Basic principles and techniques. Small Animal Surgery

PRESENTATION Small animal surgery

BROCHURE

Small animal surgery José Rodríguez (Editor and coordinator) Jorge Llinás Roberto Bussadori Salvador Guillén

Asepsis and antisepsis Surgical instruments Servet (División de Grupo Asís Biomedia S.L.) Centro Empresarial El Trovador, planta 8, oficina I Plaza Antonio Beltrán Martínez, 1 • 50002 Zaragoza (España) Tel.: +34 976 461 480 • Fax: +34 976 423 000 • www.grupoasis.com

Suture materials Drains Preparation of the patient Sterilisation Initial techniques Postoperative treatment

Surgery atlas, a step-by-step guide

Basic principles and techniques Basic surgical techniques

The publishing strength of Grupo AsĂ­s Editorial Servet, a division of Grupo AsĂ­s, has become one of the reference publishing companies in the veterinary sector worldwide. More than 15 years of experience in the publishing of contents about veterinary medicine guarantees the quality of its work. With a wide national and international distribution, the books in its catalogue are present in many different countries and have been translated into nine languages to date: English, French, Portuguese, German, Italian, Turkish, Japanese, Russian and Chinese.

Its identifying characteristic is a large multidisciplinary team formed by doctors and graduates in Veterinary Medicine and Fine Arts, and specialised designers with a great knowledge of the sector in which they work. Every book is subject to thorough technical and linguistic reviews and analyses, which allow the creation of works with a unique design and excellent contents.

Servet works with the most renowned national and international authors to include the topics most demanded by veterinary surgeons in its catalogue. In addition to its own works, Servet also prepares books for companies and the main multinational companies in the sector are among its clients.

SMALL ANIMAL SURGERY

Small animal surgery José Rodríguez (Editor and coordinator)

Basic principles and techniques

Jorge Llinás Roberto Bussadori Salvador Guillén

Asepsis and antisepsis Surgical instruments Suture materials Drains Preparation of the patient Sterilisation Initial techniques Postoperative treatment

Surgery atlas, a step-by-step guide

Basic principles and techniques Basic surgical techniques

AUTHOR: José Rodríguez, Jorge Llinás,

Roberto Bussadori, Salvador Guillén.

FORMAT: 23 x 29.7 cm.

NUMBER OF PAGES: 256.

NUMBER OF IMAGES: 600.

BINDING: hardcover.

RETAIL PRICE

88 €

In this book, the authors have tried to show, in a brief and practical manner, the basic principles and techniques that veterinary surgeons, nurses and students should know,

EBOOK

AVAILABLE

master and improve to enhance the surgical care provided to their patients.

The book features chapters about the different methods and techniques to control bacterial contamination and surgical infection, both in terms of the fight against microorganisms and the surgeons’ and assistants’ practices in the operating theatre.

Information about the instruments and suture materials most commonly used in surgery, how they should be handled, and how to use them to cause as little trauma as possible to the patient, is also provided in other chapters.

All the content is illustrated by a large number of images to follow the procedures and techniques described step by step. In addition, the e-book includes high-quality and instructive videos to complete the reader’s knowledge of surgery and his/her training.

Basic principles and techniques

Presentation of the book The frequency of surgical complications depends on the surgeon, the patient and the type of surgery performed. However, all surgeons have had to face and solve some of the complications that may appear during and after a surgical procedure. These complications include haemorrhage, wound dehiscence, seroma and infection of the wound or sepsis in the patient. These complications may make the surgery more complex and its final result less successful, and even put the patient’s life at risk.

The greater incidence of complications is closely related to the surgical environment in which the procedure is performed and to the surgical team’s knowledge and experience.

An incision that is not performed properly or a dissection or suturing technique incorrectly applied may lead to excessive bleeding, seroma formation, wound dehiscence and tissue infection. For this reason, providing information and training about surgical principles and techniques, the materials and instruments used in surgery or postoperative monitoring is essential to achieve the best results with as few complications as possible.

