Title: ASCEPTIC TECHNIQUE
1ASCEPTIC TECHNIQUE
2Define sterilization
- Killing of all microbial forms (cells, spores)
3What is the commonly used method of sterilization
for surgical instruments?
- Steam latent heat of vaporization, press
increases the temp of steam formation and
increases In efficacy, avoid overloading
autoclave and add additional penetration item for
larger packs
4List 4 alternative methods.
- Gas (ethylene oxide)
- Plasma sterilization
- Cold chemical
- Ionizing radiation
5Which of these methods is most often used for
surgical supplies?
- Steam most common have gracity displacement
sterilizers high prevacuum sterilizer and flash
sterilization (only in emergency) - Plasma sterilazation most common alternative
uses hydrogen peroxide at low temp, some items
cant be sterilized
6Why is steam under pressure more lethal than
steam that is not under pressure?
- b/c pressure increases the temp of steam formation
7Explain how a gravity displacement sterilizer
works
- Steam is lighter than air and the 2 dont mix
readily steam is admitted into the chamber and
baffled upward and air flows out the drain on the
bottom of the chamber
8. How does a prevacuum sterilizer differ from a
gravity displacement sterilizer?
- Requires energy applied to the pump to make
vacuum and does fewer number of packs at one time
9What is flash sterilization?
- When an unwrapped item is placed on perforated
metal tray in gravity displacement sterilizer,
only used in emergency
10When is ethylene oxide sterilization used?
- When you need to penetrate rubber and plastic and
have several hours to do it
11 What are the environmental and safety hazards of
ethylene oxide?
- Category 1 carcinogens , EPA has discontinued the
use of cholorofluorocarbon
12What is plasma sterilization?
- Is a vapor pressure hydrogen peroxide
sterilization
13 What are its advantages over ethylene oxide
sterilization?
- Uses low pressure sterilization with no aeration
requires
14When is glutaraldehyde sterilization used in
veterinary surgery?
- To disinfect lenses and delicate instruments,
sterilizes by protein and nucleic acid alkylation
15Describe practices that help to ensure the
efficiency of autoclaving
- Need correct relationship b/w temp, press, and
exposure time - Make sure packs arent wrapped too tightly or are
not improperly loaded into autoclave - Should be positioned longitudinally and
vertically - Heavy packs should be at the periphery
- Small amount of airspace should be b/t the packs
- Linen packs are oriented so that the fabric
layers are oriented vertically - Should use sterilization indicators- undergoes
some chemical or biological change in response to
correct pressure and temp
16What organisms do disinfectants destroy?
17Name 5 effective disinfectants.
- Phenol
- Betadine
- Chlorohexidine
- Quarternary compounds
- Alcohols
18Which of these can be used for scrubbing the
patient and surgeons skin?
- Iodine can be used to scrub and betadine and
chorhexadine
19What are advantages and disadvantages of
polyvinylpyrrolidone, chlorhexidine glyconate,
and hexachlorophene as skin disinfectants?
- Betadine inhibits chemotaxis and kills spores
- Disadvantages iodine part can be absorbed,
inactivated by organic material - Chlorohexidine ad most effective, works against
gram -/ and pseudomonas, has no systemic
absorption, may be less irritating to skin - Dis does not kill spores, residual activity, bc
it binds to keratin - Hexacholorphene less caustic and easier to
handle bc halogenated - Dis minimal activity against gram -, may be
neurotoxic
20WOUND INFECTION AND THE USE OF ANTIBIOTICS
21List the classification of surgical
procedures/wounds, and give an example of each.
- -clean non traumatic wounds without pre-existing
inflammation or infection - -clean/contaminated non-sterile luminal organs
entered without spillage (GI, resp, oropharynx,
vagina, urinary, biliary tract) minor break in
aseptic technique (break gloves) - -contaminated traumatic wound without purulent
discharge major break in surgical technique like
gross spillage or fresh traumatic wound
requires drbridement, lavage and Ab (ex. Spill
urine) - -dirty gross infection present at time of
surgery, has purulent discharge, devitalized
tissue, or foreign body (ex. Perforated viscus
and have fecal contamination)
22List the 4 sources of infection commonly
encountered in surgical patients.
- -primary surgical disease
- -as complication of surgical procedure nor
commonly associated with infection - -complication of support procedures
- -infection associated with prosthesis
23What is a nosocomial infection? What measures,
other than antibiotic use, can help in the
control of nosocomial infections?
- -nosocomial infection acquired during
hospitalization - -control via controlling endogenous flora via
patient prep, decreasing transmission via sterile
gloves, sterilization, disinfection, rational Ab
use
24Describe 6 host factors that may predispose
patients to infection of surgical wounds.
- -physical condition, nutrition, immune status,
nature of the wound, diagnostic procedures,
concurrent metabolic disorders, operating room
practice (use positive pressure ventilation),
characteristics of bacterial contaminants (can
use over nite UV light)
25How can operating room practice decrease the
incidence of surgical infection?
- -the more sterility, the less contamination in
OR should use aseptic technique, sterilization
and disinfection, prepare surgical environment,
gowning and gloving, prep of surgical patient,
operative site, surgical team
26Discuss how patient preparation and tissue
handling are important.
- -proper atraumatic tissue handling and instrument
use are important in preventing infection
traumatized tissue promotes bacteria growth
27Describe prophylactic antibiotic use, including
the specific antibiotics used, the route and
timing of administration, and the length of use.
- -give at least 30 minutes before initial incision
b/c must be present at surgical site during time
of potential contamination Ab selected must be
effective against at least 80 of probably
pathogens (Staph, E.coli, Pasteurella,
Bacteroides)
28Give 3 general indications and 3 indications in
specific procedures for prophylaxis.
