Principles of operative technique

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Almost 90 years after his death, Halsted's principles remain one of the most important creeds for the surgeon. Many of Halsted's principles are tangible and easily recognized. The importance of asepsis is stressed by everyone practising surgery (although not always adhered to as diligently as it should be). Haemostasis (or the lack thereof) is readily evident and demands attention before each surgery is completed and the patient discharged from hospital. Most surgeons understand the need to minimize dead space and take measures to close it…This chapter aims to highlight the most important principles of surgery that have an impact on outcome. It will also provide practical hints as to how better to follow Halsted's principles. The following are addressed: Incision and excision of tissue; Haemostasis; Care and handling of tissue; Closure of tissue planes; The surgical assistant; and Minimizing operative time.

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21.2 Correct instrument handling for a larger blade (No. 10). Note how the belly of the blade is applied to the surface to be cut.
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21.3 Correct instrument handling for a smaller blade (No. 15). This allows more precise application of the tip of the blade and the cutting edge directly behind it.
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21.4 Demonstration of the correct technique for making a skin incision. The skin is stretched and stabilized with the non-dominant hand, allowing the blade to incise cleanly.
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21.5 Coordination between surgeon and assistant when dividing tissue planes. The plane of dissection is established by the surgeon and the tissues are elevated prior to being separated by the assistant (in this case with diathermy).
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21.6 Correct use of surgical scissors. These blunt-sharp pointed scissors are used for cutting suture material.
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21.7 DeBakey forceps have an atraumatic tip and are designed for handling delicate tissues such as blood vessels.
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21.8 Right-angled forceps (e.g. Lahey bile duct forceps) are useful for establishing planes of tissue dissection and stabilizing the tissue plane for division with scissors or diathermy.
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21.9 Use of atraumatic forceps and right-angled forceps to isolate vessels prior to ligation during nephrectomy.
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21.12 Correct use of thumb forceps, being held in a pencil grip as an extension of the fingers.
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21.13 Allis (top) and Babcock (bottom) forceps. Allis forceps have a saw-toothed edge designed for grasping and retracting collagen-rich tissues. They cause crushing of the tissue edge and should not be used for the skin. Babcock forceps have a non-crushing tip designed for delicate tissues.
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21.14 Senn hand-held retractor. Note the sharp tines at one end and the blade at the other end, allowing the retractor to be reversed for different purposes.
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21.15 Malleable ribbon retractors. A number of retractors are being used in the abdominal cavity to expose an adrenal gland tumour. Note that the malleable retractors allow the assistants to keep their hands out of the surgical field and therefore use of retractors is preferable to fingers for the same purpose.
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21.16 Allison lung retractor. A flat-bladed hand-held retractor is useful for retracting abdominal viscera as well as the lung or heart.
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21.17 Gelpi self-retaining retractor. The sharp tips engage the tissue with little risk of slipping, but can tear the tissues if too much retraction is applied. Gelpi retractors being used in the neck during surgery for a collapsing trachea.
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21.18 Weitlaner retractors with multiple tines to distribute pressure over a greater area. The tines can be either sharp or blunt.
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21.19 Balfour retractor. This has elongated hoops and is useful for retraction of soft tissues where the blades do not need to engage the tissue (i.e. when there is little chance of slippage).
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21.20 Finochietto retractor. This is designed for thoracic retraction. The blades are ridged to engage the tissues better. In areas where slippage is likely, the Gelpi retractor is often used as well.
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21.21 Use of stay sutures in the bladder wall. Note how the abdominal contents are protected from contamination and kept moist with saline-soaked laparotomy swabs. Note also the multi-holed Poole suction cannula.
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21.22 Correct placement of the needle in the jaws of the needle-holder.
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21.23 Palm-down use of needle-holders. This is more comfortable and allows the hand to move in a more natural direction than using the instrument with the palm facing upwards. Holding needle-holders with the palm upwards. While sometimes unavoidable, this allows for less range of movement and feels more awkward.
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21.24 Surgical instruments should be placed on the table in an orderly fashion and maintained in this order wherever possible. The instruments should be cleaned by the assistant each time they are returned to the table.
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21.25 The assistant should be actively engaged in the surgery, trying to anticipate the surgeon’s requirements for the next stage, whether it be retraction or passing something from the instrument table.
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