Lecture 1.
Introduction in topographic anatomy. Operative surgery of cerebral part of head
Topographical anatomy is a science about the dimensional structure of healthy human body organs, tissues and parts of the body. “Topography” comes from two Greek words: “topos” – “a place” and “grapho”–“to write”.
The normal structure of the body has formed during the evolutional process in the presence of numerous factors: the gravity, efficacy of organs and systems, ensuring the metabolism, heat regulation, protection, reproduction of population, existence in the society, at once a person, changing the environment, also changes. These changes are observed as the versions of norm and progressive anomalies of the structure. The changes are to be studied, systematized and taken into consideration while carrying out prophylactic, diagnostic and medical measures within the system of public health.
The founder of topographical anatomy and operative surgery is Mykola Ivanovych Pyrogov (1810-1881). He made a complete revolution in conceptions of studying of topographical anatomy. Moreover, he proved the importance of applied anatomy for the clinicians.
Topographical anatomy is a clinically applied morphological science. The doctors of any speciality need the knowledge of its achievements, but the surgeons are directly interested in it. That is why this science is studied together with operative surgery. Topographical anatomy and operative surgery is “one in two science”, ofteamed “surgical anatomy”, because without the knowledge about peculiarities and variants of structure, form, location and mutual location of anatomical structures, their age-pecific and sexual properties it is impossible to diagnose in the proper time and correctly and to prescribe the necessary treatment to the patient.
Topographical anatomy studies the structure of the human body layer- by-layer that, is to say from the surface deep into.
For orientation in the body surface and unification of topical constituent, the topographical and anatomical areas are determined. The conventional lines are their borders drawn along the skin folds and the points (external guiding lines, or landmarks) – muscular, bony and connective tissue formations determined by sight or palpably (ribs, muscular borders, tendons). The human body surface is studied with the help of anthropometric measurements.
For orientation in deep tissue layers and cellular spaces, the fascias, aponeurosis, muscular containers, bundle sheaths are of great importance.
For orientation in the body cavities, it is necessary to have an idea of typical spatial location, mutual location (syntopy) and external organs’ form, or shape. The methods of studying topographical anatomy to have such an abstract idea are given below:
– holotopy- the marking of the organ’s borders on the surface of body parts;
– projection – the marking of the organ’s borders on the body areas;
– skeletopy (skeletopia)-the marking of the organ’s borders on the skeleton (bones, cartilages).
The operative surgery is the science about surgical operations, methods of surgical operations, the essence of which comes to mechanical action upon the organs and tissues with diagnostic, medical or reconstructive purpose. The operative surgery studies, elaborates and applies operative approaches and techniques taking into account preoperative preparation, operative technologies and properties of the postoperative period.
A surgical operation is one of the crucial stages of comprehensive checkup treatment of the patient of surgical type. During the operation, the surgeon takes into account the anatomical accessibility, technical possibility and physiological propriety of operation – the principles, formulated by the outstanding surgeon M.N.Burdenko.
The anatomical accessibility is the securing of fastest access to the object under operation without injuries of vitally important structures. For this aim, the surgeon is guided by the projections of interior organs (viscera) and neurovascular fascicles on the body are as, direction of the muscle fibers and fissure-lines of Langer. For example, the left-side access is proved for cervical esophagus, taking into account the declination of this one to the left relative to trachea and negligible possibility of left turning laryngeal nerve injury.
The technical possibility is the presence of techni- sources, equipment and medical facilities at the al of the surgeon for effective and successful real- i of complex and laborious stages of surgical ion, opportune ablation of possible complications tal control of the patient’ state. For example, the sx operations on the heart and great vessels he use of the artificial blood circulation system, is of vessels machine suture, ultrasound and echniques, monitors etc. i physiological propriety is the possibility to save jan at the most after operation. For example, sration on the pancreas is accessible anatomi- nd technically is not complicated but it must be sration exclusively sparing for tissues of the pan- or saving its functionality, he surgical operation is the certain algorithm hanical actions of the surgeon upon organs and of a live person for medical (healing), diagnostic nstructive purpose. The surgical operation con- three main stages: operative approach; operative method; exit of operation.
The name of operations is being determined by the operative method and being formed according to such a scheme: name of organ + type of action + mode (modification). For example, on account of stomach ulcer are using: gastrectomy (in other words, excision of the part of the stomach providing the formation of anastomosis with duodenum stump (method Billroth-1) or with a loop of empty one (method Billroth-2). Both methods may be applied according to one of numerous modes (modifications) differing by the technique of anastomosis’ formation. The operation may be named by the author, like the operation of Troyanov-Trendelenburg: the operative ligation of the great hypodermic saphenous veiear the place of its joint with the femoral vein, realized in case of superficial vein varicose of the lower extremities.
Let us examine the component parts of the surgical operation:
1. Operative access – the formation of an incisional wound within aseptic conditions. Its dimension (direction, length, depth) must ensure the extraction of the organ from the wound and placing of the surgical instruments at certain angle of the operative action for full visual control by the surgeon and assistants. The operative access must be comfortable for the realizing of the operative mode and at the same time mustn’t entail cosmetic effect after the operation. According to the direction of skin dissections, the access can be: slit, oblique, transverse, combined.
2. Operative method-realizing of a certain (medical, diagnostic, mechanical) action on body part, organ or tissues. The name of the operation reflects the action:
■incisio – the cut (dissection);
• amputatio – extraction of peripheral part a limb
• exarticulatio – extraction of the peripheral part of the extremity on the joint level
• tomia – cut, or dissection gastrotomia – stomach cut;
■ stomia – fistula, to provide with an opening, or mouth (the surgical creation of an artificial opening into hollow organ;
■ anastomos – formation of anastomosis (fistula) between the hollow
■ ectomia-ablation (excision) of an organ (e.g. cholecystectomy-
■ sectio – cutting, dissection of a hollow organ (e.g. sectio alta – high dissecton – the dissection of the urinary bladder; venesectio – cutting of veins);
■ resectio – extraction of organ’s part under condition of conservation of peripheral part
■ punctio – puncture, perforation, tapping;
• rraphia – suture; e.g. gastrorraphic – stomach suture, neurorraphia – nerve suture;
• ligature – ligation of vessel;
• im(trans)plantation – a surgical procedure that places something in the human body;
• plasty- shaping or surgical formation (gastroplasty –
plastic operation of the stomach);
■ reconstructive operation – is to reassemble or to reform from constituent parts.
3. Exit of operation – is the recovery of the normal tissues’ structure layer-by-layer (anatomical and physiological continuity of structures), violated during the operation.
According to the term, the operations may be:
emergency – the operation of the first aid in cases when the delay is dangerous for the patient’s live, for example, in case of the arterial hemorrhage it is necessary keeps the patient under observation and clinical course in dynamics, prescribes necessary diagnostic checkup, expert’s consultation. Example: appendectomy;
– planned – the operation done at any time but after the systematic examination, reasonable preparation and favorable conditions for patient, for example in case of gastrectomy.