- -cefazolin for most surgeries, 20mg/kg IV at
induction of anesthesia (slowly over 5 minutes),
may repeat in 2-3 hours discontinue immediately
a/f closure or within 24 hours - -cefoxitin for colon surgery
- -indication for prophylaxis surgery longer than
90 minutes, prosthesis implantation, severely
affected or traumatized wounds, GI strangulation
or obstruction, esophageal surgery, etc
29. How is the drug of choice for prophylactic use
determined?
- -specific indications Staph likely with thoracic
and orthopedic procedures, G cocci, enteric G-
bact likely with gastric and upper intestinal Sx
E.coli, Strep and anaerobes common in urogenital
system - -Ab selection determine system involved and
moost likely pathogen, ensure Ab reached taget
tissue, if amny are effective select the one that
is least expensive, least toxic, and most
convenient to administer
30Describe therapeutic antibiotic use and
differentiate it from prophylactic use.
- -therapy use based on clinical judgement,
knowledge of Abs mechanism of action and
micobiologic factors indicated in surgical
patients with overwhelming systemic infection,
when infection is present at the surgical site or
in a body cavity, or with any contaminated or
dirty surgical procedure usually given b/f
surgery and then 2-3 after - -prophy use is to prevent contamination and you
are not sure of that actual pathogen, but base
selection on potential pathogen
31HALSTEDS PRINCIPLES OF SURGERY
32What are Halsteds Principles of Surgery? What
is their importance to you?
- Gentle tissue handling
- Accurate hemostasis
- Preservation of blood supply
- Strict aseptic technique
- Sutures tied w/o tension
- Accurate tissue apposition
- Obliteration of dead space
- Postoperative wound protection
- They are the keys to a successful surgery.
33How does knowledge of anatomy improve surgical
technique?
- Knowing where the fascial planes are will allow
you to avoid cutting muscles and allow for
avoidence of unnecessary dissection.
34What is sharp dissection? Blunt dissection?
Which is more traumatic? Why?
- Sharp dissection is accomplished by incising
tissues with a sharp edge. - Blunt dissection is accomplished by separating
tissues along natural cleavage lines, without
cutting. - Sharp dissection is less traumatic than blunt
dissection because blunt dissection requires
pulling and tearing of tissues.
35What are two correct ways to hold a scalpel?
What are the indications for each?
- The pencil grip of he scalpel is used for short
incisions. - The slide grip of the scalpel is used for long
incisions.
36What is the tripod grip? When is it used? What
are alternative methods of holding needle
holders, and what are their advantages and
disadvantages?
- The tripod grip is used with any ring instrument,
especially scissors, to steady the tip of the
instrument. The thumb and finger next to the
pinky finger go into the rings (not through) and
the index and middle finger brace the instrument
for steadiness. Needle holders may be held in
tripod grip or palmed. The palm grid is used for
rapid suturing. Fine control is decreased. The
thenar grip is a compromise between the tripod
and the palm grip.
37How are curved scissors passed by the assistant
to the surgeon? How is a scalpel passed?
- Instruments are passed to the surgeon in an
appropriate position for use. Scalpels are
passed in a manner that avoids injury to either
party.
38What are three main reasons that hemostasis
during surgery is important? Describe three
effective means of hemostasis. What are two
complications of excessive application of these
techniques.
- Hemostasis is important because we want to
preserve the patients blood volume, maintain a
clean surgical field for surgery and to decrease
postoperative hematoma formation. Ligation with
small absorbable suture material for most
vessels. Electrocoagulation after clamping
bleeding vessel with hemostat or direct
application of electrocautery. Clamping with a
hemostat. Excessive ligating or cautery delays
wound healing and predisposes to infection.
39Why is tension at a suture line avoided if
possible? What techniques can be used to reduce
or counteract tension? What are complications of
the use of these techniques? Describe correct
undermining of skin on the trunk and on the
distal limb.
- Tension at suture line may occlude blood supply
to tissue, resulting in necrosis and tension
across suture line of anastamosis will predispose
to stenosis. When tension is present use tension
patterns and knots or undermine tissue margins to
reduce tension but avoid excessive undermining.
Undermining creates dead space, leading to seroma
formation. Undermining may damage vascular
supply to tissue margins. - Undermine skin deep to panniculus muscle to
preserve direct cutaneous arteries. Skin without
underlying panniculus muscle is determined in
loose areolar fascia beneath dermis to preserve
subdermal plexus.
40What is the purpose of using moist laparotomy
sponges on the wound margin? Why are exclusion
drapes used when opening hollow viscera?
- They serve to keep the tissues moist and they
protect the tissues when using self-retaining
retractors. To pack off the hollow viscus before
opening it in case of a spill that would cause
contamination.
41What is dead space? Why is dead space a problem
in the postoperative period? Describe four
techniques that will prevent formation or reduce
dead space.
- Dead space is space remaining after closure of
surgical or other wounds, permitting the
accumulation of blood or serum and resultant
delay in healing. Seromas may be secondarily
infected and become abscessed. Accurate tissue
apposition, use of drains and pressure bandages,
tracking tissue to deeper layer when closing and
delayed wound closure when dealing with loss of
tissue all cause obliteration of dead space.
42What are the two types of drains? Give an
example, an advantage, and a disadvantage of
each.
- Passive drains and Active suction drains.
Passive drains are covered with a sterile
dressing and removed as soon as drainage has
ceased. Pros include inexpensive, more
comfortable for patient. Cons include less
effective, greater risk of ascending infection.