The worst complication that may appear in surgery is infection. Infection is a “sword of Damocles” that is present in any surgery and may lead to its failure. Preventing the contamination and infection of the wound and patient is one of the most important aspects in surgery. External and internal intraoperative contamination must be reduced to a minimum.

Infection may appear immediately after surgery, or in the 3-10 day following the procedure. Those that are endogenous have their main origin in three foci: digestive tract, caudal urinary tract and cranial respiratory airways by bacterial colonisation. External contamination occurs by translocation of bacteria from the patient’s skin, the surgeons’ hands or the instruments and materials used or through the contact with other infectious foci after the surgery.

The authors José Rodríguez Degree and PhD in Veterinary Medicine from the Complutense University of Madrid.

Professor of Animal Medicine and Surgery at the Department of Animal Pathology of the University of Zaragoza.

Surgeon at the Hospital Veterinario Valencia Sur (Valencia, Spain).

Jorge Llinás Degree in Veterinary Medicine from the University of Zaragoza.

Diploma of Advanced Studies from the University of Zaragoza.

University specialist in Oral and Maxillofacial Surgery.

Director and surgeon at the Hospital Veterinario Valencia Sur (Valencia, Spain).

President of the Spanish Society of Veterinary Laser and Electrosurgery.

Salvador Guillén Degree in Veterinary Medicine from the University San Pablo CEU of Valencia.

Director of the Centro Veterinario Criado de Puig (Valencia, Spain).

Roberto Bussadori Degree in Veterinary Medicine from the University of Milan.

European doctorate in Veterinary Medicine.

Cardiovascular, thoracic and airway surgeon at the Clinica Veterinaria Gran Sasso, Milan, Italy.

Basic principles and techniques

Collaborators Carolina Serrano

Julia Artero Katia Gámez Lola Alférez Riccardo Sinacori

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Manuel Alamán

Communication services Web site Online visualisation of the sample chapter.

Presentation brochure in PDF format.

Author´s CV. Sample chapter compatible with iPad.

www.grupoasis.com/promo/b_surgicaltechniques

Small animal surgery José Rodríguez (Editor and coordinator) Jorge Llinás Roberto Bussadori Salvador Guillén

Asepsis and antisepsis Surgical instruments Suture materials Drains Preparation of the patient Sterilisation Initial techniques Postoperative treatment

Surgery atlas, a step-by-step guide

Basic principles and techniques Basic surgical techniques

Table of contents 1. Surgical conscience and ethics Introduction Best results with minimal complications Aseptic surgical technique Surgical principles

2. Prevention and control of infection Nosocomial infections

Prevention of surgical infections Antibiotic prophylaxis in surgery Surveillance and monitoring of surgical site infection

3. Sterilisation techniques Introduction Steam autoclaves Choice of type of autoclave

Types of nosocomial infection

Autoclave loading and unloading

Hand hygiene

Control of the efficacy of sterilisation

Cleaning and disinfection around the patient

Autoclave maintenance

Surveillance of nosocomial infection

Blood infections associated with venous catheters Technique for placing a peripheral venous catheter Care and maintenance of peripheral venous catheters Fluid therapy maintenance

Urinary tract infections associated with urinary catheterisation Transurethral catheterisation technique Maintenance of urinary catheters Percutaneous urinary catheterisation

Surgical site infections

Sterilisation of heat-sensitive material.

Chemical sterilisation High-level disinfection Formol vapour

4. Surgical instruments Basic concepts Instrument parts General categorisation of instruments Section and dissection Gripping and handling Retraction and separation

Risk of surgical site infection

Clamping and occlusion

Basic classification of surgical wounds

Suction and aspiration

Suturing and stapling Accessory instruments

5. Surgical suite. Cleaning, inspection and maintenance Introduction Characteristics of the surgical suite Cleaning of the operating theatre Recommended surgical equipment Preparation area

Cleaning, inspection and maintenance of surgical instruments Cleaning of surgical instruments Inspection of surgical instruments

6. Packaging of material for sterilisation Introduction Packaging for sterilisation Folding of surgical gowns and field drapes

Sterilisation packages Woven fabric Non-woven fabric Paper Rigid containers

Packaging bags

Packaging technique “Envelope” or diagonal packaging technique Rectangular or criss-cross packaging technique

7. Suture and ligation materials General characteristics of surgical thread and needles Characteristics of suture thread Calibre Elasticity Resistance Flexibility Surface Tissue reaction

Classification of sutures Industrial finishing Tissue reaction and degradation

Suture package information Needles Types of suture and needle by tissue.