Operations may be bloodless (closed surgery) and bloody. Among the bloodless operations are such instrument operations as: cystoscopy, bronchoscopy gastroscopy, colonoscopy; and non-instrument operations: reduction of hip dislocation, shoulder, lower jaw. The bloody operations are entailed by forced injury of vessels during the access.
According to the character and aim, operations may be radical and palliative. Radical operations are directed at the definitive recovery of the patient by the elimination both disorder provoked by disease and pathologic nidus (etiopathogenetic substratum of disease). For example, on account of tumor narrowing the intestine open, the radical operation consists in ablation of this tumor with the intestine part (resection), and then the continuity of intestine is revived with the help of anastomosis.
The palliative operations are directed to agony relief by means of pathological disorders elimination but the causes of disease remain. So, in the presence of the same tumor narrowing the intestine open for the elimination of obstruction one can make bypass fistula (anastomosis) between the adductor and adducent intestine stumps. The inoperable tumor remains.
There are single-stage and stages operations. The single-stage operation from the beginning to the end is realized at one go, that is to say during one surgical operation. The stages operations are realized in cases when the state of patient’s health or the danger of complications doesn’t permit to finish surgical operation atone stage, as a result one part of the operation is realized one day and other is realized after the patient’s recovery of trauma. For example, in case of supercystic adenomectomy. The excision of prostate adenoma in serious cases is divided into two stages. During the first stage is carried out epicys-tostomy (sectio alta of the urinary bladder and formation of fistula), then the patient is prepare for the next stage of the operation – excision of prostate (adenomectomia). The stages operations are in common practice widely in plastic surgery when the recovery, or renew, of anatomical structures is realized in several stages, for example, by means of skin item dislocation on Filatov-Gillies tubed pedicle flap to hide the defect.
If the surgical operation is realized several times on account of the same disease, it is named reoperation (repeated operation), for example, reamputation (adding the prefix “re” to the name).
There are also operations of choice. This is the group of operations suggested for surgery or certain disease. Amongst them the surgeon or conference of doctors choose those having more advantages (indications), taking into account the clinical diagnosis of the patient, his peculiarities and technical possibility of realization. For example, on account of stenosing duodenal ulcer under one condition it is possible to carry out the stomach resection by Billroth-2 and under other conditions it is organ-preserving operation is possible (selective proximal vagotomy with duodenojejunostomy).
Diagnostic operations are directed to specification of diagnosis, for example, biopsy, puncture of pleura and joints, laparoscopy, vasography, diagnostic laparotomy and thoracotomy.
According to the level of cleanness, the operations are divided into the four groups:
– Clean – planned operations without opening of caval organs (herniotomy, spleenectomy, operations on account of heart disease);
– Relatively clean – operations with the opening of the cavitary organ (stomach resection, cholecystectomy on account of gallstone disease);
– Polluted – operations with the inevitable getting of organ’s content into the wound (epicystostomy, gas-trotomy, enterotomy);
– Dirty, or primary-infected – operations on account of peritonitis, abscess, phlegmon,
Operations of pediatric surgery have their peculiarities. They must take into consideration the anatomical and physiological properties of growing organism, the mechanism of its posterior development. The emergency operations can be carried out successfully after birth (surgical correction of congenital malformation). There are certain terms of realization in expedient time for the diseases which need urgent operation. One of the main task of the pediatric surgeon is the right choice about the term of operation. The child’s age cannot be the contraindication to surgery.
The Actions of the Surgeon during Typical
Operation
I. Operative approach means to make the wound for the exposure of the organ to be operated on.
4. Preparation of the operative field: hands of the surgeon to ensure asepsis during surgery, using surgical clothes and linen to cover the area to be cut.
5. To mark the skin for dissection, to use local anesthesia if necessary.
6. The incision of the soft tissues (e.g. laparotomy), making the wound, control of hemostasis.
7. The revision (exploration, abdominoscopy, surgical revision) of the abdominal cavity, delivering the organ into the wound. Methods of revision – inspection and palpation.
■ Operative method – the main part of the operation, performing the action contained in the name of the operation.
• To determine the border between healthy pathologically changed tissues of the organ
• Mobilization of the organ – cutting from the sources of blood supply, mesenteries (ligaments).
• Application of clamps to avoid flouring out (spillage) the content of the organ into the body cavity. Crushing forceps are applied on the part of the organ to be removed, the elastic ones – on the remaining part.
• Proper operative method (p.e. cutting off).
• Renewal, or reconstruction, of the anatomical and physiological integrity and continuity of the orga- nocomplex (anastomosis, peritonization, placing sutures etc.).
■ Exit of operation.
– Obtaining a careful hemostasis.
– Insertion a drain through the wound.
– Suture of the wound.
– Aseptic bandage.
STAGES OF SURGICAL OPERATION
1. The Surgeon and Patient Preparation to
the Operation
A surgical operation is realized in sterile conditions. A prevention of penetration of infection to the operative wound is named asepsis and fight against an infection in a wound is named antisepsis. The basic principles of asepsis and antisepsis were formulated by Semmetweiss, Paster and Lister. In 1867 Lister for the first time reported about the use of carbolic acid as an antiseptic remedy. In 1882 Trendelenburg, Bergman, Shimmelbush and Furberger came to the conclusion about steam sterilization. The aseptic trend in surgery became the priority after American Khalstedt (student of Lister) had applied sterile rubber gloves in 1890, and the English Hunter had used sterile facial mask in 1900.
The sterility (an absence of bacteria and their spores) on the preparative stage of surgeon and patient to the operation is provided by certain measures in preoperative and operating rooms:
– the surgeon changes his clothes to surgical suit and scrubs his hands;
– putting on of operating dressing-gown;
– preparation of the operating field.
Putting on of the surgical suit and scrubbing of hands. In the preoperative room the surgeorr changes his clothes to the surgical suit (shirt, trousers, cap, mask, shoe covers) and scrubs his hands according to one of possible methods.
The preparation of the surgeon is hands for the operation provides:
– mechanical cleaning of the skin: cleaning of dirt and microorganisms from the skin surface by warm water and the brush;
– elimination of microbes on the skin by solution (chemical treatment);
– compression of the skin (tanning) with the aim to close opens of road clearances of sweat and oil glands.
The mechanical cleaning of the hands’ skin is carried out by the washing of hands with sterile brush and soap. A brush is moved in the direction from the fingers to the forearm. The hands all of time turn up higher, then forearms to let flow warm water run from the fingers to the elbow. Firstly, the palm’s surface of every finger of the left hand is washed, back surface of every finger, intervals between fingers and nail beds of the left hand ..Then the right hand is washed by the same order. After that begins the washing of the back and palm’s surface of the left hand, and then the right hand and, finally, wrists and forearms to the level of the their upper third are washed. The lather is constantly washed off by running water; a brush
is soaped if necessary. During the washing of the hands and after it is prohibited to touch anything. In the case of error the washing of the hands starts from the beginning.
Elimination of Skin Microbes by Antiseptic
Solution
The method of Alfred. The hands are wiped by 96% ethyl alcohol during 5 minutes. The nail phalanxes and back interphalangeal folds are cleansed by 5% solution of iodine.