Active suction drains are attached to the patient
externally with bandage material. Pros include
more effective, less risk of retrograde
infection. Cons more expensive, less
comfortable for the patient.
43List 2 reasons for protecting a surgical incision
in the postoperative period. For each reason,
describe appropriate methods of protection.
- Protection from environmental contamination which
decreases risk of superficial wound infection.
When possible, wound dressing is used. If
incision cannot be covered, frequent cleansing is
indicated. - Protection from self-mutilation. Use an
e-collar, plastic bucket, hobbles prevent chewing
or scratching or try a foul tasting liquid wound
dressing. Wounds itch most between 3rd and 7th
postoperative day.
44SUTURE MATERIALS
45List 5 characteristics of the ideal suture
material
- Easy to handle
- Minimally reactive in tissue
- Inhibits bacterial growth
- Does not support sepsis
- High knot security
- High tensile strength
- Is absorbed at a reliable rate
- Inexpensive and easily sterilized
46How is suture material sized
- Suture graded from fine to coarse
- Scale from 10-0 (smallest) to 7 (largest)
47Compare USP sizing to metric sizing
- USP of 10-0 0.2 metric gauge
- USP of 7 9 metric
- Metric sizing gauge is 10 times metric diameter
of suture
48What is flexibility in regard to suture material
- Determined by the torsional stiffness and diameter
49When is it important to choose a flexible suture
material
- Ligating vessels and for continuous suture
patterns
50Give 2 examples of flexible suture materials
- Silk, polyglactin 910 (Vicryl), poliglecaprone 25
(Monocryl)
51What are the advantages of rough and smooth
surfaces in suture material
- Rough
- Increase knot security
- Smooth
- Decrease tissue trauma
52What are the disadvantages of rough and smooth
surfaces in suture material
- Rough
- Increased tissue trauma
- Smooth
- Decreased knot security
53What is capillarity
- Process by which fluid and bacteria are carried
into the interstices, so infection may persist
54What type of suture material has capillarity
- Multifilament sutures
- Ex silk
55When is it important to avoid capillary suture
material
- In already infected sites
56Define knot tensile strength
- The force that the suture strand can withstand
before breaking when knotted
57Define knot security
- Holding capacity of a suture as a percentage of
tensile strength
58What determines the overall strength of the suture
59What determines the number of throws needed on
the knot
60What are the was in which suture material is
classified
- Absorbable/nonabsorbableMonofilament/multifilamen
tNatural/synthetic
61Classify polyglyconate
- Maxon
- Monofilament, synthetic, absorbable
62Classify polydioxanone
- PDS
- Monofilament, synthetic, absorbable
63Classify poliglecaprone
- Monocryl
- Monofilament, synthetic, absorbable
64Classify polyglactin 910
- Vicryl
- Multifilament, synthetic, absorbable
65Classify chromic gut
66Classify silk
- Monofilament, natural, nonabsorbable
67Classify stainless steel
- Monofilament, nonabsorbable, synthetic
68Classify nylon
- Monofilament, nonabsorbable, synthetic
69Classify polypropylene
- Prolene
- Monofilament, nonabsorbable, synthetic
70Classify polyester
- Mersilene, ethibond, dacron, ticron
- Multifilament, nonabsorbable, synthetic
71Classify caprolactam
- Supramid, braunamid etc
- Monofilament, nonabsorbable, synthetic
72What is the definition of absorbable
- Looses most of its tensile strength within 60
days of implantation in tissue
73When would absorbable suture be indicated
- Use for inner tissues that holding capacity is
needed for less than 60 days
74When would nonabsorbable suture be indicated
- Outer tissue layers or in inner tissues where
strength is needed for greater than 60 days
75What are the advantages and disadvantages of
monofilament
- Advantages
- No capillarity
- Minimal tissue drag
- Disadvantages
- Reduced knot security
- Easily damaged with forceps or needle holders
76What are the advantages and disadvantages of
multifilament
- Advantages
- More pliable and flexible than most monofilament
- Disadvantages
- Increased capilarity and potential to promote
infection - Increased wicking
- Increased tissue drag
77Name 2 natural sutures still used in surgery
78What are the disadvantages of natural sutures
- Associated with marked inflammatory reaction
- Looses strength rapidly in infected sites or when
exposed to digestive enzymes
79What type of suture material is coated and why is
this done
- Multifilament sutures are often coated to
decrease tissue drag - Coating reduces knot security
80What suture material is preferred for ligating
very large vessels
- Silk
- Causes inflammatory reaction which helps to close
very large vessels
81What suture material is preferred for ligating
most vessels and vascular pedicles
82What suture material is preferred for anastamosis
of blood vessels
83What suture material is preferred for closing skin
84What suture material has the greatest tensile
strength
85SUTURE PATTERNS
86Describe 4 ways in which suture patterns are
classified
- Continuous/interrupted
- Inverting/everting or apposition
- Partial or full thickness
- Tension patterns
87Define inversion
- When the edges of the incision turn inward
88Define eversion
- When the edges of the incision turn outward
89Define apposition
- When the edges of the incision come together
90What are the advantages and disadvantages of
continuous suture patterns
- Advantages
- Faster
- Less suture left in wound
- Better seal at tissue margin
- Disadvantages
- Less precise control of tension and apposition
- Disastrous result if suture breaks
91What are the advantages and disadvantages of
interrupted suture patterns
- Advantages
- Precise placement of each suture
- Stronger
- More secure
- Disadvantages
- More time required
- More suture left in wound
- More expensive
92Give an example of the use of the simple
interrupted pattern
- Skin, SQ, fascia, hollow viscera, vessels, nerves
93Give an example of the use of the simple
continuous pattern
- Skin, SQ, fascia, hollow viscera, vessels, nerves
