.
X Diameter of reaction area.
D
X
X
19
26. Suturing and knotting techniques. Techniques of suture removal.

While reading this topic, I suggest go to p.35 or "surgical techniques" to see pictures.
Knotting techniques:
A. Mariner knot (=square knot).
B. Surgical knot (=surgeon's knot).
The advantages of Surgical knot over Mariner is it has more friction and it is
more secure. (and actually this is the only one that we are really going to use)
Suture techniques:
A. Interrupted sutures
1) Simple.
2) "Mattress"
a. Vertical (Donati).
b. Horizontal.
3) Paranchymal
a. U.
b. X.
c. Z.
d. 8.
It uses to close wounds.
If it easy to put another one instead of one who damages\ruin.
B. Continuous suture
1) Simple.
2) Special (locked).
Advantages (of the continuous over simple):
Quicker for doing.
Less material has to be used.
Less places for the infection to arbor.
Disadvantages:
Can cause more damage.
If fail, all the suture has to be replace.
More painful to remove.
General properties:
Start suture from left to right.
Suture towards you.
Suture removal technique:
First, you have to swab the wound and remove the exudates. Then grasp the knot and
gently elevate it. Lastly, cut the suture with scissors where it enters the skin. (If you use
anatomical forceps then hold the suture material but if you use surgical then hold the knot itself.)
21
27. Behavioral rules in the operating theatre
In general I think that this topic is stupid but I suggest you just say all the things that you think
that are not appropriate to do in the room during surgery.
Aim: Preventing contact with microorganisms and make the surgery procedure with
the safest that it can be.
From the moment that you are in the operation theater When you dont use your hands they should be up in the air.
Dont touch anything that is sterile.
Dont rub any part of your body.
Dont run in the operation toom.
These rules are importatnt to all the people who are in the room starting from the
surgeon and ends in the obsorber (i.e. student).
21
28. Scubbing, Gowning and gloving
These are the procedures that we are doing before entering into the operation theater.
The purpose of them is to clean our hands, and to cover our body with isolated cloths.
Before starting with that. We are chance our cloths and shoes with clean ones (can be
also disposable cloths). This include:
1. scrub suite shirt & trousers.
2. theare shoes\sliper & sockes (the shoe cover).
3. surgical cap.
4. surgical face mask (or protective glasses).
A. Scrubbing: the process of removing all the pathogenic agents (microorganisms) from the skin surface of our hands. (Transient flora completely,
Resident flora - partially). Also it reduces the number of the bacterial count in
the deep pores and fixing them.
Requirements:
They have to form a film on the skin.
They mustnt reduce the effect of blood and other tissue fluids.
They mustnt dry the skin
They mustnt cause to any allergy.
Effects:
Bactericidal kill bacteria. (i.e. tubercuoloid)
Virucidal kill viruses (I.e. HBV, HIV)
Fungicidal kill fungi.
Sporocidal kill\destroys spores.
Scrub solutions:
Skinman soft N.
Skinman asept.
Biotensis.
Sterillium.
Desmanol.
Descoderm.
Desderman N.
Spitaderm.
Ditensimed.
The technique:
a. Before entering into the scrubbing room, take off the jewelries and cut your
nails (artificial fingernails) also nail-polish isn't allowed.
b. Wash your hands and forearms with soap and warm ruining water for 1-2 min.
c. Rinse from the hands downward toward the elbow.
d. Rub the antiseptic scrub solution (5 ml) on hands and forearms for about 1
min.
e. Repeat section d for 5 times, where every time you rubbing a little bit less
(first time till the elbow and in the 5th time only rub your hand).
Total length of the scrub is minimum 5 min.
Hands have to be dry in the eng of the scrubbing!
22
B. Gowning:
The gowns are kept in schimmelbusch box. On the gowns there is an indicator tape
which changes its color from yellow to brown. (Brown means it's ready!). (I do have to say
that there is a chance that I'm wrong about the color, so check this!)
You open the schimmelbusch box with something that you have for the leg (have
no idea how to call it), and then you take the gown, handle it from the collar area open it, and put your hands into the sleeves. Then, when you are done, ask from
someone to tie your gown from behind.
C. Gloving:
This is the procedure of putting on the gloves.
Someone who already has his gloves on opens one glove from the outside and you
take your opposite hand to open it (from inside of glove) then you put your hand
inside it. Then that someone will hold the other glove, and you open it again, only this
time you do it from the outside (as you have glove on the hand that you open it with).
When you done with both hands you can fix the gloves so they will be
comfortable not before!
If you want, you can also use talcum can be used dont put too much.
The gloves come in different sizes 6-8 (jump in 0.5).
When you done never put your arms below the waist level.
There is another way that we put the gloves alone. But we dont do that.
2 people worth mentioning:
Ignac Semmelweis(Hungarian) (1818-1865) in1847 invented hands wash with
chloride of lime.
William Stewart Halsted (1852-1922) in 1886 invented the surgical gloves.
29. Methods of sterilization
I think that in this topic probably the best thing is open with why we have to
sterilize. In general the aim of it is to protect the patient from infection by microorganisms and prevent complication. I'm sure that you will find more reasons.
1) Steam autoclaving (atm-oC) for gowns, isolation towels & instruments.
(120 oC, 2.5 atm, 15-30 min).
2) Dry heat (oC): for instruments. (160oC - 2hours or 180oC 1 hour).
3) Gases (using Ethylene Oxide) for gloves, Catheters, tubes.
4) Gamma irradiation - for suture materials, solution, gloves.
5) Cold sterilization (using Glutaraldehyde) for plastic devices, endoscopic
instruments.
23
30. Disinfection and isolation of the operative field
(I know that there is a chance that the first part is not really a part of the topic, but I saw what Kalmanovitch & Persitz wrote, so I
used some of theirs and added what I thought is more important for this topic)
Disinfections are the products which help removing of all the pathogenic microbes.
First, there is disinfection of the operation theater. For this we use compounds like:
Isopropyl alcohol.
Benzalconiumchlorid.
Undecylenacid.
Ethyl-alcohol.
Benzyl alcohol.
Hydrogen peroxide.
Requirements:
Wide range of effectively.
Short reaction time (about 5-10 min.).
Good solubility and penetration ability.
Effective in small concentrations for the micro-organisms.
Doesn't damage the surface.
Doesn't discolor.
Stable.
Doesnt have bad smell.
Economical.
Effects:
In general the disinfection compounds function as detractors or inhibitors of live
infective agents thus their function is:
Bactericidal kill bacteria. (i.e. tubercuoloid)
Virucidal kill viruses (I.e. HBV, HIV)
Fungicidal kill fungi.
Sporocidal kill\destroys spores.
(I think that from this part it is more relevant for this topic)
At the beginning of the operation, we have to disinfect the skin and isolate it.
Skin disinfection:
This process been done in the operative field by the usage of scrubbing of the skin
with disinfectants like
Betadine.
Dodesept.
Kodan.
Cutasept.
Technique:
There are two techniques, where in both you start from the center and work outwards:
Concentric circles.
Stripes on both sides
Repeat for minimum of two times.
It is important to remember NEVER clean same place twice with same pad.
24
Isolation (Also know as draping):

During this procedure we "hide" the patient body besides the site of the operation.
This is done by using few Isolation towels/drapes:
3 large towels:
Have 4
1 for the big table.
folds
2 to cover the sides of the patient's body.
3 small towels:
2 to cover the parts above and below the operative field.
Have 3
folds
1 for disposal material materials that we use during the surgery and it helps
us to check that we didn't forget anything inside the patient (as we can
count).
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31. Surgical Hemostasis
In general homeostasis is the process of prevention of bleeding.

