Basic Surgery

Dr.Ali Alhumood
2010
aliabh2006@hotmail.com
Forceps
 Forceps
• Forceps: consist of two tines held together at
one end with a spring device that holds the tines
open. Forceps can be either tissue or dressing
forceps.
• Dressing forceps have smooth or smoothly
serrated tips.
• Tissue forceps have teeth to grip tissue. Many
forceps bear the name of the originator of the
design, such as Adson tissue forceps.
Rat Tooth: A Tissue Forceps

• Interdigitating
teeth hold
tissue without
slipping.
• Used to hold
skin/dense
tissue.
 Adson Tissue Forceps
• Small serrated
teeth on edge of
tips.
• The Adsons tissue
forceps has
delicate serrated
tips designed for
light, careful
handling of tissue.
 Allis: An Intestinal Tissue Forceps

• Interdigitating
short teeth to
grasp and hold
bowel or tissue.
• Slightly
traumatic, use
to hold
intestine, fascia
and skin.
 Babcock: An Intestinal Tissue Forceps

• More delicate that

Allis, less directly
traumatic.
• Broad, flared ends
with smooth tips.
• Used to
atraumatically hold
viscera (bowel and
bladder).
 Sponge Forceps
• Sponge forceps
can be straight or
curved.
• Sponge forceps
can have smooth
or serrated jaws.
• Used to
atraumatically hold
viscera (bowel and
bladder).
Towel clamps secure drapes to a patient's
skin. They may also be used to hold tissue.

Backhaus Towel
Clamp
• Locking forceps
with curved,
pointed tips.
 Hemostatic forceps: Hinged (locking) Forceps. Many
hemostatic forceps bear the name of the designer (Kelly,
Holstead, Crile). They are used to clamp and hold blood
vessels.
Classification by size and shape and size of
tips

• Hemostatic
forceps and
hemostats may be
curved or straight.
 Kelly Hemostatic Forceps and
Mosquito Hemostats
• Both are transversely
serrated.
• Mosquito hemostats
(A) are more delicate
than Kelly hemostatic
forceps (B).
 Comparison of Kelly and Mosquito
tips
• Mosquito hemostats (A) have a smaller,
finer tip.
 Carmalt

• Heavier than Kelly.

• Preferred for
clamping of ovarian
pedicals during an
ovariohysterectomy
surgery because
the serrations run
longitudinally.
Clamping an Artery Using a Kelly and a
Carmalt Hemostat
 intestinal forceps
Doyen Intestinal
Forceps
• Doyen intestinal forceps
are non-crushing
intestinal occluding
forceps with longitudinal
serrations.
• Used to temporarily
occlude lumen of
bowel.
 Payr Pylorus Clamps
• Payr pylorus clamp
is a crushing
intestinal
instrument.
• Used to occlude
the end of bowel to
be resected.
Self Retaining Retractor
 Weitlaner

• Ends can be
blunt or sharp.
• Has rake tips.
• Ratchet to hold
tissue apart.
 Gelpi
• Has single point tips.
• Ratchet to hold tissue apart.
Handle Held Retractor
 Senn
• Blades at each end.
• Blades can be blunt (delicate) or sharp (more
traumatic, used for fascia).
 Hohman
• Levers tissue away from bone during
orthopedic procedures.
Instrument Handling
 Scissors and Hemostats:
• The thumb and ring finger are inserted into the rings of the scissors
while the index and middle finger are used to guide the instrument.
• The instrument should remain at the tips of the fingers for maximum
control.
• This is the wrong way to hold the
scissors. The ring finger should be
inserted into the ring.
• This is also the wrong way to hold the
scissors. The tips of the scissors should
be pointing upwards.
 Thumb Forceps:
• Thumb forceps are held like a pencil.
• Thumb Forceps are not called 'tweezers'.
• Thumb Forceps are not held like a knife.
 Scalpels:
• The scalpel is held with thumb, middle and ring finger
while the index finger is placed on the upper edge to help
guide the scalpel.
• Long gentle cutting strokes are less traumatic to tissue
than short chopping motions.
• The scalpel should never be used in a
"stabbing" motion.
Blades
#10 is the most commonly used scalpel
blade.
#15 is a smaller version of #10, and is
used in for more delicate incisions.
• Blades #11 is pointed and is used in
arthroscopic procedures (stab incisions).
• Blade #12 is hooked and is used to
remove sutures and declawing.
• Blade #22 and #23 are larger and used
primarily in large animals
Selection of Appropriate
Antiseptic
 Isopropyl Alcohol (70%)
• ADVANTAGES:
1. Causes protein
denaturation, cell lysis,
and metabolic
interruption.
2. Degreases the skin.
• DISADVANTAGES:
1. Ineffective against
bacterial spores and
poorly effective against
viruses and fungi.
 Chlorhexidine Gluconate (Nolvasan)
• ADVANTAGES:
- Rapid action.
- Residual activity is enhanced by
repeated use.
- Less susceptible to organic
inactivation than providone
iodine.
• DISADVANTAGES:
- Occasional skin sensitivity.
- Inactive against bacterial spores
- Activity against viruses and
fungi is variable and
inconsistent
 Iodophors: Iodine complexed with an
organic substrate.