94Give an example of the use of the continuous
interlocking
- Diaphragm (skin in large animals)
95Give an example of the use of the cruciate
96Give an example of the use of the intradermal
97When is an inverting pattern indicated
98When is an inverting pattern contraindicated
99What is the difference between the cushing and
connel patterns
- Cushing penetrates the submucosa but not the
mucosa - Connell penetrates the mucosa
100What is the difference between a cushing and a
lembert
- Cushing is a continuous horizontal mattress,
lembert is a variation of a vertical mattress
101When would a purse string suture be used
- Inverting visceral stumps, closing anus before
perineal surgery, closing skin tightly around
drains
102What are the advantages and disadvantages of a
horizontal mattress pattern
- Advantages
- Potential for apposition, eversion, or inversion
- Disadvantages
- Potential for strangulation of tissue margins
103What are the advantages and disadvantages of a
vertical mattress pattern
- Advantages
- Stronger than horizontal
- No risk of strangulating tissue margins
- Disadvantages
- More time consuming to place
- More suture left in wound
104What is the advantage of the near and far
variation of the vertical mattress
- Opposes tension at wound edge without applying
tension at the wound itself - Quicker to apply than standard vertical mattress
105In what tissues would you use a horizontal
mattress
- Skin, SQ, fascia, muscle, flat tendons
106In what tissues would you use a vertical mattress
107What are stents
- Object over or through which suture is placed
(prevents suture from getting too tight)
108What are 2 reasons to use a stent with an
incision that is under tension
- Reduces risk of tissue strangulation
- Obliterates dead space deep to the incision
109Define knot vs throw
- Consists of at least 2 throws laid on top of each
other
110What is a transfixing ligature
- The needle is placed through the wall of the
vessel - The ends of the suture are wrapped around the
vessel in opposite directions - The suture is tied
111When can a transfixing ligature be used
- Can be used to ligate uterine vessels in OHE
112How can you close a curved or jagged incision
accurately
113How can you close an incision in which one side
is longer than the other accurately
114How do you close a long incision accurately
- Divide very log incisions into thirds
- Start at the center and fill in
115What types of needles are atraumatic
- Taper
- Reverse cutting
- Spatula point
- Must be swaged to be atraumatic
116When would you choose a taper point needle
- Soft easily penetrated tissues
117When would you use a cutting point needle
- Tough tissues such as skin and fascia
118What suture materials and patterns are used to
close the SQ layer
- Simple continuous with monocryl/ PDS etc
119What is the purpose of closing this layer
- To oliterate dead space and reduce tension on
skin edges
120What suture material and patterns are used to
close the skin
- Nylon using simple interupted
121What special suturing is indicated in male dogs
- Preputialis muscles must be accurately apposed
using horizontal mattress or cruciate
122What suture materials and patterns are used to
close the subcutaneous layer?
- Subcutaneous tissue is closed in simple
continusous or simple interrupted pattern using
3-0 or 4-0 synthetic absorbable.
123What is the purpose of closing this layer?
- The subcutaneous layer is closed to decrease the
amount of dead space.
124What suture material and patterns are used to
close the skin?
- The skin is closed with 3-0 or 4-0 nylon.
125APPROACHES TO THE ABDOMINAL CAVITY
126List three standard approaches to the abdominal
cavity and two combined approaches.
- Standard approaches include ventral midline,
paramedian, and flank (also paracostal). - Combined approaches include ventral midline
plus paracostal, ventral midline plus median
sternotomy
127List the tissues incised in a ventral midline
approach.
- The tissues incised are the skin, subcutaneous
layer and the linea alba.
128What are the advantages of this approach?
- The ventral midline approach is the easiest and
quickest approach and closure, there is minimal
hemorrhage and you have exposure of all abdominal
organs.
129What organs or parts of organs are not ideally
exposed by a ventral midline approach?
130How does a paramedian approach differ from a
ventral midline approach?
- The paramedian approach is a ventral abdominal
incision through the rectus abdominus muscle
parallel to the midline
131 What are the advantages and disadvantages of
this approach?
- With this approach there is increased exposure to
organs on one side of the abdominal cavity,
increased hemorrhage and increased closure time.
132Describe the flank approach and the paracostal
approach.
- The flank approach is a lateral incision caudal
to the last rib and cranial to ilium. The
paracostal approach is caudal and parallel to the
last rib.
133What are advantages and disadvantages of these
approaches?
- The flank approach allows limited access to the
entire abdomen and excellent exposure of one
kidney, one adrenal gland and one ovary but
should not be done in dogs. The paracostal
approach allows for very limited exposure and is
rarely used alone.
134When would each be used, either alone or in
combination?
- A flank approach can used to spay a dog and a
paracostal approach is used with a ventral
midline when access to the gall bladder or liver
is needed.
135Why would a surgeon choose to extend a ventral
midline approach into a partial median
sternotomy?
- Doing this procedure would allow for increased
exposure of the cranial abdomen (liver and
diaphragm).
136What body cavity does this open?
- This procedure opens the pleural cavity and
mechanical ventilation is required.
137What measures must be taken during and after
surgery as a result of this approach?
- A thoracostomy tube may be required.
138Describe, in detail, the ventral midline
approach.
- Exact location and length of incision is
determined by goal of surgery in exploratory
celiotomy, the abdomen is opened from xiphoid
process to pubis.
