1. LESSON 3 Types of surgeries and anaethesia, Surgical instruments and suture materials

2. OBJECTIVES By the end of this lesson, you should be able to: 1.Describe list and describe different types of surgeries 2.List and describe different type of anaesthesia 3.Classify surgical instrument 4.Classify suture materials, describe their tensile strength and sizes and indicate where they are used

3. Types of surgeries Surgery can be classified depending on 1.magnitude of the operation - depending on the seriousness of the illness, the parts of the body affected, the complexity of the operation, and the expected recovery time into major, minor or day case surgery 2.Technique used to perform the surgery 3.Purpose of the surgery 4.Urgency – Elective (cold), urgent and emergency

4. Major Surgery These are operations which take a long to perform, have long recovery period, may involve a stay in intensive care or take several days in the hospital post operatively. There is a higher risk of complications after such surgeries. They include but are not limited to surgeries of the head, neck, chest, and abdomen.

5. Major surgery cont …. In children, types of major surgery may include, but are not limited to, the following: – removal of brain tumors – correction of bone malformations of the skull and face – repair of congenital heart disease, transplantation of organs, and repair of intestinal malformations – correction of spinal abnormalities and treatment of injuries sustained from major blunt trauma – correction of problems in fetal development of the lungs, intestines, diaphragm, or anus.

6. minor surgery These are operations which take a short time to perform, involve non vital organs, have short hospital stay and rarely complicate, Examples of the most common types of minor surgeries may include, but are not limited to, the following: – placement of ear tubes – hernia repairs – correction of bone fractures – removal of skin lesions – biopsy of growths

7. Depending on the technique used 1.Conventional surgery 2.Minimal access surgery 3.Keyhole surgery 4.Laparoscopic 5.Microsurgery 6.Endoscopic surgery

8. Purpose of the surgery Diagnostic surgery Exploratory surgery Reconstructive surgery Cosmetic surgery Transplant surgery

9. Day care A growing number of conditions needing operation can now be treated by day surgery, usually at the day surgery unit of a hospital. The patient arrives, has the operation and goes home on the same day. The hospital will be able to answer any questions patients may have about specific arrangements for day surgery.

10. Elective surgery This term is used for operations that are planned in advance, to distinguish them from operations performed as an emergency.

11. Emergency surgery Operations that require immediate admission to hospital, usually through the accident and emergency department. They are usually performed within 24 hours, and may be done immediately or during the night for serious or life-threatening conditions. Examples include acute appendicitis; haemorrhage, perforation or obstruction of the intestines; major trauma, including multiple fractures; and a ruptured spleen or aneurysm, ectopic pregnancy.

12. Keyhole surgery Advances in surgical treatments have enabled many conditions to be treated by "keyhole surgery", which involves very small incisions and less pain and trauma for the patient than in conventional surgery. The surgeon can see the area to be operated on by looking through a fine tube with a light on the end (known as a fibre optic light source) and carries out the operation by using special instruments inserted through the tube. The operations are carried out under anaesthesia.

13. Laparoscopic surgery This is similar to keyhole surgery but refers especially to operations performed inside the abdomen and in the peritoneum (the lining of the abdomen). Microsurgery Surgeons use a powerful magnifying device (microscope) to enable them to operate on tiny structures such as small arteries, nerves, the bones of the middle ear or inside the eye. Delicate and extremely small instruments are used.

14. Organ Transplant Surgery Where a patient has a failing organ, for example a diseased kidney, it is sometimes possible to replace it with a healthy one donated by another human being. In the case of a kidney the donor may be a relative or someone who has recently died and had completed an organ donor card requesting that their body be used to help others. Examples of organs that can be transplanted are the liver, kidney and the heart

15. ANAESTHESIA Anaesthesia is a medical procedure used to make patients undergoing surgery comfortable. It involves the use of medicines to block pain sensations (analgesia) during surgery and other medical procedures. Anesthesia also reduces many of your body's normal stress reactions to surgery An anaesthetist (person trained in anaesthesia) normally does the procedure

16. Types of Anaesthesia Anaesthesia is classified into: 1.General anaesthesia 2.Regional anaesthesia – Spinal – Epidural – Peripheral nerve block 3.Local anaeshtesia

17. General Anaesthesia (GA) GA involves drugs which cause unconsciousness give by inhalation (anaesthetic gases) or intravenously. The gases are given via an endotracheal tube (ETT) or a laryngeal mask placed on the opening of the larynx. Often the patient is paralysed by giving a muscle relaxant to reduce the muscle tension during surgery, in which case the patient breathing is taken over by a machine called a ventillator Often anaesthesia is induced via the intravenous route, maintained through inhalation and supplemented intravenously.