The method of Furbringer. The hands are wiped during 1 minute by solution of mercuric chloride in correlation 1:1000, and then are wiped by a 96% alcohol during 3 minutes. After this the nail beds are smeared by 5% iodine solution.
The method of Spasokukotsky-Kochergin. The hands are cleaned by 0,5% liquid ammonia solution. The hands are washed in two basins for 3 minutes by a napkin; consistently doing motions, as at washing a brush, beginning from the fingers of the left arm. In the first basin the hands are washed to the elbows, and in the second they are washed to the border of the upper and middle third of the forearm. At the end of washing hands are rinsed by the solution of liquid ammonia and lift the hands up to let the water drops flow down from the elbows. From this time the hands are constantly higher than forearms. The skin of the hands is drained by sterile napkins: firstly both hands (this napkin is thrown down), then consistently lower and middle thirds of th6 forearms. The skin is disinfected by napkins, moistened of 96% alcohol, cleansing twice the hands and lower third of forearms. Then the finger-tips, nail walls, nail beds and the finger skin folds are smeared of 5% alcoholic iodine solution.
The hands’ treatment by “pervomur” (C-4 preparation). “Pervomur” is a mixture of formic acid and hydrogen peroxide. Firstly, the basic solution area prepared in such correlation as 80 ml of 85% formic acid and 170 ml of a 33% hydrogen peroxide solution mixed up in glass-ware with ground stopper and matured in the refrigerator during 2 hours. When interacting formic acid hydrogen peroxide the superformic acid appears as a result having strong bactericidal activity. From 250 ml of basic solution it is possible to make
The hands’ treatment by chlorhexidine bigluconate. Issued as 20% water solution. For hands’ treatment are prepared 0,5 % alcoholic solution: to 500 ml of 70% alcohol is added the 12,5 ml of 20% solution of chlorhexidine bigluconate. After washing by running water with soap the hands are dried by sterile towel, and then are wiped with gauze tampon moistened by prepared solution, during 2-3 minutes.
The speeded-up method of hands’ treatment. This method is applied in ambulatory and military field conditions. For the speed-up hands’ treatment is used the disinfecting membrane-forming preparation Cerigelum having strong bactericidal effect. It consists of butyral
resin and of 96% ethyl spirit. The hands are washed with water and soap, and are dried carefully. The palms are filled with 3-4 ml of Cerigelum, the fingers, nail beds and nail walls, brushes and lower part of forearms are moistened carefully, during 10 seconds. The half-bent fingers are maintained separated during 2-3 minutes, up to the Cerigelum film appears on the skin. This film has protective and bactericidal characteristics, and after the operation it is easily taken off by gauze swabs moistened by alcohol.
The rapid hands treatment can be done by the special apparatus with ultrasonic baths, in which washing and disinfecting of hands takes 1 minute. For that the hands are dipped into the bath with antiseptic solution of, through which the ultrasonic waves let pass providing the “washing effect”.
In urgent cases hands’ skin treatment is carried out by such modes as:
– The method of Khaysner. The skin of the hands is cleansed without previous washing with water with soap but only with 5% solution of iodine in petrol.
– The method of Bruna. The hands are washed by 96% alcohol during 10 minutes. An obligatory condition of this method of skin treatment is that hands must be dry.
– The method of Zabludovsky. The hands are washed by 5% solution of tannin in alcohol (80-96%) during 2-5 minutes without previous water washing.
The general lack of these methods of hand preparation is that the skin loses the elasticity. This reduces to traumatism and to the development of pustular diseases. In addition, all the described methods of hands treatment do not provide complete and protracted sterility. That is why after hands’ skin treatment the surgeon puts on sterile rubber gloves after antiseptic solution treatment.
2. Putting a Sterile Surgical Coat on
Putting on a sterile surgical coat is the important measure of prophylaxis of contact infection. From the surgeon observance of accuracy is required, because sterility of his clothes and hands can be violated at this moment. A surgeon take a sterile surgical coat from the sterilizer box (there surgical coats are convoluted in a tube with the internal surface outside) and, having unwrapped it on his hands extended forward, returns it interior to itself. It is necessary to watch after the external surface of the sterile surgical coat does not touch surrounding objects and operating suit of the surgeon. With the help of that is to say diving movements, the surgeon throws the surgical coat over itself at the front keeping hands up. The nurse of operational unit pulls up a surgical coat by the edges and ties it. The surgeon takes the belt from the pocket of the surgical coat and, holding it at the distance of 30-
The unwrapped surgical coat can be given to the surgeon by a scrub nurse. She holds the surgical coat in front of herself with the external surface toward herself, throwing the surgical coat arms on the hands. The surgeon comes and puts his hands into the sleeves of the surgical coat. An operating nurce puts the surgical coat on the surgeon shoulders, and a nurse helps him tie up himself. Pulling up the sleeves, the glands are tied by the surgeon or a scrub nurse.
3. Preparation of the Operative Field
Preparation of the operative field to the operation consists of solution treatment of the skin and covering (isolations) sterile surgical garb (by sheets, towels, napkins).
The operative field is an area on the body surface, which can contact with the sterile surgical instruments and gloves of the surgeon. Area of the operative field is determined not only by the operative wound size, and also by the confines of the body cavity projection which contains an organ – operative object. For example, before the implementation of the laparotomy of the border of skin treatment are mentioned below: the upper border – the level of nipples, the lower border – the upper third of thighs, the lateral – reach lumbar area.
The prevention of infecting of operating wounds by microbes located on the patient’s body, carried out hygienical skin treatment before the operation and special skin treatment in the area of the operation on the operating table.
The hygienical patient’s skin treatment is carried out in a reception centre, or in a surgical department immediately before the planned operation. The patient takes a bath. A hygienical skin treatment must be done after the implementation of all of preparatory procedures: cleansing enema, gastric lavage, catheterization of urinary bladder. After hygienical skin treatment the patient puts on a clean linen and he is transported into the operating-room. Immediately before this it is necessary to shave off hair in the area of the future operating cut. After shaving off hairs the skin is not treated.
If the patient’s state is grave and he needs immediate surgical operation, the hygienical treatment of the skin can be done in an operating-room by the antiseptic solution. Sometimes in such cases one can limit himself only to treatment of the operative field.
The skin treatment methods of the operative field do not differ from the methods of hands treatment of surgeon in principle. It is forbidden to utilize alcoholic solution of iodine for treatment of the operative field. Instead a 1% solution of iodonatum (iodopironum) is utilized.
The method of Filonchikov-Grossikh. Filonchikov (1904), and after him Grossikh (1908) introduced skin treatments of the operating field the procedure of tanning, which provides closing of efferent ducts of sebaceous and sudoriferous glands, tanning prevents the microbe appearing on the skin surface. The offered method consists of the four-time skin smearing by 10% alcoholic solution of iodine:
– first smearing – 5-10 minutes before the cut of the skin;
– second smearing – immediately after the cut of skin;
– third smearing – before sutures on the skin;
– fourth smearing – after sutures on the skin.