• ADVANTAGES:
- Bactericidal, viricidal, and fungicidal.
• DISADVANTAGES:
- Occasional skin sensitivity.
- Partially inactivated by organic debris.
- Less residual activity than chlorhexidine.
- Poor sporicidal activity.
 USES
• USES:
- Supplies a film-forming solution of
iodophor and isopropyl alcohol for a final
skin prep.
- Solution is contained within an applicator
which speeds up the prep process.
- Solution provides long-lasting, fast, broad-
spectrum antimicrobial activity.
Povidone Iodine - Betadine
DuraPrep
 Hexachlorophene: a Phenol
Derivative
• ACTION: Disrupts
cell walls, precipitates
cellular proteins.
• DISADVANTAGES:
- NOT USED:
Neurotoxic.
- Slow onset of action.

Phisohex
 Antiseptics Handout

• Antiseptic -- Agent applied to living tissue

• Disinfectant -- Agent applied to inanimate
surface
A. Chlorhexidine Gluconate, 4% wv -
HibitaneR, SolvahexTM, Clenz 4
Chlorhexidine Acetate and Diacetate, 2%
- Nolvasan:
1. Broadest spectrum.
2. Better residual activity than iodophors.
3. Occasional skin sensitivity (mucous
membranes).
 B. Iodophors BetadineR, DuraprepR

1. Excellent spectrum, contains iodine.

2. Less residual activity than Chlorhexidine.
3. Partially inactivated by organic debris.
4. Occasional skin sensitivity.
 C. Isopropyl Alcohol 70% (or Ethyl Alcohol
90%)

1. Protein coagulant
2. Degreases skin
3. Ineffective against spores
 Hexachlorophene PhisohexR (no longer
recommended)

1. Very potent against Gram positive

bacteria (e.g., Staphylococcus).
2. Poor effect against enteric bacteria
(Gram negative).
3. Inactivated by organic debris and alcohol
4. Long residual action.
Steam Sterilization:
Autoclaving
 Autoclave
• An autoclave is a self
locking machine that
sterilizes with steam under
pressure.
• Sterilization is achieved by
the high temperature that
steam under pressure can
reach.
• The high pressure also
ensures saturation of
wrapped surgical packs.
 Autoclave Temperature (F) Pressure (PSI) )Time (min
Settings

General Wrapped 250 20 30

Items

250 20 30
Bottled Solutions

270 30 4-7
'Flashing'
 Preparation for sterilization
• All instruments must be
double wrapped in linen or
special paper or placed in a
special metal box equipped
with a filter before
sterilization.
• 'Flashing' is when an
instrument is autoclaved
unwrapped for a shorter
period of time. 'Flashing' is
often used when a critical
instrument is dropped.
Color Change Sterilization Indicators
• The white stripes on the tape change to black when the appropriate
conditions (temperature) have been met.
• Indicators should be on the inside and outside of equipment pack.
• Expiration dates should be printed on all equipment packs.
• Color indicators are also included on the outside and
inside of equipment sterilized in paper packages.
• Biological sterilization indicators contain spores that
are supplied in closed containers and are included with
the instrument being autoclaved. Inability to culture the
spores after autoclaving confirms adequate sterilization.
Biological indicators are the most accurate sterilization
indicators.
 Ethylene Oxide Sterilization: ETO Gas