First it is important to understand that there are few types of bleeding, according to
their location
Arterial bleeding the blood is going out with relatively high blood pressure.
Venous bleeding the amount of blood is relative big, but the pace is slower
than the arterial one.
Capillary small bleeding.
Mixed get your best guess yes, it is MIX.
Parenchymal internal bleeding.
There are two methods
1. Temporary method its aim is to give us time to carry the patient to the
hospital in a good condition, with the minor blood lost, and in the hospital to
treat him with the definitive method.
2. Definitive method surgery.
It can be one of these options:
a. Closure of the lumen.
b. Reconstruction of the lumen (vascular surgery).
Temporary method
The treatment is according to the location of the bleeding
I.
Arterial bleeding
Digital pressure central (proximally) from the bleeding site (i.e.
superficial temporal a., facial a., common carotid a., subclavian a, axillary a,
brachial a, abdominal aorta, external iliac a. & femoral a.).
II.
III.
Pressure Bandage application of tamponade.

Tourniquet till disappearing of the peripheral pulsation ( might
cause damage to vessels and nerves)
Clamping the vessel only in case of life saving situation.
Venous bleeding
Only pressure bandage.
Capillary bleeding
Sterile bandage. (It is important to pay attention that in case of hematological
disorders or if that person having an anticoagulant therapy, then this might be the
situation, and he will need more pressure and to be taking to the hospital as
well).
Definitely method
This is done in the hospital
a. Closing of the lumen this is done by the hemostatic instrument (topic 5).
1. Pean.
2. Kocher.
3. Lumnitzer.
4. Mosquitoes.
Don't forget: it is Traumatic, Permanent, and Crushing.
b. Reconstruction of the lumen of the vessel
Here you have to use the vascular clamps from the special instruments (topic 8)
1. Satinsky.
2. DeBakey.
3. Blalock.
4. Bulldog.
Again, don't forget: Temporary, Atraumatic & Non-crushing.
26
We have few methods for closing of the lumen 1. Mechanically

Ligation of vessels.
Suture ligation of vessel.
Ligation in continuity.
Surrounding ligature.
Torsion of vessel (e.g. twisting of the cut end of an artery to arrest
hemorrhage).
Ligation clips.
2. Physical
Electro coagulation.
Laser coagulation.
Ultrasound coagulation.
Thermo coagulation (hot NaCl).
3. Biological
Bioplasts.
4. Chemical
Drugs.
5. Combined methods.
27
32. Injection techniques in general (tools, steps); intracutaneus,

subcutaneous, intramuscular and intravenous injections.
When we are talking about this topic, there are few points that we have to talk about
in each one
1. Where do we do it?
2. When do we use it?
3. Contradictions when we will not use it.
4. Complications.
Intra-cutaneous injection
1. In the dermis level.
We use a relative small angel during injection.
2. We use it for diagnostic purposes cutaneous reaction, allergy reaction
tuberculosis screening and local anesthesia.
3. We will not use that in case of serious dermatopathy (disease of the skin).
4. Complications can be serious local reaction or even necrosis.
Sub-cutaneous injection
1. In the subcutaneous fat level.
We use a 45O angel into a raised skin fold.
2. Administration of slowly absorption drugs (i.e. insulin).
It is important to do this injection in different locations in case of long
treatment.
Intra-muscular injection
1. Into muscles deltoid m., gluteal region or in babies in the thigh region (as the
muscles are still now strong enough) (for the different techniques look at the relevant pages
in the book).
We use an angel of 90.

2. Administration of large volume of mild-acting effect drugs parental drugs.
(Antibiotics, vaccines & analgesics).
3. We will not use that in case of the patient has dermatitis, cellulites, congenital
or contracted hemorrhagic diathesis diseases and also under anticoagulant
treatment.
4. Complications can be vessels lesions, neural lesions, break of the needle or
infection.
Intra-venous injection
1. Into veins I. Superficial veins (basillic v., cephalic v. or medial cubital v.).
II. Central veins (subclavian v. or external jugular v.)
We use angel of 30-45 o.
2. Administration of therapeutic purposes or blood sampling for diagnosis.
4. Complication can be skin infection, hematoma, extraversion and infiltration,
thrombophlebitis (vein inflammation related to a thrombus), thrombosis,
embolisms, clot formation, fever or toxic reactions. Also we have to pay
attention not to administer into artery.
28
Technique
Before starting you have to prepare all the equipment the material that you
are going to inject (check the dates & signature)
Put on gloves.
Ask the patient if he has any known allergies or that he is under any
anticoagulation drugs (aspirin, heparin etc).
Usually use the yellow\green\blue needle.
Then, it doesn't matter what the injection is, in all of them you clean the area
with alcohol pad.
Important to remember to take out the air bubbles!
Intravenous injection
1. Put on the tourniquet.
2. Palpate the vein (Cleaning should be done after this step in this case).
3. Puncture the vein, the hole of needle have to face up in a 15-30o angle.
4. Suck blood to see if you are in the right place.
5. Release the tourniquet.
6. Start injecting.
7. Pull out the needle.
8. Apply pressure on a sterile sponge swap as soon as the needle is out.
In the others, remember the angels Subcutaneous 45o.
Intracutaneous 10-15 o
Intramuscular 90o.
29
33. Technique of blood sampling.
Test
Cap Color
Anticoagulant
Use:
Obtain blood for diagnostic.
Monitor level of components of the blood.
Instruments:
31
Required medium
We have 3 types of blood sampling, according to their location

Put on gloves.
Before starting you have to prepare all the equipment the vacuum tube, the
equipment that you are going to take the blood with (i.e. butterfly\syringe) and
ask the patients for anticoagulant treatment. (The butterfly is in use for old
people or babies).
First, it doesn't matter in which location; in all of them you clean the area with
alcohol pad.
Usually use the yellow\green needle, or blue\colorless for the butterfly.
Venous
Usually is taking from the cephalic v., basilica v., median cubital v. or the
dorsal veins of the hand.
Technique:
1. Put on the tourniquet.
2. Palpate the vein (Cleaning should be done after this step in this case).
3. Puncture the vein, the hole of needle should face up (see picture) in a 30-45o angle.
The needle should be in a sealed shield and with holder.
4. Start taking blood.
5. If you need more than one then chance the tube.
6. After the last one, release of the tourniquet and then pull out the needle.
7. Apply pressure on a sterile sponge swap as soon as the needle is out.
8. Ask patient to flex his elbow.
9. Collect the needle in trash can for dangerous-use equipment.
Arterial
Usually is taking from the radial a., brachial a. or the femoral a.
Before taking we have to do the Allen test. The aim of this test is to see if both
the ulnar artery and the radial artery function well.
Technique: we block one of the blood vessels (ulnar \radial artery) and if we
have chance in the color pale, then we have a problem with the blood flow.
Then repeat the technique of the vein.
Capillary
Is taking from the later pulp of the finger tip.
Use for hematocrit, hemoglobin, glucose or blood gas level.
31
34. Infusion solutions. Technique of infusion (tools, steps)

Tools:
Sterile infusion set (spike, drip-chamber, flexible long with flow regulator and
the injection needle with a covering cap).
Infusion bag\glass bottle it will contain the follow information:
o Infusion solution type (colloid or crystalloid see next).
o Date.
Must be checked before
o Signature.
starting the infusion!
o Drug's content.
Infusion rack.
Infusion-pump (volumetric or syringe infusion-pump).
Infusion solution
Crystalloids aqueous solutions of mineral salts or other water soluble
molecules.
Can be isotonic:
Saline (0.9%, normal salt) solution.
Salsol (sodium chloride) solution
Lactated Ringer's.
Hypotonic:
Dextrose 5%.
or Hypertonic.
Colloids large insoluble molecules such as gelatin to keep the osmotic
pressure.
Can be natural (as albumin) or artificial (as dextran).
In can be isooncotic or hyperoncotic
Use:
Accidents or traumatic injuries.
Burning injuries.
Infections.
Surgical intervention.
Dehydration.
Shock.
In general the procedure is the same as in venous injection, only here we use overneedle catheter (where the needle is in the center and it surrounded by silicon thing).
After putting the catheter inside, take out the needle and leave only the silicon part.
Then we have to fix it and only then we connect the solution.
32
35. Steps and instrumentation of venous cutdown technique.
Venous cutdown is an emergency procedure in which the vein is surgically exposed

and then a cannula is inserted into the vein under direct vision. It is used to get
vascular access in trauma and hypovolemic shock patients when peripheral
cannulation is difficult or impossible. The saphenous vein is commonly used, but
antecubital and femoral vessels are also suitable.
Technique:
Patient position (patients lies on the back, pillow under his shoulders).
Check the infusion solution (expiration date, signature & what the drug is?).
Catheter preparation (without air bubbles) and closure of it.
Instruments preparation (like cutting the catheter that we are going to use).
Skin preparation (disinfection) isolation and orientation (know where the procedure
going to take place).
Skin incision.
Stop the bleeding (with pads if the bleeding isn't too big or with ligatures see topic 31,
under "methods for closing of the lumen").
Exposure of the vein. (Using Mayo scissors and anatomical forceps).