For the mechanical cleaning of the skin the petrol
is utilized if necessary. The operative field is not washed by water with soap, because a moistened skin has worse reaction to tannings.
The Operative Field Treatment by Modern Antiseptics
The modern antiseptics are surface-active mate’s <*nich have high bactericidal action, good moistening and washings properties. They penetrate deep into the skin and provide protracted asepsis: aseptol, diocidum, degmicidum, novoseptum, roccal etc.
The operative field treatment is carried out by skin smearing from the place of future cut to periphery and in a presence of infected wound in the center of the operative field – vice versa from periphery to center. The very seat of infection is isolated from the place of cut.
During the operative field treatment by novoseptum (3%) or degmicidum (1%) the skin is wiped with a sponge moistened in anticeptic solution during 4-5 min, whereupon it is dried out by sterile napkins.
The operative field treatment by 1% roccal solution skin is wiped with a gauze swab moistened in anticeptic solution of, during 2 minutes. The appeared spume is moved off by a sterile napkin.
The operative field treatment is carried out of 1 % iodonatum according to procedure mentioned below: the skin is smeared twice by sterile tampons moistened in the element (5-7 ml) of antiseptic solution prepared before the operation by solution of preparation by boiled or distilled water in correlation 1:5.
The “pervomur” solution for operative field treatment is prepared the same way as for hands treatment. The skin is wiped twice for 30 seconds by napkins moistened in antiseptic solution.
After operative field treatment by aseptol the skin is wiped for 3 minutes by a gauze tampon moistened of 2% antiseptic solution.
After treatment by antiseptic it is expedient5 to cover the operative field a sterile sticking polymeric film. A cut can be done through the film which remains on the skin till the end of the operation.
For children and patients with a sensible skin the operative field is treated by the method of Bakkal: double smearing of 1% solution of brilliant green.
The operative field is isolated (covered) sterile linen (sheets and towels) to avoid the surgeon hands and instruments contamination and by unsterile parts of the patient’s body. In the immediate vicinity from the operative field sterile linen is packed in four layers, in periphery – in two layers.
The preparation to the operation ends with fixing of all of sheets and towels by four special sphincters (linen hook) in the corners of appeared “window”, where access will be realized. In the place of future cut the skin is treated once again twice with antiseptic – before of local anaesthesia and after it. During the access the surgeon limits the dissected layers of tissues by towels to avoid their infecting by pathogenic microflora which can appear in the abdominal cavity.
In the process of the operation, the protecting of organs and tissues from bacterial contamination from the side of the infected seats is achieved by the use of often changeable sterile napkins, towels, repeated of personnel hands treatment. At the end of the operation, before and after sutures on the skin, the edges of wound are smeared by anticeptic again.
In modern surgery, practice the high level of sterility of the operative field is achieved by its complete isolation from the air of the operating-room inside the closed room.
SURGICAL INSTRUMENTS AND RULES OF THEIR USE
1. The surgeon realizes the mechanical influence on organs and tissues by his surgical instruments.
The classification by function is more comfortable for surgeons:
I. General surgical instruments (Figure 1-
1. Instruments for parting tissue.
2. Instruments to arrest bleeding.
3. Instruments for suturing tissue.
4. Fixation instruments. Accessory instruments.
II. Special surgical instruments (neuro-surgical, traumatologic, stomatologic, ophthalmologic and other)
The structure of a surgical instrument. An instrument consists of a working portion (blade of an instrument), which is acted on patient tissues and handle kept by the surgeon. The construction of the instrument is conditioned by the character of its mechanical acting on tissues. The greater part of instruments (clamps, scissors and others) consists of two parts – branches, connected by a lock. The blade of an instrument can have grinds, windows, incisions, teeth on its tips, and others. For the firm keeping of the instrument in hand the handles should have rings, incisions or lugs. Instruments handles can be equipped by the latch for fixing branches in close position. For the firm keeping in a hand an instrument should have three points of fixing. For example, clamps, needle-holders, scissors kept by 1st, 2nd and 4th fingers (Fig. 1-6).
The surgical instruments applied in pediatric surgery have less sizes and weight, fine tips of an instruments (for example, less length and width of grips of clamps).
1. Instruments for the Parting of Tissue
For disconnection of soft tissues the scalpels, operating knives, scissors are utilized. For bone tissue – the surgical saws, chisels are utilized. In addition, the properties of electric current, laser and radiation emanation, ultrasonic waves.
A scalpel is an instrument of piercing and cutting action. For realization of mainly cutting action abdominal scalpels are utilized, for piercing – spoking (sharp-pointed) ones. There are also other configurations of cutting edge, conditioned by the features of form of organs and tissues to dissect.
There are entire-stamped, non-permanent and with a removable blade scalpels. There are certain receptions of using a scalpel (Fig. 1-7). The position of “writing pen” provides exact, dosated cuts of precise length and depth. The position of bow provides long and superficial cuts of soft tissues, the position of table- knife – deep cuts. For realizing a skin cut, a scalpel is set almost at the beginning of the future cut vertically, and then it is inclined and cuts the skin and hypodermic cellular tissue. At the end of cut the scalpel is again transferred in a vertical position.
The scissors are the instruments of crushing and cutting action. The fascias, aponeurosis, suture material are cut by scissors. By the form of branches the scissors may be straight and curved (Richter scissors – by plane, Cooper scissors – by axis). By the form ends may be blunt-pointed, sharp-pointed and button-type scissors (scissors of Lister for the bandages removal). The scissors are hold in a hand with help of 1st, 2nd and 4th fingers.
A special type of scissors is laparotomy scissors of Metzenbaum, or dissector. They are arcuated by the plane, have rounded surfaces, narrow blunt ends, long handles. They are applied for cutting off suture material, dissecting of connections in the body cavities, and also for blunt disconnection of tissues by separation of branches or piercing of non-vascular areas of copulas and frills by closed ends (e.g. during organ’s mobilization).
The ends of the bound are cut away by scissors by certain rules: 1) having strained threads by a left arm, the separated scissors’ tips carefully approached to the tied knot; 2) after stopping in the knot the branches are turned on 90° and cut away the threads excess. Such mode provides necessary minimum length of knot ends – approximately
The resection knives have the wide back of blade, allowing to make an additional effort for disconnection of dense tissues.
The catling (small, middle and large) is utilized *’of the single-stage dissection of soft tissues during amputations. For this purpose the surgeon holds the • -fe blade up and edge toward himself.
The surgical saws disconnect bone tissues: flat zones – by the saws of Jeegly and Olivecrone, tubular rones – by a dissecting blade, knife, arched and circu- ar saws. For the bones dissection also are used cut- ars of Liston, Lyuer, Dalgran, Schtille and others.
During operations on bones the surgical chisels are used (straight and grooved). Before a bones dissection the periosteum is detached layer by a layer by raspatories (straight and arcuated).