Basic concepts

8. Catheters and drains Introduction

Aspiration catheters/Drains Passive drain Active drain

9. Admission and preparation of the patient for surgery Relationships with owners Shaving and disinfection of the skin Blade cleaning and maintenance

Preoperative cleaning and washing of the patient Positioning of the patient on the operating table Abdominal procedures Thoracic procedures Procedures on the limbs

Preparation of the surgical field Field drapes Handling and placement of field drapes

10. Preparation of surgical staff Introduction Clothing in the operating theatre Surgical scrub suit Cap Surgical face mask

Specific footwear or shoe covers

Behaviour in the surgical area Presurgical hand washing Surgical drying of the hands and forearms Gowning Donning surgical gloves

11. Surgical team.

Standards during surgery Introduction Non-sterile or circulating nurse Handing over sterile items Opening of packaged material Opening laminated bags Distribution of fluids Tasks at the end of surgery

Sterile nurse Preparation and organisation of instruments Protection of the patient. Field drapes Aid and assistance to the surgeon Handling and handing over instruments to the surgeon Handling and care of tissue

12. Initial surgical techniques

Basic principles and techniques

Introduction Skin incision Long incision Precise incision

Dissection and section Sharp dissection Blunt dissection

Haemostasis Preventative haemostatic techniques Curative haemostasis techniques

Suturing

Bandaging Considerations in maintenance

Prevention of self-trauma Elizabethan collar Cervical collar Bandaging of the legs Recovery suits Anti-lick dressings and substances

Identification of complications Seroma Bleeding — haematomas Infection

Holding the needle with the needle holder

Suture dehiscence

Suturing technique

Delayed healing

Suture patterns Surgical knots

Haemostasis. Gauze pads.

Sponges. Gauze balls Surgical sponges Gauze pads and gauze balls

13. Postoperative period.

Care and monitoring Introduction Dressings and bandages Purposes of dressings and bandages Composition of dressings and bandages

Home care Removal of sutures

14. Basic surgical techniques Feeding tubes Pharyngostomy tube Laparoscopic gastrostomy tube

Midline laparotomy Orchiectomy Postoperative considerations

Ovariectomy/Ovariohysterectomy Possible perioperative complications

Basic principles and techniques José Rodríguez

Haemostasis. Gauze pads.

Sponges. Gauze balls Gauze pads and surgical sponges are commonly used in veterinary surgery to foster haemostasis, keep the surgical field clean, protect tissue, perform delicate dissections and heal wounds.

Gauze pads and sponges may be made of woven material such as cotton, or non-woven synthetic fibres such as rayon and polyester (Figs. 1 and 2).

Gauze pads, sponges and gauze balls are used in surgery to keep the operating field clean and free of blood, facilitate dissection of delicate structures, and protect and immobilise tissue during the procedure.

Non-woven gauze pads and sponges release fewer fibres, absorb more fluid and blood, are softer and more flexible, and do not adhere to tissue. However, they become slippery when wet and are not suitable for dissection as they are less abrasive.

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Surgical sponges should not be used carelessly as they are abrasive. If a large volume of blood or fluid must be removed from the operating field, it is better to use a surgical aspirator.

Gauze pads and gauze balls Surgical gauze pads are smaller and more commonly used in veterinary surgery (Fig. 1). They are mainly used to control haemostasis, clean the surgical field (Fig. 5) and perform dissection tasks (Fig. 6).