Isolate the vein between ligatures (distal and proximal).
Closure of the distal ligature.
V Shape cut in vein (known as venotomy).
Insert the catheter 6-8 cm. Then suck to see that you are in the right place.
Close the Central ligation.
Connect the infusion and start it.
Fixing the catheter (with a "u stitch")
Close the incision (after the treatment is done).
During the year, we took a movie of it, if you want look it up.
For the people who are interested, before the test we asked one of the teachers if he
can say few words on the different topics, so this is his version for the Technique:
1. First you have to take the patient in modified Jackson position, and see where the
vein is.
2. Than clean the skin and isolate it by textiles.
3. Prepare the cannula (cut down the butterfly needle from the tube, Fill the syringe
near the half of it, take out the air bubbles, connect with the cannula and fill it.
Then close it with a rubbered Pean near the syringe).
4. Make a skin cut perpendicularly to the vein.
5. Stop the bleeding (if there is any).
6. Fix the skin to the textile by Doyens.
7. Prepare the vein by Mayo scissors and anatomical forceps.
8. Take 2 surgical materials under the vein.
9. Close the distal part (distal ligature).
10. Then ask the assistant to elevate the vein.
11. Make the V-shape cut, by knee scissors and dental forceps (on the model just by
sharp - sharp scissors and anatomical forceps, because the rubber-veins wall is
too thick).
33
12. Go in with the cannula about 6-8cm, remove the rubbered pean, suck back (pull
back the cylinder of the syringe) to check if it works or not, wash back, and close
again the cannula by rubbered pean
13. Check the infusion: what is in it, date of expiry, who signed it, if there is any
corpuscular contamination in it. (I suggest saying that in the beginning).
14. Ask the circulating nurse to give you the infusion (only the end of the infusion is
sterile, so you can touch only this).
15. Remove the syringe, connect the infusion.
16. The circulating nurse first removes her rubbered Pean, than you removes yours,
then she will set the speed of the infusion, but you have to say her how fast it
should be.
17. Do the proximal ligature.
18. Take another surgical material under the vein for the U-stitch.
19. Cut down the 2 holding stitch (proximal & distal ligatures) just above the knot.
20. Ask a widow (Mathieu together with skin needle without surg. material).
21. Make the U stitch, make a first half of a surgical knot, take a gaze-ball on it, and
make a normal knot on it (as on your shoes).
22. Close the skin.
23. Make the flying stitch.
34
36. Classification of lapratomies (direction, relation to muscles)
Lapratomy is a surgical procedure involving a large incision through the abdominal

wall to gain access into the abdominal cavity.
Classification:
Microlapratomy: < 4cm abdominal incision.
Modern minilapratomy: 4-6cm abdominal incision.
Standard minilapratomy: 6-8cm abdominal incision.
Conventional lapratomy: > 8cm abdominal incision.
There are two ways of looking at the lapratomy. The first one is according to the
direction of the cut, and the other one is talking about the cut with respect to the
cutting of the muscles.
Incision's directions:
1. Vertical (midline, paramedian, transrectal, pararectal).
2. Transverse (transrectal, Pfannenstiel).
3. Oblique (subcostal\paracostal, McBurney).
4. Combined.
5. Laproscopic.
Relative to cutting of muscles:
1. Incisions not cutting muscles: midline1, paramedian2, pararectal3.
2. Incisions dividing muscles: vertical transrectal4, McBurney incision5,
Pfannenstiel incision6.
3. Incisions cutting muscles: paracostal (kocher)\subcostal7, transverse
transrectal8, inguinal9.
35
37-38. Median and paramedian lapratomy (anatomy, operative

techniques)
Median Lapratomy is in a lapratomy in the midline of the abdominal cavity. During

this procedure you have to pass thru the following structures
1. Skin.
2. Subcutaneous fat tissue.
3. Linea Alba.
4. Transverse fascia.
5. Preperitoneal fat tissue.
6. Parietal peritoneum.
In paramedian Lapratomy, you have to cut the rectus sheet, which is close to the
Linea Alba, and then the muscles deep to the rectus sheet are cut as well.
In Paramedian Lapratomy the chances to damage nerves and blood vessels is

significantly higher.
36
The procedure in both is the same

1. Patients lie on his back.
2. Orientation to know where we are going to do the cut.
3. Skin preparations skin disinfection and isolation of operation field.
4. Skin incision.
5. First isolation line using surgical forceps & doyens.
6. Stop the bleeding with pean & mosquitoes.
7. Cutting of the Linea Alba (in median) or rectus sheet (in paramedian).
8. Second isolation line ("abdominal dressing")
9. Peritoneum incision (surgical forceps or peritoneal clamps scalpel
peritoneal scissors).
10. Second isolation line fixation (surgical forceps, peritoneal clamps & 2 towel
clamps).
11. Exposure of the abdominal cavity (using auto-retractors - Gosset or manual
retractors).
12. Orientation in the abdominal cavity.
To the closure procedure please read topics 39-40.
Last thing that you have to know is that the structures that you will pass in during this
procedure are different in respect to the level of the umbilicus (this line is known as
the arcuate line).
If you are above it (A), then you will have to pass more layers then in case you will be
below it (B), due to the fact that bellow the umbilicus, transverse abdominis fascia
going anterior to the rectus abdominis muscle instead of posterior to it:
37
39-40. Abdominal wound closure in two layers or three layers (surgical

anatomy)
A. At the 2 layers: you close the peritoneum and the muscle layer together. You are
doing so by using a muscle needle and pseudo-monofilament suture material. The
stitches will be simple interrupted stitches, knot in the middle and cutting just
above the knot (dont leave a flag). The second layer is the skin. Here you have to
use skin needle, simple interrupted or Donti stitches, by polyfilament, nonabsorbable suture material. This time you make the knots on one side, cutting 1
cm above the knot (=leaving a flag).
B.
38
At closing in 3 layers: first you close the peritoneum by serosa needle,