For the dissection of the skull cavity (trepanation) there is used a trepan with the set of pinned and spherical milling cutters, for the dissection of the tubular bones cavity
The principles of soft tissues disconnection
During the disconnection of tissues the surgeon must provide:
1. Minimum cosmetic defect, favourable conditions of tissues regeneration, in other words: the skin cut direction must coincide with elastic fibres (fissure-lines of Langer), connective tissue and muscular fibres, vessels and nerves one; an incision is done by one motion of the scalpel (wound edges must be even); to be consistent with the principle of instrumentality – all of the manipulations in wound must be done with instruments.
2. The layer-by-layer access provides: every next layer of tissues is dissected only after a complete (at length of wound) dissection section of previous; during the access the direction of next tissue layer dissecting can be changed in relation to previous based on the direction of aponeurosis, muscles, vessels and nerves fibres; for the dissecting of fascias, aponeurosis, parietal serous tunic the grooved probe is used.
3. Hemostasis, that is: every next layer is dissected after the arrest of bleeding from previous vessels.
4. Asepsis and antisepsis (blastics and antiblas- tics for oncosurgery), that is: for prevention of infecting during access every layer of tissues is limited from the other one with a surgical garb (linen); change instruments and gloves, use antiseptics on suspicion of contamination.
5. The due notice of possible complications and fight against them, that is: to size up clearly in which anatomic layer the manipulation is realized; constantly get information about the general state of the patient (contact with the patient, anaesthetist, dresser, analysis of information of monitoring, colour of the blood, intension of muscles and other); give instructions to the junior medical staff of the operating-room in advance about preparation to the use of certain medical equipment and instrumentation.
II. Instruments for the Arrest of Bleeding
Among these are vascular and hemostatic forceps (clamps).
The arteries and veins of the middle and large gauge are pinched by vascular clamps to prevent hemorrhage during operations on vessels and organs (heart, lungs, kidneys, gallbladder and others). Among these are the vascular clamps of Satinsky, Hophner, Pyrogov, Mayo, Negus, Well and others.
The final hemostasis is carried out by hemostatic forceps. They are used for cross-clamping of the vessels of the small gauge, damaged during the access or separation of the organ from surrounding tissues. Such clamps are different by their construction, but they can be divided into two groups: 1) clamps with dents on the ends of working portion (Kocher’s clamps); 2) clamps without teeth (Billroth’s, “mosquito”, Pean’s clamps and others).
The straight clamp with dents on the tip Kocher firstly applied for vessels’ pinching of the thyroid gland.
The hemostasis is carried out by damaged vessel crossclamping together with surrounding tissues by the blade of the instrument (except dents). The dents do not permit the instrument to slip off. Under the clamp the thread or piercing ligature is performed. After making the first knot the clamp is carefully taken off, not breaking off to tighten the first knot and making the second one.
With the purpose of the arrest of bleeding surgical diathermy (thermal effect of electric current) is applied. The electric current with certain characteristics is put to the vessel through a metallic instrument. The electric field at this moment is closed. The arising thermal effect at passing of current through biological tissues with a little electric resistance causes coagulation and hemostasis.
III. Instruments for the Suturing of Tissue
The tissues connection is carried out by suture material, medical needles, needleholders and also by Michel’s cramps put by special forceps, staplers and by the mechanical sutures devices.
The suture material is classified after high-quality and quantitative characteristic of elemental fibres. By the structure of fibre the suture material is divided into monofilament and polyfilament (twisted and wattled).
The main destination of suture material is to approach, adapt and fix biological tissues which are to be connected for the term necessary for the formation of adhesion (seam, scar).
The general requirements regarding the suture material:
– biological compatibility (inactivity);
– durability;
– monofilament properties (absence of wick properties);
– atraumatic properties (elasticity, flexibility, smooth surface);
– expectant biodegeneration (dissolving and removing from the organism during a necessary term);
– possibility of sterilization;
– cheapness of the raw material and production.
The elastic suture material is conducted through tissues for their connection by surgical needles. The needles are held up by the needle-holders of different constructions (Hegar, Troyanov and Mathieu).
The needles are classified by their different characteristics. There are straight, circle and steep needles by their form. The needles are made with the various form of crosssection, but the widest use have round (piercing) and triangular (cutting) surgical needles. Piercing needles pull apart the fibres of biological tissue and provide impermeability of tubular structures sutures; that is why they are applied for connection of muscles, intestine walls, vessels. The cuttings needles conduct the suture material through the skin.
By the method of suture material fixing the needles are divided into traumatic and atraumatic. The traumatic needle has an eye. The atraumatic, or swagged, needle is as though the continuation of the suture material. The absence of an eye and double thread determines the minimum injuring of tissues at the putting of cosmetic suture..
The needle-holder of Hegar is most widespread (small, middle and large.For conducting of suture material through parenchymal organs the sharp-pointed Deschamp’s needle is also utilized.
After stitching up the wound edges are drawn together, compared and fixed by tying a knot with threads ends.
During the tying of the surgical knot it is necessary to provide permanent moderate intension of the suture material. A minimum of knots – 2, but, depending on the properties of the suture material, there can be more knots to prevent the untying and rupture of wound edges.
TYPES OF SUTURE MATERIAL 1. Absorbable:
Plain Catgut
Plain catgut is not commonly used in modern surgery. Although its rapidity of absorption might seem to be an advantage, this rapidity is the result of an intense inflammatory reaction that produces enzymes for the digestion of the organic material. Plain catgut is acceptable for ligating bleeding points in the subcutaneous tissues and not for very much else.
Chromic Catgut
Chromic catgut has the advantage of a smooth surface, which permits it to be drawn through delicate tissues with minimal friction Chromic catgut is useful for the approximation of the mucosal layer in a two-layer anastomosis of the bowel.
Polyglycolic Synthetics
Polyglycolic synthetic sutures (PG), such as Dexon or Vicryl, are far superior to catgut because the rate at which they are absorbed is much slower. Even after 15 days, about 20% of the tensile strength remains. Also, the inflammatory reaction they incite is mild as compared with catgut. Their chief drawback is that their surface is somewhat rougher than catgut, which may traumatize tissues slightly when the PG suture material is drawn through the wall of the intestine. This characteristic also makes the tying of secure knots somewhat more difficult than with catgut.
2. Nonabsorbable:
Natural Nonabsorbables Natural nonabsorbable sutures, such as silk and cotton, have enjoyed a long period of popularity among surgeons over the world . They have the advantage of easy handling and secure knot tying. Once the knots are set, slippage is rare. On the other hand, they produce more inflammatory reaction in tissue than do the monofilament materials (stainless steel, Prolene) or even the braided synthetics. Silk and cotton, although classified as nonabsorbable, do indeed disintegrate in the tissues over a long period of time, whereas the synthetic materials appear to be truly nonabsorbable. In spite of these disadvantages, silk and cotton have maintained worldwide popularity mainly because of their ease of handling and surgeons’ long familiarity with them
Synthetic Nonabsorbable Braids Synthetic braided sutures include those made of Dacron polyester, such as Mersilene, Ticron (Dacron coated with silicone), Tevdek (Dacron coated with Teflon), and Ethibond (Dacron with butilated coating). Braided nylon (Surgilon or Nurolon) is popular – in the United Kingdom. All these braided synthetic materials require four or five knots for secure closure, compared to the three required of silk and cotton.
