Basic principles of surgery

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1. 2. CONTENTS
DEVELOPING A SURGICAL DIAGNOSIS
BASIC NECESSITIES FOR SURGERY
ASEPTIC TECHNIQUE INCISIONS FLAP DESIGN
Prevention of flap necrosis Prevention of flap
dehiscence Prevention of flap tearing TISSUE
HANDLING HEMOSTASIS Means of promoting wound
hemostasis Dead space management
DECONTAMINATION AND DEBRIDEMENT EDEMA
CONTROL PATIENT GENERAL HEALTH AND
NUTRITION
2. 3. PRINCIPLES OF SURGERY Human tissues
,due to their innate properties ,react to injury fairly
predictably. So ,with experience certain set principles
are evolved for optimal healing.These are called as
BASIC PRINCIPLES OF SURGERY.
3. 4. DEVELOPING A SURGICAL DIAGNOSIS
Important decisions regarding surgery are made

from : Identifying signs and symptoms by 1.

Complete and thorough history 2. Physical
examination Radiographic findings Laboratory
investigations Record keeping/data in an organized
form Differential diagnosis
4. 5. BASIC NECESSITIES FOR SURGERY 1.
Adequate visibility is based on Adequate access- m
o uth o p e ning , s urg ic a l e x p o s ure , re tra c tio
n Adequate light Surgical field free of excess blood
and other fluids. 2. Assistance
5. 6. ASEPTIC TECHNIQUE It includes minimizing
wound contamination by pathogenic microbes
through: Medical asepsis Surgical asepsis
6. 7. ASEPTIC TECHNIQUE(CONTD..) 1. 2. 3.
Universal precautions are applied to prevent sepsis
and efforts fall under the following headings.
Instrument sterilization. Operatory disinfection.
Surgical staff preparation. Hand and arm preparation.
Clean technique. Sterile technique.
7. 8. INCISIONS Incisions are necessary for
many OMFS procedures. The following principles
apply. Use a sharp blade of proper size . Use firm

continuous strokes. Avoid cutting vital structures.

Incise perpendicular to the epithelial surface. Intraoral
incisions should be properly placed.
8. 9. FLAP DESIGN 1. 2. 3. Principles of flap design
help to prevent: Flap necrosis. Flap dehiscence Flap
tearing.

9. 10. 1.Preventing flap necrosis 1. 2. 3. 4. The tip

should never be wider than the base unless a major
artery is present at the base. The length of a flap
should be no more than twice the width. In the oral
cavity, the length should never exceed the width.
When possible, include an axial blood supply in the
base. The base should not be twisted, stretched or
grabbed with instruments that can interrupt or destroy
the blood supply feeding and draining the flap.
10.

11. 2.Preventing flap dehiscence

Dehiscence (separation) is avoided by approximate

the edges over healthy bone, handling the edges
gently and minimizing tension. Dehiscence exposes

underlying bone leading to pain,bone loss, infection

and scarring.
11.

12. 3.Preventing flap tearing Make incisions

long enough to give adequate access. Make more

than one releasing incision if more access is needed.
12.

13. TISSUE HANDLING Apart from

careful flap design and incision technique, the careful

handling of the tissues is also necessary for optimal
and uncomplicated healing. Excessive crushing,
pulling, extremes of temperature, desiccation and
harsh chemicals damage tissues and these should be
avoided. Toothed forceps and skin hooks are
preferred to forceps that crush the wound edges.
13.

14. TISSUE HANDLING(CONTD..) Avoid

excessive pulling forces to retract tissue. Use copious

irrigation when drilling or cutting bone to decrease bone
damage from heat. Protect soft tissue when drilling from
frictional heat and direct trauma. Wounds should never be
allowed to desicate. Only physiologic substances should
come in contact with the living tissue.
14.

15. HEMOSTASIS Prevention of excessive blood loss is

important for : Preserving patients oxygen-carrying

capacity Increased visibility To prevent formation of

hematomas
15.

16. HEMOSTASIS(CONTD..) MEANS OF

PROMOTING WOUND . HEMOSTASIS 1.Assist natural

clotting processes by applying pressure on a bleeding vessel
or a hemostat. 2.Use of heat(thermal coagulation). 3.Suture
ligation. 4.Use of vasoconstrictive substances(epinephrine)
5.By applying procoagulants(commercial thrombin &
collagen)
16.

17. HEMOSTASIS(CONTD..) DEAD SPACE

MANAGEMENT Dead space is an area that remains devoid

of tissue after wound closure. It is created by removing tissue
in the depths of the wound or by not reapproximating all
tissue planes during closure. These are usually filled with
blood (hematoma) which delays healing and predisposes to
infection.

17.

18. HEMOSTASIS(CONTD..) DEAD SPACE

MANAGEMENT Can be managed in 4 ways: 1.

Suture all tissue planes. 2. Pressure dressing. 3.

Packing(with an antibacterial medication). 4. Use of

drains.
18.

19. DECONTAMINATION AND DEBRIDEMENT

19.

20. DECONTAMINATION AND

DEBRIDEMENT(CONTD..) Debridement with copious

irrigation of wound with sterile saline during surgery
and after closure.(large volumes of fluid under
pressure) To remove debris . To reduce the
bacteria count and minimizes the likelihood of
infection. To remove necrotic, foreign and devitalized
tissue .
20.

21. EDEMA CONTROL 1. 2. Results from

the collection of serum(fluid)in the interstitial spaces

due to the transudation from damaged vessels and
lymphatics obstruction by fibrin. Variables help
determining the degree of postsurgical edema: Tissue
injury Loose connective tissue
21.

22. EDEMA CONTROL(CONTD..) Post-surgical

edema is minimized by: 1. 2. 3. 4. Careful and gentle

tissue handling Short term steroids(prior to surgery)
Use of ice packs(controversial) Head kept elevated
above the rest of the body for few postoperative days

22.

23. PATIENT GENERAL HEALTH AND

NUTRITION PROPER WOUND HEALING

23.

24. PATIENT GENERAL HEALTH AND

NUTRITION(CONTD..) Medical conditions impairing

patients ability to resist infection and wound healing :
1. Diseases inducing catabolic metabolic state
Poorly controlled IDDM End-stage renal or hepatic
disease Malignant diseases 2. Conditions interfering
with delivery of oxygen and nutrients to wounded
tissue Severe COPD Poorly compensated
congestive heart failure Drug addictions (ethanolism)
3. Drugs or physical agents that interfere with
immunologic or wound healing cells Autoimmune
diseases (long-term corticosteroid therapy)
Malignancies (cytotoxic agents & radiation therapy)
24.

25. PATIENT GENERAL HEALTH AND

NUTRITION(CONTD..) SURGEONS ROLE :

Increased chances of normal healing of an elective
surgical wound by evaluating and optimizing the
patients general health status before surgery. For
malnourished patients, improving nutritional status so

that the patient is in a positive nitrogen balance and

an anabolic metabolic state.
25.

26. Thank you for the PATIENT LISTENING