monofilament suture material, continuous or simple interrupted stitches cutting
just above the knot (dont leave a flag). The second is the muscle, using muscle
needle, poly-filament suture material, simple interrupted stitches. As before you
will take the knots to the middle, and cut just above the knot (again, dont leave a
flag).. The third layer is the skin, so like above you have to use skin needle,
simple interrupted or Donti stitches, by poly-filament, non-absorbable suture
material. This time you make the knots on one side, cutting 1 cm above the knot
(=leaving a flag.
41. Wound types and characterization
Definition of wound: the wound is a pathological state of the normal continuity of the
tissue and structures by external damage or spontaneously.
There are two classifications - morphological and etiological.
Morphological
1. Superficial wound.
2. Medium deep wound.
3. Deep wound.
Etiological
1. Incised wounds - caused by a clean, sharp-edged object such as a knife, a razor
or a glass splinter.
2. Puncture wounds - caused by an object puncturing the skin, such as a nail or
needle.
3. Shot wounds - caused by a bullet or similar projectile driving into or through
the body. There may be two wounds, one at the site of entry and one at the site
of exit, generally referred to as a "through-and-through."
4. Penetration wounds - caused by an object such as a knife entering and coming
out from the skin.
5. Tear wounds - irregular tear-like wounds caused by some blunt trauma.
6. Burn wounds caused by burning or by touching very hot things.
7. Bite wounds caused by a bite from an animal, highly contaminated and
infected.
While we are talking about properties of the wound, we also have to pay attention to
the next points:
Position of the wound: location on the body.
Number of wounds.
Type of the wound (according to the etiological classification)
Characteristics of the wound necrotic, coated, granulated and epithelisant.
Volume of wound secretion minimal, mild or large quantities.
Type of the secretion serous, purulent, heamo-serous, odorless or putrid.
Characteristics of wound edge under-expanded, edema, cavity formation,
eczema, laceration, dry or wet.
Wound pain Yes\no.
39
42. Basic principles of wound treatment. Main steps of wound healing,

wound dressing.
Wound treatment:
First few days - Careful examination and skin disinfection.
Possible to use local anesthetic which allows a deeper examination of the
wound.
Debridement it is a medical removal of the patient's dead, damaged or
infected tissue to improve the healing potential of the remaining healthy tissue.
Wound closure:
Primary < 6 hours.
Delayed primary <3-8 days.
Early secondary >2 weeks.
Late secondary > 4-8 weeks.
Bandages use bandages can help by preventing contamination of the wound
area, and also it help creating a warm closed area that make the healing
process faster.
Antibiotic therapy\tetanus prophylaxis in case of cutting from dirty objects.
Wound healing:
***it is part there is a chance that I went too much into details, but I will leave you to decide that***
Have 3 main phases:

1. Inflammatory phase:
This is a degenerative phase. Just before the inflammatory phase is initiated,
the clotting cascade takes place in order to obtain hemostasis, or stop blood
loss by way of a fibrin clot. Thereafter, various soluble factors (including
chemokines and cytokines) are released to attract cells that phagocytose
debris, bacteria, and damaged tissue, in addition to releasing signaling
molecules that initiate the proliferative phase of wound healing.
It this phase we can see the inflammation sign
Redness (Rubor).
Swelling (Tumor).
Heat (Calor).
Pain (Dolor).
Loss of function (Functio laesa).
It can be
Necrobiosis - defined as the physiological death of a cell, and can be caused
by certain conditions such as basophilia, erythema or the presence of a tumor.
It is identified both with and without necrosis. It is also known as black
wound.
It can also have heavy exudation, infected and putrid wound. This is called
yellow wound.
2. Granulation phase (proliferative phase):
About two or three days after the wound occurs, fibroblasts begin to enter the
wound site, marking the onset of the proliferative phase even before the
inflammatory phase has ended. As in the other phases of wound healing, steps
in the proliferative phase do not occur in a series but rather partially overlap in
time. It this phase there is proliferation of the blood vessels (angiogenesis) and
collagen deposition. It also known as red wound.
41
3. Epithelization phase:
The formation of granulation tissue in an open wound allows the reepithelialization phase to take place, as epithelial cells migrate across the new
tissue to form a barrier between the wound and the environment. Basal
keratinocytes from the wound edges and dermal appendages such as hair
follicles, sweat glands and sebaceous (oil) glands are the main cells
responsible for the epithelialization phase of wound healing. They advance in
a sheet across the wound site and proliferate at its edges, ceasing movement
when they meet in the middle. In this phase the wound is called pink wound.
Wound dressing:
A dressing is an adjunct used by a person for application to a wound to promote
healing and prevent further harm. A dressing is designed to be in direct contact with
the wound, which makes it different from a bandage, which is primarily used to hold a
dressing in place.
Various types of dressings can be used to accomplish different objectives including:
Controlling the moisture content, so that the wound stays moist or dry.
Protecting the wound from infection.
Removing slough.
Maintaining the optimum pH and temperature to encourage healing.
Types:
1. Covering bandages.
2. Adherent bandages.
3. Pressing bandages.
4. Compressing bandages.
5. Fixing bandages.
41
43. Catheter types; catheterization in general.
Catheter is a tube that can be inserted into a body cavity, duct or vessel. They allow
drainage, injection of fluid access or removal by surgical instruments. The process of
inserting a catheter called catheterization.
Properties of catheters:
Shape.
Thickness.
Material.
Number of lumens.
Holding position.
The different between catheter and cannula is that catheter is longer and
flexible, unlike the cannula which is shorter and more rigid.
Diameter of catheter:
The external diameter is coming in French (F) or Chariere (Ch) units.
Where 0.33 mm = 1F = 1Ch.
Common places:
Blood vessels administration of drugs.
o Veins (external\internal jugular v., subcalvian v. or femoral v.).
o Arteries (radial a., femoral a. or pulmonary a.) -> swan-ganz catheter.
Gastrointestinal tract checking of blood the cavities (peritoneal lavage).
Urogenital tract catheterization of urinary bladder.
In children (newborns) catheterization of the umbilical vessels ("spaghetti"
catheter).
Types:
The catheters can be soft, Medium or hard.
Soft catheters (p. 115 for pictures)
They can be made out of latex, rubber, plastic or silicon (these made of silicon can be
used for longer time 4-6 weeks)
1. Nelaton strait.
2. Thiemann strait and tip in the end.
3. Foley (read more in topic 45) a balloon is situated in the end in order to fix
the catheter in the bladder. It can come with one balloon, two balloons
or three lumens (one for the drainage, one for injection and the other
use to prevent blood clotting formation).
4. Pezzer used after urinary bladder and prostate operation. (Not used
anymore).
5. Malecot.
Medium (mercier) catheters
These catheters made out of silk with special impregnation. They are soft in
body temperature and become rigid at 10oC.
Hard catheters
They made out of metal, plastic or glass. (i.e. kovacs catheter).
42
44. Preparation of venous catheter

This is what you have to do before the venous cutdown.
Materials:
1. One butterfly needle.
2. One Syringe.
3. Fluids.
4. 2 rubbered peans.
5. One infusion.
Technique:
1. Cut down the butterfly needle from the tube by a Cooper scissors, the cutting
line have to be a little bit angled, so it will not cause any damage to the blood
vessel when inserted.
2. Fill the syringe by physiological saline near the half of it.
3. Take out the air bubbles from the syringe.
4. Connect the tube to the syringe (if there is a cap at the end of the tube you
have to remove before it).
5. Fill in the cannula without air bubbles.
6. Close by a rubbered Pean near the syringe.
7. Close by another rubbered Pean just to be sure (this one will be used by the
nurse).
45. Urinary bladder catheterization
In urinary catheterization, a plastic tube, known as a urinary catheter, is gently slid

into a patient's bladder via his\her urethra. Catheterization allows the patient's urine to
drain freely from the bladder for collection, or to inject liquids into the bladder, used
for treatment or diagnosis of bladder conditions.
Types:
Foley catheter (read more in topic 43) - is retained by means of a balloon at the tip
which is inflated with sterile water. The balloons typically come in two
different sizes: 5 cc and 30 cc. They are commonly made in silicon rubber or
natural rubber.
Robinson catheter - flexible catheter used for short term drainage of urine.
Unlike the Foley catheter, it has no balloon on its tip and therefore cannot stay
in place unaided.
Coud catheter - designed with a curved tip that makes it easier to pass
through the curvature of the prostatic urethra.
Technique:
1. Wear sterilized gloves.
2. Preparation of the equipment.
3. Check out the integrity of the retention balloon.
4. Apply the antiseptic on the carton balls and lubricate the distal tip of the
catheter
5. Inject 10-15ml of viscous lidocain (anesthetic material) to the urethra.
6. Hold the penis with your non-dominant hand.
7. Clean the glands with the antiseptic
8. Insert the catheter
9. Inflate the balloon when catheter is inside.
10. Secure the catheter.
11. Connect the collecting bag to the catheter.
43
46. Drain in general. Puncture of the abdominal wall and thoracic