139What is the best anatomical landmark on the
ventrum of the dog and cat?
- . The umbilicus should be included in the
surgical field as a landmark.
140What are the relative lengths of the incisions in
the layers of the body wall?
- . The skin incision is extended 1cm cranial and
caudal to the anticipated body wall incision.
The subcutaneous layer is incised in the same
line as the skin. The linea alba is identified
and incised. The linea in dogs is most easily
recognized at or cranial to the umbilicus. The
cranial superficial epigastric vessels parallel
the linea cranial to the umbilicus. The
falciform ligament may be removed completely
(ligae cranial vessels) or moved to one side.
141How does the approach differ in male dogs?
- In male dogs the preputial orifice is draped out
of the field. The skin incision curves lateral
to the penis and prepuce.
142What vessels are encountered in male dogs? In
all dogs and cats?
- . After caudal superficial epigastric vessels
lateral to the prepuce are ligated, the incision
returns to midline.
143What is the holding layer of the ventral body
wall?
- The external rectus fascia is the holding layer
of the ventral body wall.
144Why is the internal rectus fascia not routinely
closed in small animals?
- The internal sheath is not usually closed because
it does not add to the strength of closure and
increases adhesion formation.
145Why is the rectus abdominis muscle not included
in the closure?
- The rectus muscle layer is avoided because it
also does not add to strength of closure and
increases inflammation.
146What is the spacing and bite of sutures in the
linea alba? What determines this spacing?
- Full thickness bites must be taken in the linea
alba and should be placed 5 to 10mm apart and
incorporate 4 to 10mm of tissue.
147Describe the standard suture patterns used in
closing the linea alba. What suture materials
are acceptable for each pattern? Which are
unacceptable? What size should the suture
material be in dogs? In cats?
- Simple interrupted closure absorbable or
monofilament nonabsorbable suture size 2-0 to 1
in dogs, 2-0 or 3-0 in cat, place one suture in
center of incision, then close each end toward
the center. - Simple continuous closure synthetic absorbable
or monofilament nonabsorbable suture, size 2-0 to
1 in dogs, 2-0 or 3-0 in cats with extra throws
that must be placed on the knots. Start at each
end and close toward the center of the incision.
Tie two sutures together at center of incison.
Do not use chromic gut or stainless steel suture
in continuous pattern in linea alba.
148SURGERY OF THE STOMACH
149Describe, in detail, the abdominal approach used
for gastric procedures in small animals.
- Approach ventral midline incision from xyphoid
process to umbilicus, go through skin, sub Q,
linea alba, on stomach incise through mucosa and
submucosal layers
150Include the location of the incision, the tissue
layers incised, the vascular structures
encountered and how they are handled, and the
methods that may be used to manipulate the
falciform ligament.
- Vascular structures watch for cranial epigastric
artery - Falciform ligament cut it out
151How is the stomach elevated to the level of the
incision?
- Via placement of 2 stay sutures or babcock forceps
152 Where is the incision made in the stomach?
- In an avascular area on ventral body of stomach,
between greater curvature and lesser curvatures
153 Describe 2 methods of closing a gastrotomy
incision, with an advantage of each.
- 2 inverting layers cushing advantage
penetrates submucosa but not mucosa - Then a connell or lembert
- Connell penetrates mucosa a through and through
pattern - Lembert penetrates submucosa not mucosa, no
wicking effect
154What suture material (type and size) would you
choose for this application?
155Describe, in detail, the care of the
post-gastrotomy patient in the first 24 hours
following surgery.
- NPO for 12-24 hours
- Maintain hydration ie preload fluids
- Offer small amount of fluids at 12-24 hours
- If no vomiting offer small amount of digestible
food 1-2 hours later - Gradually return to normal diet 2-3 days later
156Of the 4 pyloric surgeries discussed, which
is/are a.) indicated only for congential pyloric
stenosis b.) best for biopsy sample c.) likely
to provide the largest increase in size of
pyloric opening d.) best choice for necrosis or
neoplasia of pylorus or pyloric antrum e.) a
clean procedure?
- Congenital pyloric stenosis fredet-ramstedt
pyloromyotomy - Biopsy sample Heineke-Mikulicz pyloroplasty
- Largest increase in size of pyloric opening
pylorectomy and gastroduodenostomy - Necrosis or neoplasia of pylorus or pyloric
antrum parital gastrectomy - Clean procedure ???
157What is the most common indication for partial
gastrectomy in the dog?
- Ischemic injury ( secondary to GDV) or
penetrating injury - Ischemic injury commonly at greature curvature
- Ischemic injury involving greater and lesser
curvatures
158 Which part of the stomach is most commonly
resected?
- Part of greater curvature
159Describe 2 types of resection and the closure for
each.
160What are the indications for a Billroth II
procedure?
161Why might you choose this procedure rather than a
Billroth I?
- Bc decreases tension on suture line when
extensive resection is required
162What complication may occur with a Billroth II
that does not occur with a Billroth I?
163Healthy canine gastric tissue almost invariably
heals extremely well. What do you think is the
most important reason for this?
164SURGERY OF THE INTESTINE
165Explain why intestinal surgery should be done as
soon as it is determined to be necessary.
- To prevent worsening of the condition and
decreased gut wall competance
166Which layer of the intestinal wall is the holding
layer?
167Which layer provides the earliest fluid-tight
seal?
168Why are inverting patterns not usually used for
anastamosis of the small intestine in dogs and
cats?
- Will decrease the size of the lumen
169Why is the omentum brought to the site of an
intestinal incision?
- To seal off the area and provide a blood supply
170When is serosal patching indicated, rather than
wrapping with the omentum?