18. GA Cont …. It affects the brain as well as the entire body. The patients are completely unconscious and do not feel pain during the surgery. In addition, general anesthesia may cause forgetfulness (amnesia) in postoperative period.

19. Regional Anaesthesia Regional anaesthesia involves injection of a local anesthetic around major nerves or the spinal cord to block pain from a larger but still limited part of the body. Patients on regional anaesthesia are usually given sedatives to help them sleep or relax during surgery. Major types of regional anesthesia include: 1.Spinal anaesthesia 2.Epidural anaesthesia 3.Peripheral nerve blocks

20. Spinal anaesthesia Spinal anaesthesia involves injecting a local anaesthetic drug in the subarachnoid space into the cerebrospinal fluid. It produces profound numbness and loss of movement in the lower part of the body The LA is introduced into the subarachnoid space via a lumbar puncture (LP) which is made by a fine spinal needle after LA is infiltrated in the skin of the back

21. Epidural Anaesthesia Epidural anaethesia involves identification of the spinal epidural space and injection of LA into the space the onset of anaesthesia is slow and is infrequently used alone. Most often a fine tube called an epidural catheter is introduced into the space to give pain relief after the operation to infuse analgesic. This is call spinal analgesia. Using epidural anaesthesia usually give better pain relief post operatively. This is particularly important in major operations and in patients with other illnesses that cause pain

22. Peripheral Nerve Blocks A local anesthetic is injected near a specific nerve or group of nerves to block pain from the area of the body supplied by the nerve. Nerve blocks are most commonly used for procedures on the hands, arms, feet, legs, or face. Usually used with GA to give longer lasting pain relief

23. Local Anaesthesia (LA) Involves injection of a local anesthetic directly into the surgical area to block pain sensations. It is used only for minor procedures on a limited part of the body. The patient may remain awake, although the patient may be given a sedative to help them relax or sleep during the surgery

24. Surgical Instruments A surgical instrument is a specially designed tool or device for performing specific actions of carrying out desired effects during an operation, such as modifying tissues, or to provide access for viewing it. Some surgical instruments are designed for general use in surgery, while others are designed for a specific procedure or surgery. Accordingly, the nomenclature of surgical instruments follows certain patterns, such as a description of the action it performs, the name of its inventor(s), or a compound scientific name related to the surgery

25. Classification of Surgical Instruments There are several classes of surgical instruments: Graspers, such as forceps Clamps and occluders for blood vessels and other organs Retractors, used to spread open skin, ribs and other tissue Distractors, positioners and stereostatic devices Mechanical cutters (scalpels, lancets, drill bits, rasps, trocars, ligature, etc.)

26. Surgical instruments cont … Suctions tips and tubes, for removal of bodily fluids Dilators and specula, for access to narrow passages or incisions Sealing devices as surgical staplers,... Irrigation and injection needles, tips and tubes, for introducing fluid Tyndallers, to help "wedge" open damaged tissues in the brain. Powered devices, such as drills and dermatomes

27. Surgical instruments cont… Scopes and probes, including fiber endoscopes and tactile probes Carriers and appliers for optical, electronic and mechanical devices Ultrasound tissue disruptors, cryotomes and cutting laser guides Measurement devices, such as rulers and calipers

28. Suture Materials Surgical suture is a medical device used to hold body tissues together after an injury or surgery. It generally consists of a needle with an attached length of thread. A number of different shapes, sizes, and thread materials have been developed over time. In modern surgery, many kinds of ligature and suture materials are used. All sutures can be grouped into two classes: 1.Non-absorbable sutures 2.absorbable sutures

29. Non-absorbable sutures These are sutures that cannot be absorbed by the body cells and fluids in which they are embedded during the healing process. When used as buried sutures, these sutures become surrounded or encapsulated in fibrous tissue and remain as innocuous foreign bodies. When used as skin sutures, they are removed after the skin has healed. The most commonly used sutures of this type and the characteristics associated with each are listed below:

30. Non absorbable suture cont … Non-absorbable sutures are made of special silk or the synthetics polypropylene, polyester or nylon. Stainless steel wires are commonly used in orthopedic surgery and for sternal closure closure in cardiac surgery. These may or may not have coatings to enhance their performance characteristics. Non-absorbable sutures are used either on skin wound closure, where the sutures can be removed after a few weeks, or in stressful internal environments where absorbable sutures will not suffice.