cavity.
Surgical drains are inserted to empty existing fluids and those that might collect later.
If we use them correctly, we can minimize the post-operative complications and help
the healing process of the patient, but in case we don't use it right then in can cause
serious complications!
Through the drainage we can collect:
Blood.
Pus.
Body secretion.
Air.
Introduced fluids.
Types:
1. Rubber wick.
2. Penrose drain (prevent from fluid storage).
3. Redon drain with\without vacuum system.
4. Drain with double lumen.
5. Robinson drain.
6. Easy flow drain.
7. Shirly drain.
8. Sump drain (use suction).
Position:
Subcutaneous.
Sub-fascial and intramuscular.
Extra-\intra- peritoneal.
Pleural cavity.
Abscess, cysts and fistulas.
Most important is to put the drainage in the button of the cavity.
NEVER damage important structures (like vessels \ anastomosis).
Advantages:
Reduce the post-operative complications.
Reduce the infection of the wound.
Help in the healing process.
Disadvantages:
Can cause tissue irritation or even necrosis.
Blood clots may obstruct the drainage.
Can have an opposite effect and cause infection.
Foreign body feeling.
Puncture of the thoracic cavity:
1. Patient is sitting and leaning forward.
2. Disinfect the area (midclavicular line, 4cm below the tip of the scapula at the
upper margin of the rib not to hurt any vessel or nerve),
3. Anesthetize.
4. Insert needle.
5. Once reaching the fluid, take out the needle and attach the syringe.
44
Puncture of the abdominal cavity:

1. Elevate patient to 45 degrees.
2. Disinfect 2cm below the umbilicus or 1/3 from the umbilicus in a line between
the umbilicus and the anterior superior iliac spine.
3. Anesthetize.
4. Pull skin up and insert the needle (use Z technique to prevent fluid leakage
later).
5. Once reached the fluid, take out the needle and attach the syringe.
6. Drain the fluid (<4 L each time), take out the catheter and use pressure
dressing (patient should stay supine for 2-3 hours).
45
47. Conicotomy (indication, surgical anatomy, operative techniques)
A Conicotomy is an incision made through the skin and cricothyroid membrane to

establish a patent airway during certain life-threatening situations, such as airway
obstruction by a foreign body, angioedema, or massive facial trauma. Conicotomy is
nearly always performed as a last resort in cases where tracheal and nasotracheal
intubations are impossible or contraindicated. Conicotomy is easier and quicker to
perform than tracheotomy (see next), does not require manipulation of the cervical
spine, and is associated with fewer complications. However, while Conicotomy may
be life-saving in extreme circumstances, this technique is only intended to be a
temporizing measure until a definitive airway can be established.
This is a procedure that is taking only in case of emergency - emergency operation
(see topic 11). From the moment that a person losses his breathing, we have about 4
minutes before he will have a permanent brain damage.
It is used in case of upper air obstruction. The sign for that can be
1. Dyspnoe Difficulty in breathing, often associated with lung or heart disease
and resulting in shortness of breath.
2. Inspiratory stridor - A crowing sound during the inspiratory phase of
respiration during general anesthesia due to relaxation of the laryngeal
muscles.
3. Cyanosis - Cyanosis is a physical sign causing bluish discoloration of the skin
and mucous membranes.
4. Unconsciousness - a state of complete or partial unawareness or lack of
response to sensory stimuli as a result of hypoxia caused by respiratory
insufficiency or shock.
Causes:
1. Constriction due to edema.
2. Obturation due to foreign body, phlegm (viscous liquid secreted by the mucous
membranes), blood or tumors.
3. Obstruction due to trauma to the larynx or the recurrent laryngeal nerve.
4. Compression due to tumor.
Procedure:
1. Patient lie in Jackson position (pillow under his shoulder)
2. Orientation (looking for the place to do the hole).
3. Skin incision (2 fingers under thyroid cartilage).
4. Cut cricothyroid membrane
5. Keep hole open in any way.
46
48. Tracheostomy (indication, surgical anatomy, operative techniques)

This is among the oldest described surgical procedures; Tracheostomy consists of
making an incision on the anterior aspect of the neck and opening a direct airway
through an incision in the trachea. The resulting stoma can serve independently as an
airway or as a site for a tracheostomy tube to be inserted; this tube allows a person to
breathe without the use of his or her nose or mouth.
This is an elective operation (see topic 11).
--------------------------------------Read from the topic above the addition information-------------------------------------From the moment that a person losses his breathing, we have about 4 minutes before he will have a permanent
brain damage.
It is used in case of upper air obstruction. The sign for that can be
1. Dyspnoe.
2. Inspiratory stridor.
3. Cyanosis.
4. Unconsciousness.
Causes:
1. Constriction.
2. Obturation.
3. Obstruction.
4. Compression.
----------------------------------------------------------------Till here----------------------------------------------------------------
We have 3 options for that Tracheostomy superior above thyroid gland isthmus.
Tracheostomy inferior under isthmus.
Tracheostomy media cut isthmus.
Procedure:
1. Patient lie in Jackson position (pillow bellow the shoulder).
2. Orientation get know the patient's anatomy (SCM muscle, thyroid cartilage cricoid
cartilage thyroid gland clavicles).
3.
4.
5.
6.
7.
Skin disinfection and then Isolation.

Skin incision.
Divide the infra-hyoid muscles (sternohyoid m. & sternothyroid m.)
Cut the pretracheal fascia.
Cut between the 2nd 3rd or 3rd 4th "C" ring (T shape or window incision).
The reason for not cutting from the 1st ring is that in that case we increase
dramatically the risk for stenosis (=narrowing) of the trachea.
8. Check the Luer tube (if the lumen is potent), then insert the tube.
9. Wound closure (muscle and skin stitches)
10. Fixartion of the tube.
47
49. Early and late complications of tracheostomy.
Intraoperative complications:
Injury of nerves:
o Vagus nerve.
o Recurrent laryngeal nerve.
Injury of vessels;
o Common carotid artery.
o Jugular vein.
o Inferior thyroid artery (also known as ima artery).
o Thyroid plexus.
Injury of the esophagus.
"fossa route" to put that in the wrong place (i.e. in esophagus instead
trachea).
Postoperative complications:
Early complications Hematoma.
Bleeding.
Subcutaneous emphysema air in the subcutaneous tissue.
Late complications
Laryngitis sicca infection of the larynx.
Stenosis (stricture) narrowing of the trachea.
Arrosive bleeding when the blood vessels narrowing.
Chondromalacia when the hard "C" cartilages become soft.
48
50. Priorities in upper airway obstruction.
In upper airway obstruction, the main problem is the lack of oxygen supply. We have
about 4 minutes before a brain damage will be form, due to the lack of the oxygen
supply.
Before doing tracheostomy\ Conicotomy, we have a few things that we have to try
doing in a specific order\priorities:
1. Mechanical cleaning making sure the base of the tongue doesn't obstruct
the airway or any other thing that might get stuck in there.
2. Pharyngeal airway (pipe) you put that in the mouth of the patient, and
besides preventing from him to chock, you also prevent from him to swallow
his tongue.
3. Endotracheal tube - a catheter that is inserted into the trachea in order for the
primary purpose of establishing and maintaining a patent airway and to ensure
the adequate exchange of oxygen and carbon dioxide.
4. Needle cricothyroidotomy this is use to increase the air flow for only a
short time as a needle can't really maintain the air supply that a patient need to
survive. But in this case we have time to take the patient to hospital and to do
him tracheostomy.
5. Tracheostomy - more secured procedure. Cleaner. When we have time then
we will do that.
6. Conicotomy - should be made only as emergency. If no possibility to make a
quick tracheostomy.
The Conicotomy which is more dangerous long term and its an emergency
procedure only.
49
51. Basic principles of intestinal surgery