• Colorless gas, very toxic and

flammable.Requires special equipmentOdor
similar to ether.
• Used for heat sensitive instruments: plastics,
suture material, lenses and finely sharpened
instruments.
• Materials must be well aerated after sterilization.
• Materials/instruments must be dry.
• This specific type of EtO sterilizer is only found
in larger veterinary hospitals
Large Two-Chamber EtO Sterilizer
 Compact One-Chamber EtO
Sterilizer
• Anprolene® is the most commonly used EtO
sterilizer in veterinary practices.
• Cartridges release 100% pure ethylene oxide
• Kills all known viruses,bacteria (including
spores), and fungi.
• Annual safety inspections are recommended.
• For more information on the Anprolene® system,
go to the commercial vendors section.
Compact One-
Chamber EtO
Sterilizer
Cold (Chemical) Sterilization:
• Instruments must be
dry before immersion.
• Glutaraldehyde (Cidex)
is the most common
disinfectant.
• 3 hours exposure time
is needed to destroy
spores.
• Glutaraldehyde is
bactericidal, fungicidal,
viricidal, and sporicidal.
 Radiation Sterilization:
• High energy ionizing radiation destroys microorganisms
and is used to sterilize prepacked surgical equipment.
• Used for instruments that can't be sterilized by heat or
chemicals.
• Radiation sterilization is being promoted as an
alternative to ETO sterilization.
• Care needs to be taken because not all materials can be
irradiated successfully
• Currently used by manufacturers, but not used in
veterinary hospitals
• Common sources of radiation include electron beam and
Cobalt-60
• For more information on specific sterilizers which utilize
radiation, go to the commercial vendors section
 Filter Sterilization:
• Filters are used for
removal of
microorganisms in fluids
and gases. They come in
a wide variety of types
and sizes.
• A 0.2 micron filter is
required to remove
bacteria from fluids.
• The filter is placed in the
IV line or on a syringe, so
that the contaminated
solution is sterilized
before reaching the
patient.
 Gas Plasma:
• Based on a patented process involving the generation of
a low-temperature hydrogen-peroxide gas plasma
• Recently on the market, its efficiency in practice is still
unproven
• Requires only a 74 minute cycle time and leaves no toxic
residues or emissions
• Unlike EtO, it does not require special installation,
ventilation, or aeration
• Effectively sterilizes most heat- and moisture-sensitive
medical devices and surgical instruments
• For more information, go to STERRAD® in the
commercial vendors section
 Sterilization Methods Handout
A. Methods of Sterilization:
1. Physical Methods .
2. Chemical Methods.

