Basic_surgical_principles_lms_ (1).pdf

Dr. Irfan Shah BDS

KCD

(Peshawar)

1997

FCPS

de - Mont.

(Lahore)

2003

Fellowship AOCMF

LMU

(Germany)

2011

MHPE (in - Progress)

Dow University (Karachi)

2013- 2016

Associate Professor Army Medical College / AFID (NUST) Rawalpindi

OMF S U R G E R Y

S C O P E

BASIC SURGICAL PRINCIPLES

Surgical Principles That Have Evolved Through

Scientific Research & Trial & Error

Before Starting …. •

Knowledge of Basic & Clinical Sciences

•

Accurate Diagnosis & Treatment Planning

•

Informed Consent

•

Sterilization & Cross-Infection Control Measures

•

Visibility & Access

•

Assistance

•

Pain Control & Anesthesia

DIAGNOSTIC

ALGORITHM

History

Clinical Examination

• Demographic data. • • • • •

• Extra oral …Vital Signs.

Chief Complaint (s). History of Present Illness. Medical History. Family History. Socio-economic History.

Head & neck

• Intra oral …Soft Tissues Hard Tissues.

Provisional Diagnosis Investigations • Radiological

• Hematological • Microbiological • Histopathological

Definitive Diagnosis

DIAGNOSTIC SIEVE DISEASE

TISSUES Developmental

Epithelium Con. Tissues Bones S. Glands

Muscles vascular Lymphatic Nerve

Infec/ Inflam

Traumatic

Neoplastic

Nutritional

--------

Radicular Cyst / Ameloblastoma ? ? ?

What Tissues ???

? ? ?

Sterilization & Cross-Infection Control …2014

• Concepts & Definitions

(Irum Tariq)

• Chemical Sterilization

(Javeria Arshad)

• Heat

(Iqra Dildar)

Sterilization

• Radiation Sterilization

(Marium Rao)

Informed Consent

Informed Consent 1.

Inform the Patient / Relatives ( Nature of the Disease )

2.

Treatment Options

3.

Recommended Treatment

4.

Risks

5.

Risks of Not Following the Advice

6.

No Absolute Guarantees

( + Advantages & Disadvantages )

( + Frequency )

Informed Consent … (Contd) TYPES:

Tacit / Implied Consent

Express Consent …Verbal Written

SPECIAL SITUATIONS: Emergencies

Patient Asks Not to be Informed Mentally Retarded Individuals Children < 18 Years

BASIC SURGICAL PRINCIPELS 1. Flap Designing 2. Incisions 3. Tissue Handling

4. Debridement

5. Hemostasis 6. Dead Space Management 7. Suturing 8. Post – Op Care & Follow Up

Oral Cavity Tissue Flaps

Flap Designing 1.

Adequate Access to the Surgical Site

2. Minimum Tissue Trauma 3. Avoid Damaging Significant Anatomic Structures • Base Wider Than Apex

4. Retention of Vascular Supply

• Length  Twice Width • Axial Supply (Where Possible) • Avoid Twisting Base of the Flap

5. Replaced Over Healthy Bone ( Without

Tension )

Intra – Oral Flaps ( Flaps on the Buccal Side )

Envelop Flap

Intra – Oral Flaps ( Flaps on the Buccal Side )

Tri – Angular Flap

Intra – Oral Flaps ( Flaps on the Buccal Side )

Four Cornered / Trapezoidal Flap

Intra – Oral Flaps ( Flaps on the Palatal Side )

Intra – Oral Incisions Flaps

Semi Lunar Flap

Palatal Rotation Flap

What Flap ?

What Flap ?

What Flap ?

What Flap ?

Tongue Flaps

Palatal Flaps

Oral Cavity Flap Designs ???

Surgical Incisions (Basic Principles)

Surgical Incisions (Basic Principles) • Proper Instruments

(Bp No. 15 + Handle No. 3)

• Sharp Blade (s) • Incision Perpendicular to Epithelial Surfaces • One Continuous Stroke

• Appropriate Depth

( Full Thickness / Layered )

• Marking of Incision Site

Extra - Oral Incisions

Tissue Handling • Be Gentle While

Handeling / Retracting

Tissues

Toothed Tissue Forceps

Non - Toothed Tissue Forceps

Skin / Tissue Hook

Allis Forceps

• Avoid Excessive Heat • Avoid Tissue Desiccation

• Avoid Non – Physiological Chemicals • Keep A Vigilant Eye

Tissue Forceps / Retractors

Tissue Forceps

Tissue Retraction & Protection

Debridement ( Removal of Necrotic / Ischemic Tissues / Foreign Material )

•

Required In:

Traumatic Wounds Infected Wounds Intra – Operatively

•

Curettage / Excision

•

Irrigation ( Saline / Antiseptics / Antibiotics )