- If there is significant damage to the serosal
surface
171What antibiotic is recommended for prophylaxis in
the small intestine?
172Is the same drug used for prophylaxis in colonic
surgery?
173Why is an enterotomy incision to remove a foreign
body made distal to the foreign body, rather than
over or proximal to it?
- Because you need to make the incision in healthy
tissue
174How can closure of an enterotomy increase luminal
diameter?
- Close transversely, placing first suture at ends
of incision
175List 3 reasons for using the end-to-end
appositional (approximating) technique for
intestinal resection and anastamosis in small
animals.
- Technically easy
- Maximizes luminal diameter
- Results in rapid mucosal regeneration
176Describe placement of the sutures when using a
simple interrupted pattern and a modified simple
continuous pattern.
- The first suture is placed at the mesenteric
border (leave suture long if you are using simple
continuous) - The second suture is placed at the antimesenteric
border (leave suture long if you are using simple
continuous) - If you are doing simple interrupted place the
remaining sutures 2mm from the edge and 2-3 mm
apart - If you are doing simple continuous use the long
ends of the suture to complete each half of the
incision
177Why is the first suture placed at the mesenteric
border?
- Because its the hardest to place
178Why is the mesentery closed?
- To avoid strangulating intestine that may get
stuck inside the hole
179What complication must be avoided in suturing the
mesentery?
- Avoid strangulating the mesenteric vessels
180List 3 methods of correcting disparity in lumen
size during anastamosis.
- Transect small segment at acute angle, large
segment at more obtuse angle - Space sutures in large segment farther apart
- Incise antimesenteric border of smaller segment
to spatulate or fish mouth smaller segment
181Which one is best for a large disparity?
- Incise antimesenteric border of smaller segment
to spatulate or fish mouth smaller segment
182Which is technically easiest to do ?
- Transect small segment at acute angle, large
segment at more obtuse angle
183How does closing the colon after colectomy in the
cat differ from closing the small intestine after
resection and anastamosis?
- Inverting closure for colectomy vs end to end
anastamosis for SI
184Why is this application a good use of an EEA
stapler?
- Provides a double layer inverting closure
185Ovariohysterectomy
186Where is the incision placed on the ventral
abdomen of the dog for ovariohysterectomy?
- The incision for the dog is a ventral midline
approach. The incision begins in the cranial 1/3
of distance from umbilicus to pubis.
187Where is it placed for the cat?
- In the cat, the incision is in the middle 1/3.
188Why should keyhole incisions be avoided?
- A keyhole is a small incision and these should be
avoided because if a pedicle starts to hemorrhage
the hemorrhage will not be detectable through
such a small incision.
189Describe the location of the ovaries and uterus
in the abdominal cavity as a whole and in
relation to the kidney, the colon, the urinary
bladder and the uterus.
- The mesovairum and mesometrium contain ovarian
and uterine vessels with or without fat. The
ovaries are located at the caudal pole of the
kidneys. The uterine horns are dorsal-lateral in
the body cavity. The uterine body is located
between urinary bladder and colon, adjacent to
ureters.
190 What are the attachment sites of the proper
ligament and the suspensory ligament?
- The proper ligament attaches the uterine horn and
ovary. The suspensory ligament attaches the
ovary to the body wall (cranial and dorsal to the
kidney).
191Which arteries supply the ovaries and the uterus?
- The ovarian arteries supply the cranial uterine
horns. The ovarian arteries and some branches of
the uterine arteries supply the ovaries and the
uterine arteries supply the uterus.
192How does venous drainage differ between right and
left sides of the animal?
- The right ovarian vein drains into the vena cava
and the left drains into the left renal vein
193What is the most important difference to you as a
surgeon between the mesometrium and mesovarium of
the dog compared to the cat?
- . In dogs, fat in the ovarian bursa, mesovarium
and mesometrium may obscure vessels.
194Describe the use of a spay hook to elevate the
uterine horn.
- The spay hook is placed into the abdominal cavity
in a dorsaocranial direction with the hook
portion facing the abdominal wall. The hook is
then turned around and brought back towards the
incision, this action should catch the uterine
horn.
195Why is the proper ligament clamped instead of the
uterine horn for retraction?
- The proper ligament is clamped to manipulate the
ovary and this ligament is used because of its
relative toughness as a tissue.
196Why is the suspensory ligament torn?
- The suspensory ligament is torn to permit
elevation of the ovary.
1971. What are two disadvantages to cutting the
suspensory ligament rather then tearing it?
- . The suspensory ligament is torn and not cut
because the suspensory ligament is located deep
in the cavity and one can not see what is being
cut.
198Describe the placement of Rochester-Carmelt
forceps when using the three clamp method of
ligation of the ovarian pedicle.
- Three Rochester Carmealt forceps are placed
across the ovarian pedicle through the window in
the mesovarium. The most distal clamp must be
proximal to the entire ovary.
199What suture material (type and size) is used for
ovarian and uterine ligations?
- The ligation of the ovarian pedicle absorbable
suture material (2-0 for dogs, 2-0 or 3-0 for
cats) or hemoclips are used.
200What suture material is contraindicated?
- Do not use non-absorbable material.
2011. How do you decide if the mesometrium must
be ligated in the dog?
- If the dog is very fat then ligation may be
required.
202What is the reason for removing all of the
uterine body in a dog?
- The entire uterine body in the dog is removed
because of a few cases of stump pyometria where
the dogs developed an infection following
spaying.
2031. Is this thinking valid, or would
ovariectomy be a better procedure?