1. Atraumatic try to work as safe as you can. Under the serosa, microhematora
can be formed which will lead to adhesion, and can cause mechanical ileus.
The layers of importance in the intestine are:
Inner a) Mucosa.
b) Sub mucosa the most important layer for intestinal anastomosis.
c) Muscle layer
Outer d) Serosal layer the most sensitive.
2. Wet You have to use physiological saline in room temperature, to keep the
part of the intestine that was taken out from getting dry. A dry intestine, when
put back into the abdomen cavity will result in adhesion formation (see topic52).
At the same time you also have to wet the area that is under the surgery so also
this part will not get dry as well.
3. Clear work- during the lapratomy there is bleeding, so always clean the
abdominal cavity and try to stop the bleeding as fast as possible. Clean the
cavity from all kind of fluid and avoid spilling the bowl content to the cavity
(the juices and the microorganisms that found in the different parts of the
intestine cause a severe infection and inflammation of the abdominal cavity).
4. Opening the bowl Gas may fill the intestine, this may cause a problem to
use an electrical knife due to the chance that by doing so, it can lead to the
explosion of the bowls. So first puncture the bowl with the scalpel and then
cut the rest.
5. Anatomy
a) See the layers of the intestine - The serosal surface is very sensitive and in
order that the healing process will be good, one MUST make sure to
suture serosa to serosa.
b) Blood supply of the intestine the small intestine are supply from the
superior mesenteric artery, which gives branches to the arcuated vessels,
which then branch to the vasa recta that supply the intestine via the mural
trunks. During the surgery, we have to cut the blood supply to the region
that we cut, and to connect the mesentery back again after, to prevent
tearing of it this all process known as skeletozation.
51
6. Suture info
a) Sutures types:
i.
Lembert Seromuscular stitch. Since the serosa is very thin, it is not possible
to suture only the serosa.
ii.
Albert all layers stitch.
b) The sutures can be either:
i.
Interrupted sutures mostly preferred on children (as they are still growing).
ii.
Running sutures (continuous) only in adults.
c) Technique
i.
The sutures need to be free of tension to avoid suture insufficiency.
ii.
The depth of the sutures needs to be around 3 mm.
iii.
The distance between the sutures is around 3 mm.
d) Suture materials
i.
Monofilament or pseudo-monofilament
ii.
Size 3/0 or 4/0
iii.
Needle round body, serosal (atraumatic), and circle.
iv.
Staplers linear or circular.
7. Types of anastomosis
a) End to end - physiologically.
b) End to side.
c) Side to side.
8.
i.
ii.
iii.
iv.
v.
vi.
The techniques
Skeletozation clumping of the arcuate vasa recta.
Use intestinal clumps 3 cm on each side of the place that going to be sutured
Make two "holding" sutures.
Close the posterior wall of the intestine.
Anterior suture of the intestine
Suture of the mesentery.
9.
"Waterproof" Make sure there is no leakage which will lead to infection.
10. Count & make sure check again for bleeding or remains of materials in the
abdominal cavity. Also count the number of instruments and towels. In the test
the teacher asked me if I know how we can see if we forgot any towels in the body on the
patient. She said that there is a blue sign on the towels that can be seen in X-ray.
51
52. Adhesion problem in abdominal surgery
Adhesions are fibrous bands that form between tissues and organs, often as a result of
injury during surgery. They may be thought of as internal scar tissue. It is a natural
part of the bodys healing process after surgery, while some adhesions do not cause
problems, others can prevent tissues and organs from moving freely, sometimes
causing organs to become twisted or pulled from their normal positions.
The Main problem that can occur in intestine operation is adhesion, which can be
caused:
1. Serosa problem there is a damage to the serosa. Can be because we didn't do
the work good enough or due to post-operation complication.
2. Traumatic work we weren't carful enough and we damaged the area.
3. The bowels weren't kept wet enough.
4. There was not a clear work too much blood or fluid.
5. Assistant work Sure Let's blame him . (Have no idea what they really
want... but probably they want us to say that he didn't do his work properly).
6. "Foreign Bodies" we forgot something inside or even the suture material
itself. That is why we have to count and check for all the instruments in the
end.
7. Body temperature if the body's temperature increases it may make the
adhesion process faster.
52
53. Basic principles of liver surgery.
The Decathlons of the liver (Decathlons, according to the department is Parenchymal organs'
surgery):
1. Atraumatic we don't want to damage the structure of the liver. That is why
we will use Parenchymal needle (blunt tip)
2. Capsule the livers capsule, the Glisson capsule, is sometimes not very
strong, sometimes it can hold the stitch and sometimes it cannot.
3. Segments of the liver from the surgical point of view the liver have 8
segments (I-VIII), which are not the same with the anatomical division of the
liver.
a) Segmentectomy 1 segment removed.
b) Bisegmentectomy 2 Segments removed.
c) Trisegmentectomy 3 segments removed.
d) Lobectomy right or left lobe removed.
e) Hemihepatectomy 4 segments removed.
a. Hepatectomy all the liver removed.
The liver has a great ability to regenerate, till about 75% can be regenerate.
I heard that someone was asked about "can you tell me the segments of the liver and
how does it been divided". Do whatever you want with the following information:
Traditional gross anatomy divided the liver into four lobes based on surface features. The falciform
ligament is visible on the front (anterior side) of the liver. This divides the liver into a left anatomical
lobe, and a right anatomical lobe.
If the liver is flipped over, to look at it from behind (the visceral surface), there are two additional
lobes between the right and left. These are the caudate lobe (the more superior) and the quadrate lobe
(the more inferior).
From behind, the lobes are divided up by the ligamentum venosum and ligamentum teres (anything left
of these is the left lobe), the transverse fissure (or porta hepatis) divides the caudate from the quadrate
lobe, and the right sagittal fossa, which the inferior vena cava runs over, separates these two lobes
from the right lobe.
4. Blood supply - The liver is supplied by the portal vein and the hepatic artery,
which then divided further and further to be part of the hepatic triad.
5. Suture info
a) Sutures types :
i. U suture.
ii. Z Suture.
iii. 8 suture.
iv. "Mattress" horizontal\vertical.
b) Surgical techniques
i. Baron's maneuver pressing the hepatodeudonal ligament for 10 minutes.
ii. Pringle maneuver clamping of the hepatodeudonal ligament, and by that
controlling of bleeding.
iii. Finger fracture technique pressing with the finger to look where the
bleeding is coming from.
iv. Cavitron ultrasonic surgical aspirator suction of fluids.
v. Laser.
vi. Ultrasound.
vii. Infra-red.
viii. Staplers
53
c) Needles parenchymal needle.