Synthetic Nonabsorbable Monofilaments Monofilament synthetics like nylon and Prolene are so slippery that as many as 6-7 knots may be required.Both Prolene and various braided polyester sutures have achieved great popularity in vascular surgery.
Monofilament Stainless Steel Wire
Monofilament stainless steel wire has many characteristics of the ideal suture material; however, it is difficult to tie. Also, when it has been used for closure of the abdominal wall, patients occasionally have complained of pain at the site of a knot or of a broken suture.
Modern Suture Material
Dermalon – monofilament nylon.
Ethibond – braided Dacron polyester with butilated coating.
Ethilon – monofilament nylon.
Mersilene – braided Dacron polyester.
Nurolon – braided nylon.
PDS – Polydiaxanone, synthetic monofilament absorbable suture; slowest rate of absorption of cur- rendy available suture materials.
PG – polyglycolic acid, Dexon, polyglactin, Vicryl.
Prolene – monofilament polypropylene.
Surgilene – monofilament polypropylene.
Surgilon – braided nylon coated with silicone.
Tevdek – braided Dacron polyester coated with “eflon poiytetrafiuorethylene.
Thumbtack – titanium hemorrhagic occluder pin .vrtti applicator.
Ticron – braided Dacron polyester coated with S’iiCOn.
Vicryl – Polyglactin, synthetic absorbable suture material.
During the anaesthetic management of the operation it is always necessary to remember about that the risk of anaesthesia did not exceed the risk of operation. The higher risk of operation, the more careful analysis of all present information is needed to choose accurately the method of anaesthesia.
The variants of anaesthetizing (anaesthesia) can be divided into the general and local anaesthesia.
The local anaesthesia is a method of influence on ways which conduct information about pain beginning from receptors which generate pain impulses (terminal, local infiltration anaesthesia) and concluding by sensory nerves up to their joining to the spinal cord (regional anaesthesia: conduction, epidural, spinal, nerve block nerve plexus block).
The terminal anaesthesia (surface, or permeation, analgesia) is utilized for some operations on mucous membranes. The anaesthetic solution is applied by spraying, injection or permeation of superficial tissues.
The local infiltration anaesthesia. For realizing simple surgical operations in the majority of cases it is sufficient to apply the infiltration anaesthetizing by a 0,25% or 0,5% solution of novocaine or trimecaine by method of creeping infiltration of Vishnevsky. His peculiarity is that after anaesthesia of skin and hypodermic fatty tissue the anaesthetic are injected abundantly in the proper interfascial compartment in the operation area. So the dense infiltration is forming which due to the high hydrostatical pressure spreads on a considerable scale along fascias, washing nerves and vessels. The low concentration of anaesthetic solution and its independent excretion on the measure of flowing out from a wound practically eliminates the danger of intoxication, without regard to the injection of the large volume of solution.
The principle of infiltration is assumed as a basis effective enough blocks which offered by O.V.Vishnevsky: case blocks on upper and lower extremities, lumbar perinephric block, sacrospinal block.
Unlike classic block anaesthesia in these blocks the direct putting of local anaesthetic to the nerve trunk is not provided.
The regional anaesthesia. It includes, in particular, block, plexus, epidural and spinal anaesthesia. The regional anaesthesia technically is more difficult than the infiltration one, requires the knowledge of topography of the nerve trunk or nerve plexus and also practical skills.
The block (plexus) anaesthesia. It is a type of regional anaesthesia which is achieved by putting of local anaesthetic solution directly to the nerve trunk (nerve plexus) proximally from the operative area. This type of anaesthesia took the leading place among the methods of anaesthetic providing of operations especially on the extremities.
The technique of the brachial plexus block by the method of Kulenkampf. The position of the patient: the upper part of the trunk of is lifted, the head is returned to opposite side, the shoulder is lowered. Above the middle of the collar-bone in depth 1st rib is palpated at strong pressure, at superficial palpation there is determined the pulse of the clavicular artery which is located medially from the brachial plexus. The place of pricking by the needle is the 0,5-
The hit of needle in the plexus branches is characterized by parastesias, which the patient indicates. After getting the parastesias (it is desirable in the lower third of the forearm or fingers), not changing position of needle, inject 10-20 ml of a 1,5-2% solution of novocaine with adrenalin.
Subdural and Epidural Anaesthesia ubdural injection of the anaesthetic is block- 3a of the sensible nerve immediately before of ito the spinal cord. This area is not covered by ane and that is why is very sensible to anaes- spidural anaesthesia the preparation is injected into the epidural space – fissure between a pachymen-inx and ligamentous apparatus of spinous process of vertebra. Here a nerve is already covered by a membrane and less sensible to the anaesthetic action. In this connection the doses of anaesthetics are different depending on the type of anaesthesia. At subdural injection the dose too much less than at injection to the epidural space (50-80 mg and 400-600 mg of lidocaine accordingly). In this connection, during epidural anaesthesia, when there caot be certainty that a catheter (whether a needle) is in epidural space, but not in subdural, the so-called test with a sample dose (50 mg lidocaine) is done. If in a 5 min. after injecting of anaesthetic the sensitiveness of the area of anaesthesia does not change, it is possible to say that a catheter is not in the subdural space. If such a test is not done, early or late the large dose of anaesthetic will get to the subdural space and can cause grave complications.
The epidural anaesthesia by the technique of realizing is more difficult than the subdural one, however in the majority of clinics the preference is given to the first one
The epidural anaesthesia. The significant advantage of epidural (peridural) anaesthesia consists in providing the adequate relaxation of muscles, and also in the possibility of the continuation of anaesthetizing in the postoperative period. The most difficult elements of implementation of the method are puncture and catheterization of the epidural space (fig.). It is necessary to take into account that this space is very narrow (in the thorax 2-
The general anaesthesia is the influence on central nerve structures, beginning from the back roots of spinal nerves and concluding by the cerebral cortex.
The methods of the general anaesthesia can be divided into:
– Anaesthesia which not entailed by stopping of bark of cerebrum and consciousness.
– Anaesthesia which by stopping of cerebral cortex and consciousness of patient. Such method is called narcosis.
METHODS OF TEMPORAL AND DEFINITIVE HAEMOSTASIS
Temporal stop of bleeding:
■pressure (compressive) bandage;
■ digital occlusion of a vessel more proximal to wound;
■occlusion of the vessel in a wound;
■occlusion of the vessel along its course;
■application of compression Esmarch’s bandage (Esmarch’s tourniquet) on an extremity;
■ application of clamp on a vessel in wound;
■the maximal flexion of an extremity in a joint;
Definitive haemostasis:
■ vascular suture;
■ligation of a vessel in wound;
■ligation of a vessel along its course;
■ sewing of a vessel together with surrounding tissue;
■ surgical diathermy, or electrocoagulation;
■ angioplasty (substituting of the vessel defect by a transplant);
■ conservative measures (blood transfusion is in broken doses, injection of calcium chloride, Vikasolum, tamponade by a fibrin sponge and so on).