- . It is very possible that because the incidence
is so low that this is not really a valid reason
for performing this procedure and that an
ovariectomy would be a better procedure.
204Describe methods of exposing the right and left
ovarian pedicles if hemorrhage occurs
- The right ovarian pedicle is examined for
bleeding by using the mesoduodenum to retract the
intestines. The left ovarian pedicle is examined
by using the mesocolon to retract the intestines.
Extension of he incision may be necessary to see
the ovarian pedicles.
205(No Transcript)
206CYSTOTOMY
207Describe the location of the urinary bladder in
relation to other abdominal organs.
- The full bladder is located along the ventral
abdominal wall. It is directly ventral to the
uterus in the female and directly ventral to the
rectum in the male
208Describe the anatomy of the organ ligamental
attachments, location of ureters and trigone,
apex, neck of bladder, urethral sphincter.
- The lateral ligaments contain the ureters and
must be preserved - The ventral ligament of the bladder attaches the
bladder to the ventral body wall and may be
excised - The ureters enter the bladder at the trigone
which is on the dorsal aspect of the bladder - The apex of the bladder is the most cranial
portion whereas the neck of the bladder is at the
caudal aspect - The urethral sphincter is the most caudal portion
of the trigone of the bladder and is within the
neck of the bladder
209Is the sphincter grossly visible at surgery?
210Why is a cystotomy incision commonly made on the
ventral aspect rather than the dorsal?
- To avoid the trigone and the nervous attachments
211What is one procedure in which the incision must
be on the ventrum?
212What is one possible complication of a ventral
incision?
- Risk of inverting the ventral ligament of the
bladder into the incision - Urine leakage is more likely
213Is the incision in the wall of the bladder more
or less likely to leak when the incision is made
on the ventrum?
- More likely due to gravity
214How can edema of the bladder wall during
cystotomy be minimized?
- Avoid handling of the bladder
215What part of the bladder is especially prone to
becoming edematous with surgical manipulation?
216How can the surgeon handle this specific problem?
217The urinary bladder is well vascularized and
usually heals very rapidly. In what 2 situations
might you expect healing to be delayed?
- Chronic cystitis
- Presence of a large amount of edema
218What suture pattern(s) would you use if you
expect healing to be delayed?
219If you are suturing a healthy bladder with a
simple continuous suture pattern, what type of
suture must you use?
- 3-0 or 4-0 absorbable suture
220The bladder usually bleeds profusely when
incised. How is hemorrhage from the cystotomy
incision controlled?
221Blood clots should be removed from the lumen of
the bladder before the bladder is closed. The
mucosa will continue to bleed during closure, but
large clots are seldom passed out the patients
urethra after surgery. What is happening to
control bleeding and to prevent formation of
large clots in the lumen of the bladder?
222CRYOSURGERY, ELECTROSURGERY AND LASER SURGERY
223What are 3 advantages of cryosurgical treatment
of a tumor, compared to treatment by sharp
excision or by chemotherapy?
- Rapid relief of pain
- Hemostasis
- No cumulative effect
224What is the major disadvantage, again compared to
other treatment modalities?
- Can only be used for superficial tumors
225List the events of direct and indirect cellular
injury expected with freezing.
- Direct
- Formation of ice crystals
- Intracellular ice crystals (most damaging d/t
rupture of cell membranes) - Extracellular ice crystals
- Indirect
- Vascular stasis (increased vessel permeability,
loss of plasma, causes thrombosis and infarction)
226 Why does slow thawing cause more reliable cell
death?
- Permits recrystallization, expansion of small
crystals to larger more damaging size
227Does the rate of thaw affect direct or indirect
cell injury?
228Why is a second freeze-thaw cycle used why is
one cycle not always sufficient?
- Tissues near periphery of ice ball or near major
blood vessels may not be destroyed - Pre-cooled tissue freezes faster
229List 3 anatomical/physiological characteristics
of tissue that reduce susceptibility to
cryonecrosis.
- Low water content (ie cornea)
- Low cellularity (nerves and bones)
- Highly vascular tissues and large blood vessels
230Which of these situations is helpful to you as a
surgeon?
- Low cellularity- you wont damage nerves or bone
231What are 2 reasons that liquid nitrogen is used
routinely as a cryogen, rather than nitrous
oxide?
232What are 2 advantages of spray application of
liquid nitrogen, compared to probe application?
- More heat removed from tissue
- More effective
233What are 2 advantages of probe application?
- Easier to control
- Less lethal to tissues
234Why is only about 75 of the tissue within the
visible ice ball destroyed?
- Not all of the cells in the periphery of the ice
ball will die due to higher temperatures
235When using a pyrometer, where are the temperature
probes placed?
- In the normal tissue adjacent to the deepest
portion of the target tissue
236What recorded temperature indicates that the
target tissue is destroyed?
237Is sterile preparation of the target tissue
required for cryosurgery?
- The area is clipped and cleaned if possible but
not necessary
238Describe the preparation used for a lesion on
the eyelid of a dog
239Describe the preparation used for a lesion in a
cats mouth.
240How can surrounding tissues be protected when
using spray application?
- Use Styrofoam or petroleum jelly
241Describe the steps of tissue death, necrosis and
healing immediately after freezing, at 1-3 days,
and at 1-2 weeks.
- Immediately- edema and erythema followed by
vascular stasis, thrombosis and ischemia - 1-3 days dark, sharply demarcated zone
separating necrotic tissue from surrounding
tissue - 1-2 weeks tissue sloughs, leaving granulation
tissue bed
242What type of healing occurs?
243In what parts of the animals body might this
process cause secondary problems?