It is inadvisable to use them in an uncontrolled manner in the surgical field as they could be retained. In addition, these gauze pads are often discarded during surgery, and this makes it more difficult to count them all at the end of the procedure to ensure that none have been retained in the patient.

It is advisable to use gauze pads and surgical sponges with a high thread count per cm2 (> 18 threads/cm2).

To perform delicate dissections and haemostasis by compression (Fig. 6) it is preferable to use gauze balls. Gauze balls can be bought ready-made (Fig. 7) or prepared manually from surgical gauze pads.

Surgical sponges Surgical sponges (Fig. 2) are mainly used in abdominal surgery to protect exposed tissue (Fig. 3), and to dry a deep surgical field as each one absorbs approximately 100-150 ml of saline or blood.

Their rough surface is very useful to immobilise organs and viscera and prevent them from slipping in the operating field (Fig. 4). In all these cases, sponges should be used dampened in warm sterile saline to protect and not damage tissue.

a

b

Fig. 1. Surgical gauze pads: (a) Woven gauze pad (100 % cotton). (b) Non-woven

gauze pad (polyester and rayon). Cotton gauze pads may become frayed during handling.

Fig. 2. Sponges made of 100 % cotton with their edges hidden and sewn to prevent fibres from being retained in the operating field. Some types have a radiopaque marker so that they may be identified on an X-ray. The tape sewn in the sponge on the left may also be used to secure the sponge to field drapes with forceps and better identify the sponge during surgery.

Initial surgical techniques/Haemostasis. Gauze pads. Sponges. Gauze balls

Fig. 3. Surgical sponges are used to protect tissue exposed to the outside environment and encourage haemostasis by applying pressure to the bleeding surface. A midline sternotomy is being performed on this patient. The sponges placed foster haemostasis of the sectioned sternebrae and protect the sternum during surgery.

Fig. 4. The sponges prevent the intestinal loops from slipping towards the surgical field. This facilitates the surgeon’s manoeuvres. Here, an ameroid ring is being placed around a portosystemic shunt located in the greater curvature of the stomach.

185

Fig. 5. The assistant often uses a gauze pad to perform haemostasis by compressing small bleeding vessels and to keep the surgical field clean.

This allows the surgeon to work comfortably and precisely, as seen in this image taken during a lateral thoracotomy.

Fig. 6. Here, a gauze ball (yellow arrow) held with a gauze ball holder is being used to perform haemostasis and blunt dissection of adhesions of the right pancreatic lobe to the surrounding tissue (blue arrow).

Basic principles and techniques

Compression methods and techniques are not always effective to achieve definitive haemostasis; if they are not, ligations, vascular clips or other techniques must be used.

In delicate, meticulous procedures, it is preferable to use cotton swabs or sterile lancets to perform dissection and haemostasis more precisely (Figs. 8 and 9).

Applying dry or wet gauze pads directly to low-pressure blood vessels is an effective technique to achieve haemostasis of these blood vessels.

Fig. 7. Commercial gauze balls used for haemostasis and atraumatic tissue dissection. These are available in different sizes. Some even have radiopaque material so that they may be identified on an X-ray should it be suspected that they have been retained inside the patient.

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Fig. 8. Use of a sterile cotton swab for dissection and haemostasis of tissue surrounding patent ductus arteriosus.

Fig. 9. Microsponges or lancets are mainly used in ophthalmology to perform haemostasis of small blood vessels and to absorb blood that is obstructing the proper view of the surgical field. This image shows them being used during resection of a sclerocorneal melanoma.

Initial surgical techniques/Haemostasis. Gauze pads. Sponges. Gauze balls

Preparing gauze balls

Preparing gauze balls using forceps

As previously mentioned, gauze balls can be bought ready-made, or made from surgical gauze pads as explained below.

This technique is indicated when the assistant prepares gauze balls during the surgical procedure.

