Basic Surgical Techniques

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FIFTH EDITION

R M Kirk MS FRCS Honorary Consulting Surgeon, The Royal Free Hospital, London UK

~~

-

/ , , \ CHURCHILL LIVINGSTONE

CHURCHILL LIVINGSTONE An iltlpfJlll of Ebevler 'Clenc,; Lirn"ed

n:,crv,' ,-",(1 Ihl' pu L,(, ,her< I,,,v'l1

In

Cncolhyrotomy T e

Incisl

n IS

l'"Ie blOken hne.

I - / - - r - - - Str~p muscles ) - - - Thyroid cartilage

_________ lHn-I-+-_+

lncision in cricothyroid

membrane

J-'-t-i+r--I---- Cricoid cartilage

J--t-cHf--r---- I s( tracheal ring

-=t+'--+-(---f----- Thyroid gland

5. [t is traditional [0 reverse the knife. insert the handle into the laryngeal incision and (lim il to open the incision. Prefer to hold Ihe knife blade quile slill ;:md insert alongside il a haemost::llic or other forceps. Now withdraw the knire blade, open the for cost o( Width.

'axial p:.lltem 1l1lp~ '.

Z-plasty I. Thi:-; overcomes the problem of linear shortening by taking advallliJgc of the fa:-vent I r"orn bpln' , Inserted all ,11 the same distance from [he edges lend to dra ,1W,l, th diameter of the tendon transversely, immediately opposite the point of insertion. Reinsert the needle close to the point of ell1ergl~nce, to emerge at the cut end. Bridge the gap belween [he cut ends and enler the olher end. emerging 1.5 cm from the end, crossing the diameter of the tendon. back to the CUI end (Fig. 7.8). lL is olLen conVCllJo.':l1t lO employ a straight needle but hold II with 1"1 needle­ holder. Draw the two ends together. ensuring that they fil withollttwisting. Tie a perfect knollhat will lie bet.ween the ends. holding the ends in perfect apposition, without bundling. FlIlally, inseJ1 t have: a good blood supply, perfect apPOSition of the edges, absence o(tenslon.

LIVER Liver is amenable to finc-needle aspiration or to neectk biopsy. U It rasound or other imaglllg methods Illay be useu to guide the needle (0 lesions. A fine needle call be imerted pcrcut ,Jtl.) hed t

Into the mou h of Ihe '1,,'(Jt/nd NOle

I,ll eo metal ~n os Ie

Qutslde h

W

lind

6. Prerer [0 loring a mobile slruclure to the SUrraCl: or the w(lund III preference to carrying out a c1'licate pn)Ccdllre ill the depths where the

lighting and

acce,~s ar~'

linHk·{!. Sometimes a pad

can he placed bcncalh cI "tructurc 10 ralst' it (Fig. 9.~): alternatively, try dcpre:,\ing the edge:-- of Ihe IIlCi~IOIl (Fig. 9.4).

Fig. 9.1

Retrad ingNlth mger,

'I

r" g~"ze swab t

~~

Impr'OVE'

the g" p on Iippel)' tl~sues

".

.

f.

.-

.

.' .

B' '-- --:

Fig. 9.4

•

~~~

--:~

.."

".\

- ,,'

D splavlng a fixed deep 51rUCldl'P. /"$;;n .llte'natlve to

retr~ 111

the wound ell es. as I A. IS rt posSJble to depress t eli' as. I~ B?

~

Key point Exposure IS prejudiced by poor hiiemostasis, Blood staining obscures the dlstlnC1Jve appearance of dlffenn t:ssues, If you wish t

Fig. 9.2

Use tissue forceps t

retract tough w,:;ues.

see what you are dOing, stop the bleedin .

SHARP DISSECTION

BLUNT DISSECTION

I. The scalpel diyidc~ tissue~ with the rnllllnllllll damage. I( the tis~lI(:' move under th t ' drag of the ,c,lIre!. steady tl1cI11 wi lh your fingas, ir neces~ary exerting tension to open up the incision 10 display lhe deeper structllrcs (Fig. 9.5). 2. Expertly performed SCI~sors dissection produces minim. SCic.sOf\ can be used LO split a sheel after It has been penetrated in one place and separated (1'0111 deep structures. Insert one blade of ~ilmosl lull y clo~ed ~cissors inlO the hole and push them in the direction of the fibre~ (Fig. 9.7). A eli rrcreni ~pl itting action can be aeh ieved wi th ~ci~sors by holding them perpendicular to the plane 01 the tissues. Push the closed ti ps between the fibres Clnd gently open the- blades (Fig. 9.8). Alternativt!y, use arlery forceps instead of ~cis~ors, ~ince tile tip~ 1ll1l~C

= Fig.9.7

SplltLrfl_ pdl-ollel fibres "''.'Ith SCissors, AlrrlQst ~Ic$e the

$(1$:;,''>($ ,md pllsh the srnJl1 '\I' bet W1:CTl I hE' blade tipS Il1tO the tI5SU~" dlong tr.c line

or The fib"".;

InCISion wherl (ut Ir 'filth il scalpel. lOU disp!a/ the depth, of the

w un , 0 you do not In"dverientl/ cut too deeply,

Fig.

9.8

Sphtll

pal"illl~1 fibres With SCI"O".

tiPS 'nto the ,h et of timle

Fig. 9.6

lwes

Push the losed and open the,." parall I to the fibre:;,

When culling '.'11th SCIssors, prDtect the underlying

If t ere are underly'ng stnJCtures with sld~ bl-anches, open the

frorn Inadvertent ddTTlilge by the deep blade,

SCISSOrs at

nght ;I ngl€'s 0 th 111l€' of ti-Je Il1t a malignant tumour. that must be excised together with a surrounding layer of healthy tissue, in ~uch a way that you do not expose or encroach 011 the tumour, for fear of disseminating the malignant cells. The difficulty is twofoid: you must know the norlllal anacomy and the possible

If disease h s dl to led he anatomy, do not inexora Iy persist In your intended approach Try appmaching t from different aspects, Also, try sta'1ing your dissection from a short distance away In normal tiSSUe' and work towards the diseased area

DIVIDING TISSUES I. Membranous layers orten overlie important struc­ (ures and it Illily be impOSSIble to bt' sure if the underlying structures ;)re 311C1ched unt il you have

breached the layer. If the membrane is sufficienlly lax, pinch up a fold with your fingers to e. Do Ilot concentrate on delai b at the expense of important principles. if you encounrer difficulty_ do Ilol obsessively continue along the palll of your original deCIsion: review lhe P()~ 'ibilities aJld decide if' you should chaJlge your rriorities. Good surgcon~ incorporate all their findings into thei r (lecisiol1~_

Handl'ing bleeding

PREVENTION

Definitions

Prevention

Technical aids

Control

Arlcrie~

I. Study lhe analorny so you can expose and control major vessels before you cut Ihem. 2. When yOll encounter an imporlant blood vessel

bleed bright red bloo(1 in spurts when

lI~ll;i1ly

constrict ;tncl seal if they are

lr:insected. provided they are hcallhy: diseased,

calcified arleries canlJot comract ertJciently.

Vcin~ ooze dark blood. They call constrict - but

do nOltrust them~

Capillary bleedmg will stop following genlle

compression - provided there is no cloltlng defect.

cuI. They

DEFINITIONS 1. Primary /1(I1'lI/lIr,-IIII.'-:I' (G haima = blood + rhegnyllat = to bursl) occurS during operation. 1. Reactionary bleeding re.sulLs jn lhe postoper­ alive period when the blood pressure recovers, or straining raises venous pressure, dislodging respec­

that muSI be preserved, obtain control by placing a non-crush; ng clamp ready to be closed if

acro~~ j I

necessary, or cilci rc Ie it with flex ible SI licone rubber slings or tape- (see eh. 5). 3. If you wish to divide a major vessel. displ are collapsed (lnd \vhelher there is any liquid in the pleural cavity. From the X-ray and by pCI·t::tls,jon :lnd auscu!lation, decide where to insert the drain. You may decjde the safest place 1$ the 5th or 6th inlerco~!al ~pace in the anterior