- Any area that is subject to frequent movement (ie
knee)
244List 2 specific indications for cryosurgery
- Cutaneous lesions
- Lesions on or near the eye
- Oral lesions, perineal lesions
245List 2 specific contraindications for
cryosurgery, explain the possible problems that
may result from use of cryosurgery.
- Mast cell tumors- cell lysis releases histamine
and heparin - Tumors with major bony involvement- may result in
spontaneous fractures - Lesions near major blood vessels and nerves- can
be destroyed by necrosis and sloughing of
surrounding tissues
246What are the advantages of electroscalpel
technique?
- Decreases total blood loss
- Decrease need for ligatures therefore decrease
foreign material left in wound - Decrease operating time
247What are the disadvantages of electroscalpel
technique?
- Decrease wound healing
- Decrease resistance of wound to infection
248 In which tissue layer is delayed healing most
pronounced?
249What are 2 contraindications for electrosurgery?
- Presence of alcohol, methane, bowel gases, ether,
or cyclopropane - Tissue with poor blood supply
250Hemostasis by electrocautery is not effective if
the vessels are too large. What are the limits
in diameter of vessels for this technique?
- Arterieslt 1mm in diameter
- Veins lt 2 mm in diameter
251Explain the pathway of the current used with
monopolar cautery and with bipolar cautery.
- Monopolar
- From active electrode through patients body to a
ground plate - Bipolar
- Current passes from one tip through tissues to
opposite tip
252What are advantages associated specifically with
monopolar cautery?
- Same handpiece used for coagulation, cutting and
fulgration - Modulated pulsed sine wave permits simultaneous
cutting and coagulation
253What are 2 important advantages of bipolar
cautery?
- Less current required because current passes
through much smaller volume of tissue - Less risk of injury to surrounding tissues
- No risk of alternate pathway burns
- Effective coagulation in wet field
254Define electrofulguration.
- Passage of a damped current from an active
electrode to tissue using a spark gap of gt1mm - Dehydrates superficial tissue, resulting in cell
death and coagulation of small vessels
255Give an example of appropriate use of
electrofulguration in small animals
- Good for rectal polyps
- Very superficial tissues
256What is photothermal laser-tissue interaction?
- Laser light absorbed and converted to heat within
tissue
257What is the primary use of this type of
interaction?
- Precise cutting by vaporizing tissue
258What is a possible complication?
- Risk of carbonization of tissues
259Define photodisruptive and photochemical
laser-tissue interaction.
- Photodisruptive- mechanical disruption of tissue
or calculi - Photochemical laser-tissue interaction- directly
breaks chemical bonds or excites molecules to
reactive biochemical sates
260What are potential uses of these modalities?
- Photodisruptive- lithotripsy, ophthalmic
procedures - Photochemical- killing neoplastic cells
261List 2 advantages associated with use of
operative lasers.
- Excellent hemostasis
- Reduced postop swelling and pain
262List 1 disadvantage associated with use of
operative lasers.
- Slow healing compared to scalpel created
incisions
263List 3 dangers associated with use of operative
lasers.
- Corneal and retinal injuries (protect patients
eyes) - Smoke
- Fire (laser safe ET tube must be used)
264Several applications of laser surgery in small
animal practice are mentioned in your notes.
With the information you have been given about
many surgical procedures, can you think of other
possible applications?
265CASTRATION
266Describe the clipping and prepping of the skin
before prescrotal castration in the dog. How
would this differ in castration by scrotal
ablation?
- The prescrotal area is clipped and prepped
routinely but be careful with clipper blade, may
cause edema. The scrotum is prepped by cutting
hairs with scissors, it is draped out of the
field - The scrotum is shaved and draped within the field
for scrotal ablation
267What are the landmarks for the skin incision in a
prescrotal castration in the dog?
- From caudal end of penis to the cranial base of
the scrotum
268What precautions must be taken in making this
incision?
- Avoid damaging the penis and urethra
269What are two ways of making this incision (skin
incision)
- Incise through the tunic (open)
- Dont incise through the tunic (closed)
270List the tissue layers incised for closed
castration and for open castration?
- Closed
- Skin of scrotum, spermatic fascia
- Open
- Skin of scrotum, spermatic fascia, parietal tunic
271What are the 2 important advantages of open
castration?
- Less risk of ligature slipping
- Less risk of abdominal hemorrhage
272What are the 2 important advantages of closed
castration?
- Less risk of scrotal hematoma
- Less postop swelling
- Slightly quicker
273Describe closure of a prescrotal castration.
- Deep fascia/SQ tissue
- SQ tissue
- Skin or intradermal pattern
274In what important way does feline castration
differ from canine castration?
- Complications are more rare in cats
275Is feline castration an aseptic procedure?
276Is canine castration an aseptic procedure?
277In which species is infection following
castration more common?
278Why do you think would this be true?
- Complications in general are more common in the
dog - The incision is closed in dogs which doesnt
allow for draining
279SURGERY OF THE EAR
280What are 2 surgical procedures used for
correction of auricula hematoma?
- Fresh hematoma
- aspirate of hematoma, injection of
glucocorticoid into space, pressure bandage - Fresh or chronic hematoma
- incise, evavuate hematoma, suture
281What are the indications and complications for
each procedure?
- Pressure necrosis
- recurrance
282 Where are the major arteries and veins of the
pinna?
- Arterial branches of great auricular artery
from external carotid artery - Medial caudal auricular artery
- Intermediate caudal auricular artery
- Lateral caudal auricalar artery
- venous branches of internal maxillary vein
- Cranial auricular vein
- Caudal auricular vein
Slide 283