31. Examples of non-absorbable sutures Silk - frequently reacts with tissue and can be “spit” from the wound. Cotton - loses tensile strength with each autoclaving. Linen - is better than silk or cotton but is more expensive and not as readily available. Synthetic materials (e.g., nylon, dermalon) - are excellent, particularly for surface use. They cause very little tissue reaction. Their only problem seems to be the tendency for the knots to come untied.

32. Synthetic non-absorbable suture cont… Nylon is preferred over silk for face and lip areas because silk too often causes tissue reactions. Rust-proof metal Usually stainless steel wire Has the least tissue reaction of all suture materials and is by far the strongest. The primary problems associated with it are that it is more difficult to use because it kinks and that it must be cut with wire cutters.

33. Absorbable sutures Absorbable suture materials include the original catgut as well as the newer synthetics polyglycolic acid (vicryl), polylactic acid, polydioxanone(PDS), and caprolactone. They are broken down by various processes including hydrolysis (polyglycolic acid) and proteolytic enzymatic degradation. It is this characteristic that enhances their use beneath the skin surfaces and on mucous membranes. Depending on the material, the process can be from ten days to eight weeks.

34. Absorbable sutures cont … They are used in patients who cannot return for suture removal, or in internal body tissues. In both cases, they will hold the body tissues together long enough to allow healing, but will disintegrate so that they do not leave foreign material or require further procedures. Occasionally, absorbable sutures can cause inflammation and be rejected by the body rather than absorbed. Surgical gut fulfills the requirements for the perfect suture i.e ease of manufacture, tensile strength, and variety.

35. Manufacture of catgut Though it is referred to as “catgut,” surgical gut is derived from the submucosal connective tissue of the first one-third (about 8 m) of the small intestine of healthy government-inspected sheep. The intestine of the sheep has certain characteristics that make it especially adaptable for surgical use. Among these characteristics is its uniformly fine- grained tissue structure and its great tensile strength and elasticity.

36. Tensile strength of sutures Suture sizes are defined by the United States Pharmacopeia (U.S.P.). This suture material is available in sizes of #6-0 to #0 and #1 to #4, with #6-0 being the smallest diameter and #4 being the largest. The commonly used catgut sizes in general surgery are #4-0 to #2 The tensile strength increases with the diameter of the suture. Modern sutures range from #5 (heavy braided suture for orthopedics) to #11-0 (fine monofilament suture for ophthalmics).

37. Needles Traumatic needles are needles with holes or eyes which are supplied to the hospital separate from their suture thread. Atraumatic needles with sutures comprise an eyeless needle attached to a specific length of suture thread. The suture manufacturer swages the suture thread to the eyeless atraumatic needle at the factory. There are several shapes of surgical needles. These include straight, 1/4 circle, 3/8 circle, 1/2 circle, 5/8 circle, compound curve, half curved, and half curved at both ends of a straight segment.

38. Needles cont … Needles may also be classified by their point geometry; examples include: Taper (needle body is round and tapers smoothly to a point) Cutting (needle body is triangular and has a sharpened cutting edge on the inside) Reverse cutting (cutting edge on the outside) Trocar point or tapercut (needle body is round and tapered, but ends in a small triangular cutting point) Blunt points for sewing friable tissues Side cutting or spatula points (flat on top and bottom with a cutting edge along the front to one side) for eye surgery

39. Conclusion Different types of surgeries – major, minor, conventional, minimal access, endoscopic Types of anaesthesia – GA, RA, LA Surgical Instruments - Classification Suture Materials – Classification, thread tensile strength and sizes, needles sizes and types

40. 8/17/2015