THE PRINCIPLES OF PRIMARY SURGICAL TREATMENT OF WOUND (INITIAL DBRIDEMENT, INITIAL HANDLING)
The Primary surgical treatment of wounds is a complex of medical measures on the removal of casual (non-operative) wound at first hours after a trauma and warning of possible complications related to pain shock, bleeding, development of purulo-necrotic processes.
The primary surgical treatment is carried out in a certain order. The features of its implementation are based on the principles of connection of soft tissues and topographical and anatomic features of the body area where wound is located. Let us examine primary surgical treatment of wound of the calvarium under local anaesthesia.
• Temporal arrest of bleeding.
• Mechanical treatment of wound edges.
• Treatment of wound edges by antiseptic.
• Local infiltration anaesthesia.
• Revision of wound.
• Final arrest of bleeding.
• Actually primary surgical treatment.
• Control of hemostasis.
• Wound closure.
• Treatment of wound edges.
• Constrictive bandage.
The border between the head and neck lies on such andmarks as: mental protuberance, lower part of the rase, angle and posterior border of the ramus of the mandible, lower semi-circle of the external auditory meatus, superior nuchal line, external occipital protuberance (inion)
The head is divided into cerebral and facial parts – by the line beginning from the glabella, then going above the superciliary arch, zygomatic arch to the external acoustic meatus and so on to the lower part of the mastoid process.
The shape of the head is characterized by individual, sexual, racial, age-specific distinctions besides the numerous congenital and acquired deformations of the skull and cerebrum occur.
There are large membranous and unossified gaps (fontanelles) between the bones of the skulls of the fetus and newborn which allow the head to deform during its passage through the birth canal. Most of the fontanelles are closed during the first year of life. Full ossification of the thin connective tissue ligaments separating the bones at the suture lines begins in the late twenties and is normally completed in the fifth decade of life.
CEREBRAL PART OF THE HEAD (THE SKULL)
There are four regions consisting of the fornix of the see Fig. 2-1): 1) fronto-parieto-occipital (single), 2) oral (couple), 3) mastoid (couple), 4) auricular (couple).
Thev fronto-parieto-occipital region is limited e line going from glabella, under the superciliary a ongthe superior temporal line, superior nuchal : Tie external occipital protuberance (inion).
Layers of the Scalp
Layer 1: Skin. Hair covers the scalp in the head of the majority of people. The skin of the scalp is thin, especially in elderly people, except in the occipital region. The skin contains many sweat and sebaceous glands and hair follicles. The skin of the scalp has an abundant arterial supply and good venous and lymphatic drainage systems.
Scalp lacerations are the most common type of head injury requiring surgical care. These wounds bleed profusely because its communicating arteries enter around the periphery of the scalp and they do not retract when lacerated because the scalp is tough. If these wounds are not treated appropriately, a scalp infection may develop and spread into the underlying bones of the calvaria, causing osteomyelitis. The infection can also spread to the cranial cavity, producing an extradural (epidural) abscess, meningitis, or both.
The ducts of the sebaceous glands that are associated with hair follicles in the scalp may become obstructed, resulting in the retention of secretions and the formation of sebaceous cysts (wens). Because they are in the skin of the scalp proper, sebaceous cysts move with the scalp.
Layer 2: Connective tissue. This thick, subcutaneous layer of connective tissue is richly vascularized and well supplied with nerves. Its collagenous and elastic fibers criss-cross in all directions, attaching the skin to the third layer of the scalp (aponeurosis epi-cranialis). Fat is enclosed in lobules between the connective fibers. The amount of subcutaneous fat in the scalp is relatively constant, varying little in emaciation or obesity, but decreases with advancing age. As a result, the scalp is thinner in elderly
Layer 3: The Epicranial aponeurosis is a strong membranous sheet that covers the superior aspect of the calvaria. This aponeurosis is the membranous tendon of the fleshy bellies of the epicranius muscle (tw occipital bellies (occipitalis) and two frontal bellies (frontalis) that are connected by the epicranial aponeurosis.The frontal bellies pull the scalp anteriorly and wrinkle the forehead transversely, whereas the occipital bellies pull the scalp posteriorly and wrinkle the skin on the posterior aspect of the neck. The epicranial aponeurosis is continuous laterally with the temporal fascia covering ttemporalis muscle. This fascia is attached to the zygomatic arch.The epicranial aponeurosis is a clinically important layer of the scalp. Owing to its strength, a superficial laceration in the skin does not gape because its margins are held together by this aponeurosis. When suturing a superficial wound, deep sutures are not necessary because the epicranial aponeurosis does not allow wide separation of the scalp proper. Deep scalp wounds gape widely when the epicranial aponeurosis is split or lacerated in the coronal plane, owing to the pull of the frontal and occipital parts of the epicranius muscle in different directions). For this reason, deep coronal lacerations gape most widely. As mentioned,bleeding from scalp wounds is severe because the arteries cannot retract owing to the density of the connective tissue in the second layer of the scalp.
Layer 4: Loose areolar tissue. This subaponeurotic layer of areolar or loose connective tissue is somewhat like a sponge because it contains innumerable potential spaces that are capable of being dis- The emissary veins are not connected with the intracranial venous sinuses, e.g. the superior sagittal sinus. Infections in the loose connective tissue layer may produce inflammatory processes in the emissary veins, leading to thrombophlebitis of the intracranial venous sinuses and the cortical veins. Awareness of the limits of the loose connective tissue layer (also known as the subaponeurotic space) is important so that the possible spread of an infection can be anticipated. An infection is unable to spread into the neck because the occipitalis muscle is attached posteriorly to the highest nuchal line of the occipital bone and posterolaterally to the mastoid parts of the temporal bones. An infection is unable to spread laterally beyond the zygomatic arches because the epicranial aponeurosis is continuous with the temporal fascia, where it is attached to these arches. An infection or fluid (e.g., blood or pus) can enter the eyelids and the root of the nose because the frontalis muscle is inserted into the skin and dense subcutaneous tissue and is not attached to the frontal bone. Because of the free movement permitted by the loose connective tissue layer, it is through it that the scalp proper separates during accidents.
Layer 5: Pericranium. The pericranium is the deepest layer of the scalp and is the periosteum on the outer surface of the calvaria. The periosteum adheres to the suture-lines of the skull; collections of pus or blood beneath this layer, therefore, outline the affected bone. This is particularly well seen in birth injuries involving the skull (cephalohaematoma).
Nerves of the Scalp
The sensory innervation of the scalp anterior to the auricles (external ears) is through nerves that are branches of all three divisions of CN V, the trigeminal nerve. Posterior to the auricles, the nerve supply of the scalp is from the spinal cutaneous nerves (C2 and C3) of the neck from the cervical plexus. The areas of distribution of the branches of the trigeminal and cervical nerves are usually about equal.