d) Suture materials absorbable.
6. Bioplasts are preparation made of natural material artificially. They can be
implanted in the body, and they are completely absorbed. They cause little or
no damage to tissue. The bioplast have haemostatic effect.
7. Surgical tissue adhesive these make immediate and permanent connection
between wound edges.
8. Juice problem in case of the liver is the bile, which can leak and
contaminate the abdominal cavity.
54
54-56. Basic principle of spleen, renal and pancreas (surgical anatomy,

operative technique, + possibilities of organ saving surgery (only spleen))
Atraumatic
Capsule
Segments
Blood
supply
Spleen
Kidney
Pancreases
Working atrumaticly to prevent further damage
Very thin and Have three capsules:
Thin capsule
sensitive.
Proper capsule
Very hard to
located on the
handle.
surface of the
kidney. It is made
of strong
connective tissue
fibers, but they can
pale off easily.
Fatty capsule
surrounds the
kidney. Expand
into the renal
sinuses as well.
Renal fascia outer
most layer. It is the
connective tissue
fascia of the
kidney.
Usually 2, but
5 segments apical,
4 segments head,
sometime can
lower, upper, middle
body, tail and neck.
also be 3.
and posterior.
Via the
Via renal artery
Anterior &
splenic artery
(from abdominal
posterior superior
(from the
aorta).
gastrodeudonal &
pancreaticodeudonal
celiac trunk).
(from celiac trunk)
Anterior &
posterior inferior
pancreaticodeudonal
(From superior
mesentery artery)
Inferior, caudal
and dorsal
pancreatic arteries
(from the splenic
artery)
Moving and
holding
relation of
the traction
and Blood
Pressure
55
At the hilum of the kidney

there is a ganglion
(ganglion Stellatum) so if
you pull the hilum the
blood pressure falls down,
that's why you have to
infiltrate the territory of
this ganglion by local
anesthetics before the
operation.
Suture info
a) Sutures types :
i.
U suture.
ii.
Z Suture.
iii.
8 suture.
iv.
Mattress horizontal\vertical.
b) Surgical techniques
i.
Cavitron ultrasonic surgical aspirator suction of fluids.
ii.
Laser.
iii.
Ultrasound.
iv.
Infra-red.
c) Needles serosal needle.
d) Suture materials absorbable, monofilament.
Bioplast &
tissue
adhesives
Juice
problems
Must be used
Can be used
Must be used
Bleeding problem
Urine can escape.
Pancreatic juice can

escape.
Important thing: don't forget to mention in the case of the spleen partial resection of
the spleen it is possible that it will regenerate, and also that it is possible to make autotransplantation of the spleen after trauma to it.
56
57. Transplantation possibilities of the abdominal parenchymal organs.

Historical data
Pioneering work in the surgical technique of transplantation was made in the early
1900s by the French surgeon Alexis Carrel, with Charles Guthrie, with the
transplantation of arteries or veins. Their skillful anastomosis operations, the new
suturing techniques, laid the groundwork for later transplant surgery and won Carrel
the 1912 Nobel Prize in Physiology or Medicine. From 1902 Carrel performed
transplant experiments on dogs. Surgically successful in moving kidneys, hearts and
spleens, he was one of the first to identify the problem of rejection, which remained
insurmountable for decades.
The first attempted human deceased-donor transplant was performed by the Ukrainian
surgeon Yu Yu Voronoy in the 1930s; rejection resulted in failure. Joseph Murray and
J. Hartwell Harrison, M.D. performed the first successful transplant, a kidney
transplant between identical twins, in 1954, successful because no
immunosuppressant was necessary in genetically identical twins.
Timeline of successful parenchymal transplants:
1954: First successful kidney transplant by Joseph Murray (Boston, U.S.A.).
1966: First successful pancreas transplant by Richard Lillehei and William
Kelly (Minnesota, U.S.A.).
1967: First successful liver transplant by Thomas Starzl (Denver, U.S.A.)
1995: First successful laparoscopic live-donor nephrectomy by Lloyd Ratner
and Louis Kavoussi (Baltimore, U.S.A.).
1998: First successful live-donor partial pancreas transplant by David
Sutherland (Minnesota, U.S.A.).
57
58. Bioplasts. Definition, types, application fields.
Preparations made of natural materials artificially implanted in the body. As they

absorb completely, they are causing minimal or no damage to tissue.
Bioplasts are made of one of the following material:
1. Fibrin.
2. Gelatin.
3. Oxidized cellolose.
4. Collagen.
5. Collagen + fibrin.
6. Garamycin.
Advantages:
Good haemostatic effect.
Absorbable.
Minimal tissue reaction.
No antigen effect.
No toxic effect.
Easy to form or to cut.
Easy to handle.
Form good conditions for wound healing.
Uses:
58
Surgery of parenchymal organs.

Management of Oozing bleeding.
Securing of stitches.
Covering of resection surfaces.
Secure of anastomosis.
Vascular surgery and GI surgery.
Operation of brain vascular aneurysm
Dental interventions and oral surgery.
Most of the time I tried not to put pages from the department, but this time I found it
hard to organize it well for you, so
59
59. Surgical tissue adhesives
Materials that make immediate and permanent connection between the wound
edges.
In recent years, topical cyanoacrylate adhesives ("liquid stitches"), also known as
super glue; have been used in combination with, or as an alternative to, sutures in
wound closure. The adhesive remains liquid until exposed to water or watercontaining substances/tissue, after which it cures (polymerizes) and forms a flexible
film that bonds to the underlying surface. The tissue adhesive has been shown to act
as a barrier to microbial penetration as long as the adhesive film remains intact.
Limitations of tissue adhesives include contraindications to use near the eyes and a
mild learning curve on correct usage.
Skin glues like Histoacryl were the first medical grade tissue adhesives to be used.
These worked well but had the disadvantage of having to be stored in the refrigerator,
were exothermic so they stung the patient, and the bond was brittle. Nowadays, after
changing the chemical structure they being more flexible, making a stronger bond,
and being easier to use.
Types:
1. Gelatin-resorcine-formaldehyde (GRF) adhere in about 2 min.
2. Cyanoacrylate (histoacryl blue) most in use.
3. Fibrin (tissucol, beriplast).
Advantages:
Secure joint of wound edges application.
Good conditions for wound healing.
Good haemostatic effect.
Absorbable.
Minimal tissue resection.
Minimal functional parenchymal loss.
61
60. Basic principles of vascular surgery.

1. Types:
a) Arterial surgery.
b) Venous surgery.
c) Lymphatic surgery.
2. Anatomy
a) Intima sensitive & vulnerable. Very thin.
b) Media mix layer of elastic and muscle.
Variable in thickness.
c) Adventitia connective tissue and contains
nerves. It is necessary to clear it during the
surgery.
Vein\lymph vessels have thinner wall then
artery, and also more elastic, where the artery is
more muscular.
3. Suture info a) Intima to Intima all layers has to be suture.
b) Suture type
i.
Interrupted.
ii.
Continues never in children as their blood vessels still growing.
c) Material
Non absorbable.
Monofilament.
5/0-8/0 or microsurgical 11/0.
d) Needle
i.
Atraumatic, round bodies, 1/2 circle.
ii.
Double armamentarium.
4. Vascular clumps
i.
Satinsky.
ii.
DeBakey.
iii. Blalock.
iv.
Bulldog.
Temporary, Atraumatic and Non-crushing.
5. Anastomosis types
i.
End to End physiologically.
ii.
End to Side used in transplantation.
iii. Side to Side - in liver cirrhosis
(portocaval anastomosis).
6. Operative technique
i.
Skin incision parallel or perpendicular.
ii.
Preparations keep the vessel in the hand; clump both sides of the vessel
with vascular clamps (Satinsky, DeBakey or Blalock).
iii. Clump small branches with bulldog
61
iv.
Suture by the triangular technique (invented by Alexis Carrel who got

Nobel Prize in 1912. The technique suggests forming a triangle with 3
suture materials and then stretching it together with the blood vessel at the
same time. In that way the chances to getting the same size of vessels and
symmetrical suturing has the best chance to occur.
If we will do that right we suppose to get a new vessel which is
isodimentional which means that it have the same size of the old blood
vessel. But if not it can be
Negative disproportion the size of the new vessel is smaller than it
supposes to be.
Or positive disproportion the side of the new vessel is larger than it
suppose to be.
7. Prosthesis or grafts
i.
Patch technique closure of small holes.
ii.
Bypass to put another vessel instead parallel to a blocked one.
iii. Resection and Anastomosis to cut the damaged area and then reconnect.
We can use also graft that is taking mostly from the Great saphenous vein in
the leg.
8. Anticoagulant therapy
Local or general therapy should be used in order to avoid complications.
62
61. Basic principles of venous and lymphatic surgery.