To perform this technique the steps below must be followed (Fig. 10):

Technique for preparing a gauze ball with forceps (Fig. 10)

1

2

3

4

5

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Watch this video on the electronic version Preparing a gauze ball using forceps

Step 1: place the gauze pad with the cut edges face up so that threads cannot be released in the surgical field.

Step 2: fold each corner of the gauze pad inwards.

Step 3: secure the four corners of the gauze pad in the centre with the gauze ball holder.

Step 4: compact the gauze ball by folding the corners inwards again.

Step 5: immobilise the gauze pad with the gauze ball holder. It is now ready to be used as a gauze ball.

Basic principles and techniques

Preparing gauze balls by hand When using a woven cotton gauze pad, the cut edges should be folded inwards to prevent loose threads from being retained in the patient.

Manually folded gauze balls should be prepared and sterilised in advance. This is a more laborious technique, but they release fewer fibres and are applied more precisely.

To perform this technique the steps below must be followed (Fig. Â 11):

Technique for preparing a manually folded gauze ball (Fig. 11)

1

Step 1: fully unfold the gauze pad.

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3

Step 3: fold the longer edge over twice towards the top corner.

5

Step 5: tie or twist the free ends together.

2

Step 2: fold one corner over to the opposite corner.

4

Step 4: hold the gauze pad in the centre with the index and middle finger.

6

Step 6: join the two tips.

Initial surgical techniques/Haemostasis. Gauze pads. Sponges. Gauze balls

Watch this video on the electronic version Preparing a manually folded gauze ball

7

8

Steps 7 and 8: roll it up towards the finger.

9

10

Steps 9 and 10: stretch out the upper corner, insert it where the index finger was, and use it to wrap the previously formed roll.

11

12

Steps 11 and 12: turn the initial fold outwards to wrap the rest. The manually folded gauze ball is complete.

189

Basic principles and techniques Instructions for use of gauze pads and gauze balls Hold the gauze ball with a gauze ball holder such as Foerster forceps. Place the gauze ball directly on the bleeding vessel at a perpendicular angle and apply gentle pressure until achieving haemostasis. Remove the gauze ball in the same way, without sliding it on the tissue (Figs. 6 and 12).

Gauze balls can be used dry or dampened in sterile saline.

It must be remembered that surgical gauze pads are abrasive, and if they are moved at a parallel angle to the tissue in a sweeping motion, they will create microlesions, which increase tissue trauma, and strip away any blood clots formed, which causes vessels to bleed again.

Complications of the use of gauze pads and sponges: textiloma or gossypiboma Apart from the possible complications mentioned above resulting from improper use of gauze pads and sponges, the most significant and serious complication is the formation of textiloma or gossypiboma*.

Textiloma is a term used to describe a mass inside the body that forms due to a retained gauze pad and the resulting fibrinous or granulomatous tissue reaction to a foreign body (Fig. 13).

This complication is more commonly detected in medium- to large-sized patients, particularly in ovariohysterectomies and when there is significant bleeding during surgery.

In these cases, there may be no symptoms or a wide variety of clinical signs, including peritonitis, septicaemic shock, the appearance of fistula tracks on the skin and intestinal obstruction (Figs. 13 and 14). It has also been reported that it may degenerate into a sarcoma.

“Sweeping” tissue with a gauze ball to clean it will increase tissue damage and promote bleeding.

Blood loss can also be estimated by counting blood-soaked gauze pads and gauze balls. The absorption capacity of the gauze ball depends on the size and composition of the gauze pad.

The clinical signs of gossypiboma depend on the extent of bacterial contamination and the location of the gauze pad inside the patient.

Small blood-soaked gauze pads are difficult to see, particularly in a deep surgical field. For this reason, they should not be left in the operating field unless they are held with a gauze ball holder (Fig. 6).

Used gauze pads must be immediately removed from the surgical field and surrounding area to prevent them from accidentally entering these areas. They must be discarded in a specific container in order to estimate blood loss during surgery.

190

Fig. 12. Cleaning and haemostasis of the surgical field with a gauze ball must be performed by applying direct compression at a perpendicular angle to the bleeding vessel. Cleaning must not be performed with a sweeping motion.