Hemostasis

Hemostasis

To Reduce Blood Loss

To Improve Visibility To Prevent Hematoma

Formation

Hemostasis • Pressure • Heat

Stasis Protein Coagulation

Direct Heat

Electro cautery Argon

Beam Coagulator

Coagulation Sealing of Vessels

Hemostasis • Ligation of Blood Vessels • Topical Hemostatics / Vasoconstrictors Adrenaline Gelatin Sponge Oxidised Cellulose Bone Wax

• Therapeutic Embolization

Hemostasis Vessel Size

Management

Capillary Ooz

Pressure

 2 mm

Electro coagulation

2 – 3 mm

Ligation (Resorbable)

 4 mm

Ligation (Non-Resorbable)

Discussion on Wound Healing After One Month

Surgical Dead Space (Tissue

Void / Defect

Left After Surgery)

Surgical Dead Space

Dead Space … Management • Replace Lost Tissue (Where • Layered Wound Closure

• External Pressure • Cavity Packing / Dressing • Cavity Drainage

Possible)

Surgical

Drains

( Device For Free Flow of Blood , Serum , Pus , Etc )

Passive Drains

Active Drains

• Gauze / Rubber Sheet • Corrugated Rubber Drain

• Penrose Drain

• Wall Mounted Suction • Portable Suction Device

Basic Principles of Suturing

Suturing 1. To Close Incision / Wound Margins 2. To Secure Hemostasis

3. To Ligate Ducts 4. To Hold / Retract Tissues 5. For Specimen Orientation

Materials / Instruments:

Suture ( Thread ) Needle Needle Holder, Tissue Forceps, Scissors

Natural (Silk, Catgut, Collagen) Synthetic ( Prolene, Vicryl, PDS )

Sutures / Threads

Resorbable

(Catgut, Vicryl, PDS)

Non - Resorbable (Silk, Prolene)

Monofilament Polyfilament

Size (3/0, 4/0 ….11/0)

 3/0 Surgical Silk / Catgut / Vicryl

(Catgut, Prolene) (Silk, Cotton)

Threads / Sutures

Catgut Catgut

Vicryl

Straight

¼ circle

Half Curved

3/8 circle

½ circle

Curved

5/8 circle

Round Body

 ½ circle, 16 - 22 mm Cutting Needle with Swaged Thread

Simple Interrupted Sutures

Principles …..

Suturing

1. Needle Grasped at Anterior 2/3 & Post. 1/3 2. Perpendicular to Skin / Mucosal Surface 3. From Mobile to Fixed Tissues 4. 3 mm from Incision Margin & Equal on Both Sides 5. 5 -10 mm Distance Between Adjacent Stitches

Principles …..

Suturing

6. Tissue Tension

Undermining

7. Tissue Blanching

Approximation ONLY

8. Margin Inversion

Eversion

9. Knots Away From Incision Line 10. Removal

in 5 – 7

Days

Suturing ….. Techniques • Patterns:

Simple Interrupted Continuous (Simple / Locking ) Horizontal Mattress Vertical Mattress

• Techniques: Manual Instrumental (Needle Holders)

• Knots:

Square Knot

Surgeon’s Knot Ligation Clips / Staples Tissue Adhesives ( N-Butylcyanoacrylate )

Discussion on Wound Healing After Two Weeks

Post – Op Swelling

Control of Post – Op Swelling Tissue Trauma

Loose Connective Tissue

Control: • Minimize Trauma • Cold Application • Posture • Anti – Inflammatory Agents (Steroids / NSAIDs)

Documentation ( Operative

Notes )

1. Date & Time 2. Patient Name & Identification 3. Surgeon (s) + Anesthetist’s Names 4. Pre – operative & Operative Diagnosis

Documentation ( Operative 5. Anesthesia ( Type, 6. Procedure

Notes )

Amount & Technique )

( From Incision To Closure )

7. Post – Op Medications + Instructions

8. Follow Up ( Date

& Time ) Name & Signature

Follow Up & Review

Follow Up & Review … PURPOSES • To Monitor Response to Treatment •

To Recognize & Manage Complications

•

To Remove Stitches / Drains / Dressings

•

To Recognize & Manage Recurrent Disease

•

For Teaching / Training Purposes

At Follow Up ….. • Enquire About Patient’s Well Being (Subjective) • Examine the Patient (Vital

Signs)

& the Operative Site (Objective)

• Radiographic / Lab Investigations

• Wrong Diagnosis

• Reasons For Failure / Complications

• Inadequate Surgery • Depressed Host Defenses • Lack of Compliance • Un-realistic Expectations

• Identify Mistakes / Shortcomings & Avoiding them In Future

Discussion on Wound Healing After One Weeks

Thank You