B. Sterilization Shelf Life of Packaged

Supplies.
C. Sterility Check List.
 A. Methods of Sterilization:
1. Physical Methods:
b. Steam Thermal – Autoclave:
i. Definition -- a self-locking apparatus for the
sterilization of material by means of steam
under pressure.
ii. Settings for general wrapped items:
- Temp. - 250oF Pressure - 20 PSI
- Time -- 30 min Setting -- Fast Exhaust &
Dry
 iii. Settings for bottled solutions:
Always vent bottles to avoid bursting!
- Temp. - 250oF Pressure - 20 PSI
- Time -- 30 min Setting -- Slow Exhaust
iv. Setting for "Flashing" an unwrapped
instrument:
- Temp. - 270oF Pressure - 30 PSI
- Time -- 4-7 Min Setting -- Fast Exhaust
v. Notes -- The above are general steam
autoclave settings. Different models may
operate with varying settings. Always refer to
the appliance literature before operating a new
piece of equipment.
b. Radiation:
i. Use on materials that cannot be
sterilized by heat or chemicals.
ii. Radiant energy destroys
microorganisms.
iii. Filtration -- is a method utilizing filters
capable of screening out
microorganisms.
 2. Chemical Methods:
a. Ethylene Oxide Gas:
i. Colorless gas at room temperature.
ii. Odor similar to ether .
iii. Very toxic and irritating to skin and mucous
membranes.
iv. Microorganism destruction is caused by a chemical
reaction.
v. Materials sterilized need to be aerated in well ventilated
room or placed in an aerator. Length of time required
depends on items sterilized.
vi. Effective sterilization is dependent on concentration of
gas, exposure time, temperature, and relative humidity
vii. Hazardous chemical, use great care .
a. Cold Sterilization:
i. Instruments should be completely dry before
soaking to prevent dilution.
ii. Instrument soaking solution - 10-20 minute
emersion only disinfects.
iii. Incomplete destruction of spores, unless soak
is for 10 hours.
iv. Examples: Instrument Germicide (Phenol and
Ethyl alcohol), CidexTM (Glutaraldehyde).
v. Most require thorough rinsing before using
instrument.
vi. Contact time required varies with product used.
 B. Sterilization Shelf Life of Packaged
Supplies
1. The following wrapped items, if carefully
maintained, are sterile for up to one (1)
month:
a. Double cloth wrapped instruments.
b. Double paper wrapped instruments.
c. Inexpensive peel pouches for gauze
sponges.
d. NalgeneR saline bottles.
2. Two (2) packaging methods are sterile for up to
six (6) months:
a. MonarchR Instrument Canisters -- Special
box system with single use filters for use in
steam autoclaves.
b. Sterility Maintenance Covers -- Sealable
plastic covers to place over freshly autoclaved
and cooled packs to extend shelf life by
diminishing air penetration.
c. Heat sealed packages commercially prepared
in tube or peel pouch form may be considered
sterile for up to one (1) year.
 C. Sterility Check List
Before assuming a pack is sterile, always
evaluate the following before opening the
pack:
1. Expiration or sterilization date.
2. Indicator color change.
3. General condition of wrapper and how
it had been stored.
4. Always check for holes or moisture
damage.
 Chromic Surgical Gut
• Advantages:
- monofilamentous
• Disadvantages:
- inflammatory reaction
- rapid loss of tensile strength (2-3 weeks)
Disposable Gown,
Hair Cap & Boot.
 Disposable Paper Gown
• ADVANTAGES:
- Paper gowns are resistant to
wetting so they are less
permeable to bacteria. They are
preferred for wet bloody surgery
(equine abdominal surgery).
- Donning a new gown for each
surgery and disposing of it at the
end ensures sterility.
• DISADVANTAGES:
- Paper is less ecologically sound
because it is not reusable.
 Linen (cloth) Gowns
• ADVANTAGES:
- Linen gowns are both
comfortable and reusable.
- Previously worn gowns can
be autoclaved to regain
sterility.
• DISADVANTAGES:
- Linen is a woven material so
that when it becomes wet,
bacteria can permeate
through its interstices.
- Linen is not the gown
material of choice for wet,
bloody surgical procedures.
 Plastic Gowns
• ADVANTAGES:
- Plastic is superior in its
resistance to wetting and
bacterial penetration.
Plastic can be used to
reinforce paper gowns
during wet surgery (plastic
sleeves for abdominal
surgery).
• DISADVANTAGES:
- Plastic is extremely
uncomfortable to wear
because of the inability to
shed heat and perspiration.
Beard Cover
Short Hair Cap with a duck-billed mask
Long Hair Cap with a pleated mask
Boots used in small animal surgery
Boots used in large animal surgery
Preparing The Equipment For
Surgery
 Folding of a Gown for Sterilization
• Hold the gown so that the outside is facing away from
you. Place the outside right and left ties into the white
tab.
• Fold the gown in half lengthwise twice
making sure that the inside of the gown is
showing.
• Lie the gown on a table and fold in half lengthwise again.
Then fold end to end twice. The gown is folded in such a
way that the top of the inside of the gown is presented
when the sterile pack is unwrapped. This is the area
grasped by the surgeon to begin donning the gown.
 SCRUB
TECHNIQUE
 1) Trimming and Cleaning Nails
• Trim fingernails and clean with disposable
nail file.
 2) Initial Wash and Scrubbing Fingers

• Wash for 30-60 seconds with surgical scrub.

• Scrub fingers with a sterile scrub brush
• Make sure to scrub all sides of each finger,
including the area between fingers.
 3) Scrubbing Hands and Forearms
• Scrub hands and arms with a sterile scrub brush.
• Make sure to scrub each surface of each hand and arm.
• An accepted contact time is 10 brush strokes per surfac
 4)Rinse
• Rinse hands and rescrub
as in step 3. During
scrubbing, rinsing and
drying, hands are held
above elbows. This is
done so that water will
not be dripping from
upper arms onto lower
arms and hands.After
both scrubs and rinses,
total contact time should
be 5 minutes.Some
surgeons do not rinse off
the chlorhexidine in order
to enhance residual
activity.
Surgical Scrub
Disposable Brushes (Hibiclens):

- Packaged with antiseptic already contained within the brush.