Fig. 13. Removal of a gauze pad retained in a patient having undergone an ovariohysterectomy a few weeks earlier. It was not possible to fully remove the textiloma capsule due to adhesions to the neighbouring organs (intestine, colon, bladder and ureters).

* Gossypiboma is a term derived from the Latin gossipium, meaning “cotton”, and the Swahili boma, meaning “place of concealment”.

Initial surgical techniques/Haemostasis. Gauze pads. Sponges. Gauze balls

Fig. 14. Fistula tracks on the right flank of a patient

several weeks after an ovariohysterectomy, as a result of a gauze pad retained in the patient during surgery.

Methods to reduce the risk of a gauze pad being retained in the patient In theory, gauze pads and surgical sponges must be counted before and after the procedure and it must be checked that none have been retained in the patient. However, unfortunately, this is not a common practice in veterinary surgery. It is therefore important to strive to comply with this protocol or, failing this, check the surgical field regularly to identify any gauze pad that is unaccounted for.

To reduce the potential for standard (10 × 10) gauze pads (Fig. 1) being retained inside the patient, it is advisable to use larger sponges.

Ideally, they will have a strip of tape that remains outside the operating field and has a radiopaque marker so that it may be identified on an X-ray (Fig. 2).

To minimise the potential for gossypiboma, the following matters must be considered (Table I).

191

Table I. Matters to be considered to prevent gossypiboma Count gauze pads before and after surgery. Use packets with a specific number of gauze pads, for example 4 sponges and 10 gauze pads.

Regularly check the operating field for hidden gauze pads.

Immediately remove small gauze pads once they are used and blood-soaked. Do not discard them directly in the waste bucket.

Do not leave a gauze pad inside the patient to perform haemostasis.

The scrub nurse should regularly count the material used and remind the surgeon that there are gauze pads and sponges being used in the operating field and that they must be returned.

6. In deep places, hold the gauze ball with forceps.

7. Do not leave used gauze pads on the field drapes or close to the operating field.

8. Use larger surgical sponges, particularly those with tape sewn in them, as they are more visible.

9. Count gauze pads and sponges before proceeding to close the operating field.

10. Use gauze pads and/or sponges with radiopaque markers, as these are easily located on a postoperative X-ray in the event of any doubt.

1.

2.

3.

4.

5.

The publishing strength of Grupo AsĂ­s Editorial Servet, a division of Grupo AsĂ­s, has become one of the reference publishing companies in the veterinary sector worldwide. More than 15 years of experience in the publishing of contents about veterinary medicine guarantees the quality of its work. With a wide national and international distribution, the books in its catalogue are present in many different countries and have been translated into nine languages to date: English, French, Portuguese, German, Italian, Turkish, Japanese, Russian and Chinese.

Its identifying characteristic is a large multidisciplinary team formed by doctors and graduates in Veterinary Medicine and Fine Arts, and specialised designers with a great knowledge of the sector in which they work. Every book is subject to thorough technical and linguistic reviews and analyses, which allow the creation of works with a unique design and excellent contents.

Servet works with the most renowned national and international authors to include the topics most demanded by veterinary surgeons in its catalogue. In addition to its own works, Servet also prepares books for companies and the main multinational companies in the sector are among its clients.

PRESENTATION Small animal surgery

BROCHURE

Small animal surgery José Rodríguez (Editor and coordinator) Jorge Llinás Roberto Bussadori Salvador Guillén

Asepsis and antisepsis Surgical instruments Servet (División de Grupo Asís Biomedia S.L.) Centro Empresarial El Trovador, planta 8, oficina I Plaza Antonio Beltrán Martínez, 1 • 50002 Zaragoza (España) Tel.: +34 976 461 480 • Fax: +34 976 423 000 • www.grupoasis.com

Suture materials Drains Preparation of the patient Sterilisation Initial techniques Postoperative treatment

Surgery atlas, a step-by-step guide

Basic principles and techniques Basic surgical techniques