Arteries of the Scalp
The blood supply of the scalp is from the external carotid arteries – through the occipital, posterior auricular and superficial temporal arteries and from the internal carotid arteries – through the supratrochlear and supraorbital arteries. All these arteries anastomose freely with each other. The bones of the calvaria are supplied mainly by the middle meningeal arteries, branches of the maxillary arteries, but these bones receive some blood from pericranial vessels that enter the cranium through Volkmann’s canals
Veins of the Scalp
The vena comitantes accompany the arteries of the scalp and have the same names. The supraorbital and supratrochlear veins unite at the medial angle or canthus of the eye to form the facial vein. Here, it communicates with the superior ophthalmic vein, thereby making a link that may allow facial infections to reach the cavernous sinus. The superficial temporal vein joins the maxillary vein to form the retromandibular vein posterior to the neck of the mandible. The posterior auricular vein drains the scalp posterior to the auricle and often receives a mastoid emissary vein from the sigmoid sinus, an intracranial venous sinus.
Lymphatic drainage of the Scalp
Lymphatic drainage of the scalp generally follows the pattern of arterial distribution. The lymphatics in the occipital region initially drain to occipital nodes near the attachment of the trapezius muscle at the base of the skull. Further along the pathway occipital nodes drain into upper deep cervical nodes. There is also some direct drainage to upper deep cervical nodes from this part of the scalp.
Lymphatics from the upper part of the scalp drain in two directions: 1) posterior to the vertex of the head they drain to mastoid nodes (retro-auricular/posterior auricular nodes) posterior to the ear near the mastoid process of the temporal bone and efferent vessels from these nodes drain into upper deep cervical nodes; 2) anterior to the vertex of the head they drain to pre-auricu- lar and parotid nodes anterior to the ear on the surface of the parotid gland. Finally, there may be some lymphatic drainage from the forehead to the submandibular nodes through efferent vessels that follow the facial artery.
OPERATIONS ON THE HEAD
Primary surgical treatment of cranial wounds
The primary surgical treatment of cranial wounds a complex of medical measures on the removal of ssual (non-operative) wound at first hours after a trauma aid warning of possible complications related to pain s~ock, bleeding, development of purulo-necrotic pro- :ssses.
The main stages of primary :. rgical treatment of cranial wound under local anaes- res-a are:
3ec 4. Temporal arrest of bleeding by means of hemostatic mosquito forceps or digital occlusion of the tom vessel.
Sec 2. Mechanical treatment of wound edges. Simply, it is a shaving off the hair, removing of grumes and foreign bodies around the edges of wound.
Sec 3. Treatment of wound edges by antiseptic. Edging the wound by sterile linen
Sec – Local infiltration anaesthesia. The surgeon in- ects 0,5% Novocaine solution into the edges of Aound in different directions. The superfluous sterile Novocaine solution washes up re grumes and small foreign bodies from the aound.
Sec 5 Revision of wound. During this procedure a surgeon examines the edges and floor of the woundorder to verify continuity of a bone.
Sec 5. Final arrest of bleeding by methods of definitive -aemostasis.
Sec ” Actually primary surgical treatment. The crushed and nonviable edges of wound must be eco- -xjmically cut off for prevention of its necrosis. The shape of wound must be oval =~er the treatment of edges
Sec 5 Control of hemostasis. A surgeon checks up re arres_t of bleeding.
Sec r Wound closure. The wound must be sutured ayer-by-layer, without the cavities in it depth (placement of cutaneous stitch to eliminate dead space), otherwise the localized uptake of the wound effluent results in suppurative inflammation.
Step 10. Treatment of wound edges by antiseptic.
Step 11. Constrictive bandage.
Trepanation of the Skull (Craniotomy)
Craniotomy, or trepanation, is neurosurgical approach to the cranial cavity through the soft tissues and bone of the calvarium.
The surgical art of trepanation was practiced by several prehistoric cultures. Amazingly, more than a few patients survived this ordeal, as evidenced by ossification around the bony edges of the wound.
The oldest existing case histories of craniotomy are from the false Hippocratic writings, about 330 BC, and one is reconstructed about the death of Ptolemy VI in 145 BC. Greek surgeons had rational indications for trepanning, when the difficulties of the times are understood. All compound fractures were infected, so death from an extradural abscess was likely. Trepanning was intended to drain the extradural space.
Osteoplastic Trepanation by H.OIivecrona
The osteoplastic trepanation provides the recovery of cranial continuity. The operative wound is closed by osteocutaneous flap. Among the indications for this operation are intracranial hemorrhage, hematoma, tumor and others pathologic processes of cranial cavity. The main steps of operation are:
Step 1. Forming of dermato-aponeuroticflap. The horse- shoe-shaped skin-incision is made.The dermato-aponeuroticflap is separated and epi- cranium is exposed.
Step 2. Forming of periosteal-osteal flap. The five or six orifices of the bone are made by cutter
The Polenov’s guide is inserted through the orifices and the saw cut by wire file between the adjacent orifices is made
Step. 3. Operative method. The cranial cavity is opened. The dura mater of brain is exposed and cut The brain is exposed for operative measure.
Step. 4. Exit of operation. The operation wound is closed by dermatoaponeurotic and periostealosteal flaps (autoplastic closure of cranial defect).
Resectional Trepanation by Kushing
The resectional, or decompressive, trpanation provides the elimination of the grume or another origin of intracranial pressure through the small trepanation orifice without recovery of bone continuity. The defect of a bone is closed by soft tissues only. The main indications for this operation are haematoma as a result of middle meningeal artery bleeding, increase of intracranial pressure (brain-growth), progressive traumatic oedema of brain. The main steps of operation are: Step 1. Forming of dermato-aponeurotic flap. The horseshoe-shaped skin-incision of temporal region is made The dermato-aponeuroticflap and the temporal muscle are separated, the epicranium is exposed
Step 2. Forming of osteal defect. The orifice of the bone are made by cutter. The opening of cranium is enlarged by Dalgren’s forceps.
Step. 3. Operative method. The dura mater is exposed and cut crosswise (Fig. 2-30c). The brain is exposed for operative measure. The elimination of grume and arrest of bleeding are realized.
Step. 4. Exit of operation. The dura mater is not sutured. The operation wound is closed by dermatoaponeurotic flap.
Antrotomy (Mastoid Process Trepanation)
ndication: purulent inflammation of cellulae mass a – purulent mastoiditis. The main steps of opera- are:
1 Preparation of operation area.
– A semicircular cut of soft tissues is made be- -vnd the ear on
– After the dissection of soft tissues periosteum s moved aside. Limits of Shipot’s triangle are determined
Step 4. The external wall of the mastoid process ribrated by Voyachek’s chisel. Bone cellulae and i must be opened and washed; granulations c oe removed by Faulkman’s or Brownse’s spoon. 8 actions are performed to avoid damage of middle a *ossa lying upward, wall of sigmoid venous si- i ing backwards, facial nerve canal lying forwards. Step 5. Drainage of the wound.
Step 6. Skin is sutured.