- Antiseptic can be chlorhexidine or iodophor based surgical scrubs.
 Non-disposable Brushes
• Can be resterilized before each use.
• Can be used with chlorhexidine or iodophor based
surgical scrubs.
Surgical Prep of the Large
Animal Patient
• During orthopedic procedures a stockinette is used to
cover the distal part of the limb. The entire
circumference of the distal limb is covered so that the
surgeon can grasp and manipulate the limb. Proximal to
the proposed incision site, a 'V' shaped drape is folded
over the limb so that the entire circumference is covered
and can be manipulated. In addition to the limb, the
entire horse is covered with drapes.
• Step 1: Clipping: Generously clip area around
the proposed incision with #40 surgical clipper
blade. Isopropyl alcohol poured on site will
facilitate clipping. Vacuum or brush and dispose
of clipped hair and debris.
• Step 2: Gross Preparation: Use a surgical scrub
product (Chlorhexidine [Nolvasan®], or Providone-iodine
[Betadine®]) and tap water. Scrub and rinse until area is
free of debris and water beads as it flushes across skin.
Rinse with tap water.
• Step 3: White Glove Test: Soak 10-15 white 4x4 gauze
sponges with isopropyl alcohol (70%). Wipe the
scrubbed skin (always work from proposed incision site
to the periphery) and check for remaining dirt and debris.
Discard gauze if you pick up debris. Once you reach the
periphery, discard gauze and start again at the proposed
incision site with a new gauze sponge.
• Step 4: Final Skin Preparation: Saturate 10-15 gauze
sponges with antiseptic solution (2% Nolvasan®
Betadine®). Add ten milliliters of Nolvasan® or
Betadine® surgical scrub to the top sponges. Scrub in a
circular motion starting at the surgical site and moving
toward the periphery. Never scrub in the direction of the
periphery towards the proposed incision site. Total
contact time should be 5 minutes.
• When picking up the sponges to begin
scrubbing, fold and hold the corners of the
sponge so that you do not touch the surface of
the sponges that will be in contact with the
surgical site.
• Starting with 1 to 3 sponges, scrub in circular
motion starting at the proposed incision site and
moving towards the periphery. Discard sponges
as you reach the periphery (do not move
peripheral debris toward the central incision
site). Repeat for a total of five minutes.
• Step 5: Rinse: Rinse with sterile saline or 70% isopropyl
alcohol. Continue rinsing until the area is free of fat
and/or surgical scrub residue (rinsing solution will bead
as it is flushed across skin. Rinsing solution should
always flow from central (clean) to periphery
(contaminated).
• Step 6: Final Antiseptic Preparation: Apply
70% Isopropyl alcohol to skin and let dry. Finish
by applying an even coating of 2% Nolvasan® or
Betadine® solution with spray bottle.
Preparing The Patient For
Surgery
Draping Technique for the Small
Animal Patient
Four Corner Draping:
The function of draping is to separate the
sterile surgical site from contaminated
areas of the patient.
 Unfolding the Drape
• The drape is unfolded and an edge folded under
towards the patient. Wrap the corners of the
drape around hands.
 Placement of Drapes:
• The drape should be floated above the patient
and placed in the appropriate position (i.e. do
not drag the sterile drape along the patient's
contaminated body). When applying the drapes
make sure the sterile drape is in between the
surgeon's sterile gown and the unsterile
(undraped) surgical table. The drape should only
be adjusted minimally once it has been laid onto
the patient. If the drape needs to be adjusted it
should only be moved in a direction AWAY from
the sterile surgical site and NEVER towards the
sterile site.
 Securing the Drapes:
• Drapes are secured to each other and to the patient's
skin with Backhaus towel clamps.The towel clamps are
tucked underneath the drapes, making sure that they are
not lying on the patient's skin.
Step by Step Photo
Series of Surgical
Prep of the Small
Animal Patient
 Step 1: Clipping:
• Clip operative site (wide borders) and remove all hair (central
vacuum).
• Wipe skin with clean moist 4x4 gauze sponge to remove all hair and
debris.
• Hair is removed in order reduce contamination of the surgical site by
bacteria on the patient's skin and in the patient's hair follicles.
Shaving is a less acceptable method of removing hair because
shaving damages the skin to a greater degree than clipping.
• Any method of hair removal damages the patient's skin.
Inflammation increases the risk of bacterial colonization. In order to
reduce this risk, hair is removed immediately prior to surgery.
• For orthopedic procedures on long bones, the entire limb must be
clipped to dorsal midline. Wounds within the surgical site must be
coated with a water soluble jelly so that they do not collect hair and
debris during the process of clipping.
 Step 2:Initial Scrub
• Soak scrub brush with tap water and 2%
Chlorhexidine Gluconate (Nolvasan®).Using
foam side of brush, apply mixture to entire
clipped area.Collect and remove any loose hairs
and debris.
 Step 3: Scrub Incision Site

• With a new
brush, scrub at
the incision site
for 2 full
minutes.
• Do not stray
from the incision
site.
 Step 4: Periphery Scrub
• Soak a new scrub brush with tap water and
Chlorhexidine Gluconate scrub.
Step 5: Rinse
Step 6: Final Antiseptic Spray
• The entire scrubbed area
is then sprayed with a
final preparation solution
of 0.5% Chlorhexidine
Diacetate in 70%
isopropyl alcohol. This
spray solution is made by
diluting 1 part Nolvasan®
(2% Chlorhexidine
Diacetate) in 3 parts 70%
isopropyl alcohol.