Again, a problematic topic Sorry friends, only a picture
63
62. Anastomosis; intestinal and vascular sutures in general.
Anastomosis is the joining of two hollow organs (viscus), usually to restore continuity
after resection, or to bypass an unrespectable disease process. Historically such
procedures were performed with suture material, but increasingly mechanical staplers
and biological glues are employed. While an anastomosis may be end-to-end, equally
it could be performed side-to-side or end-to-side depending on the circumstances of
the required reconstruction or bypass. The term re-anastomosis is also used to
describe a surgical reconnection usually reversing a prior surgery to disconnect an
anatomical anastomosis, e.g. tubal reversal after tubal ligation.
Anastomosises are typically performed on:
Blood vessels: Arteries, veins and lymph. Most vascular procedures, including
all arterial bypass operations (e.g. coronary artery bypass), aneurysmectomy of
any type, and all solid organ transplants require vascular anastomosis. An
anastomosis connecting an artery to a vein is also used to create an
arteriovenous fistula (abnormal connection or passageway between
two epithelium-lined organs or vessels that normally do not connect) as an
access for hemodialysis.
Gastrointestinal tract: Esophagus, stomach, small bowel, large bowel, bile
ducts, and pancreas. Virtually all elective resections of gastrointestinal organs
are followed by anastomosis to restore continuity; pancreaticoduodenectomy
is considered a massive operation, in part, because it requires three separate
anastomosis (stomach, biliary tract and pancreas to small bowel). Bypass
operations on the GI tract, once rarely performed, are the cornerstone of
bariatric surgery. The widespread use of mechanical suturing devices (linear
and circular staplers) changed the face of gastrointestinal surgery.
64
63. Surgical instruments. Operative techniques, famous surgeons,

discoveries.
If you want to add this topic to the weird topic list so you are free doing so.
I collected all the famous people that did something in the book. I suggest to choose
few (3-5) and to learn a little bit more on them - learn very basic things.
Nobel Prize winners:
Theodor Kocher (1841-1917) invented the Kocher scissors. Got the Nobel
Prize in 1909.
Alexis Carrel (1874-1944) invented the triangular technique (in vascular
surgery). Got the Nobel Prize in 1912.
Hungarians inventors:
Sandor Lumniezer (1821-1892) - invented the Lumniezer scissors.
Petz Alar (1888-1956) invented the surgical staplers.
Ignaz Philip Semmelweis (1818 -1865) invented the hand wash with
chloride lime (1847).
The rest:
Sir astley Cooper (1768-1841) - invented the Cooper scissors.
Charels Horace Mayo (1865-1939) invented the Mayo scissors.
Emile Jules Pean (1830-1839) - invented the Pean clamps.
Lord Joseph Lister (1827 -1912) invented the hand wash with soap and
carbolic acid.
Alfred Blalock (1899-1964) invented the Blalock vascular clumps.
William Stewart Halsted (1852-1922) invented the surgical gloves (1886).
65
64. Differences between lapratomy and laparoscopic interventions.
Laparoscopic surgery is a modern surgical technique in which operations mainly in

the abdomen are performed through small incisions (usually 0.51.5 cm) as compared
to the larger incisions needed in lapratomy (for more info go to topics 36-40). This procedure is
done by insertion of small instruments and a camera into the area, and operating by
watching the inside with a screen.
Places of us Abdominal cavity.
Pelvic cavity.
Same as in lapratomy.
Place of incision
The hole is made in the abdominal or thoracic cavity
Bellow the umbilicus.
Bellow the xyphoid process.
Bellow ribs.
Next to the iliac spine.
Compared with lapratomy which can be done in many locations.
Advantages (compare to lapratomy)
Less pain.
Less hemorrhaging.
Shorter recovery time.
Instruments
Monitor.
Video camera.
Cold light source.
Insuffation (insertion of CO2 into the body).
and also
Veres needle.
Trocars.
Dissectors.
Scissors.
Hooks.
Clip applying forceps.
It can be used by robots.
Risks
Intestinal damage.
Hypothermia due to the CO2 Gas.
Use
Fixing herniations.
Removal of appendix.
Cholecystectomy is (removal of the gallbladder).
Diagnostic purposes.
66

Surgical Instruments Classification and Techniques"TITLE"Guide to Common Surgical Tools and Procedures" TITLE"Overview of Basic Surgical Procedures and Instrumentation

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Basic Surgical Techniques Topic 2011, Guy Raveh

Definition: Deontology is the science of professional duties and etiquette.

Basic Surgical Techniques Topic 2011, Guy Raveh

In this topic you have to talk about three things

Basic Surgical Techniques Topic 2011, Guy Raveh

3. Classification of surgical tool

We can divide it into two groups Scalpels & Scissors.

Basic Surgical Techniques Topic 2011, Guy Raveh

Basic Surgical Techniques Topic 2011, Guy Raveh

Function Stopping of the bleeding.

Basic Surgical Techniques Topic 2011, Guy Raveh

We can divide it into two groups Forceps & Clamps.

Basic Surgical Techniques Topic 2011, Guy Raveh

Basic Surgical Techniques Topic 2011, Guy Raveh

Characteristic (of the vascular clamps):

Basic Surgical Techniques Topic 2011, Guy Raveh

Suture material: (more info please read topics 23-24)

Basic Surgical Techniques Topic 2011, Guy Raveh

10. Definition of operation and reoperation

11. Definition of elective, urgent and emergency operation

12. Indication and contradiction. Absolute and relative indications.

Basic Surgical Techniques Topic 2011, Guy Raveh

13. Tools' order on the big table

Basic Surgical Techniques Topic 2011, Guy Raveh

14-20. Tools' order on the different Sonnenburg tables

First I would like to thank Yogev Hertz for the drawing!

Basic Surgical Techniques Topic 2011, Guy Raveh

21. Surgical needles

In general there are two types of needles

Basic Surgical Techniques Topic 2011, Guy Raveh

22. Surgical clips. Staplers and their application fields.

Basic Surgical Techniques Topic 2011, Guy Raveh

23-24. Absorbable & non Absorbable suture materials (classification,

Basic Surgical Techniques Topic 2011, Guy Raveh

Advantage of the Pseudo-Monofilament\Monofilament over the Polyfilament material is that they

It comes in different sizes:

Basic Surgical Techniques Topic 2011, Guy Raveh

25. Properties of the ideal suture materials. Reaction index.

Basic Surgical Techniques Topic 2011, Guy Raveh

26. Suturing and knotting techniques. Techniques of suture removal.

Basic Surgical Techniques Topic 2011, Guy Raveh

27. Behavioral rules in the operating theatre

Basic Surgical Techniques Topic 2011, Guy Raveh

28. Scubbing, Gowning and gloving

Basic Surgical Techniques Topic 2011, Guy Raveh

29. Methods of sterilization

Basic Surgical Techniques Topic 2011, Guy Raveh

30. Disinfection and isolation of the operative field

Basic Surgical Techniques Topic 2011, Guy Raveh

Isolation (Also know as draping):

Basic Surgical Techniques Topic 2011, Guy Raveh

31. Surgical Hemostasis

In general homeostasis is the process of prevention of bleeding.

Pressure Bandage application of tamponade.

Basic Surgical Techniques Topic 2011, Guy Raveh

We have few methods for closing of the lumen 1. Mechanically

Basic Surgical Techniques Topic 2011, Guy Raveh

32. Injection techniques in general (tools, steps); intracutaneus,

We use an angel of 90.

Basic Surgical Techniques Topic 2011, Guy Raveh

Basic Surgical Techniques Topic 2011, Guy Raveh

33. Technique of blood sampling.