Principles of surgery

DR. MOHAMMAD M.ABU MOWAIS

BDS,MSC, P. BOARD (ORAL SURGERY)
DEVELOPING SURGICAL DIAGNOSIS

► THE DECISION TO PERFORM SURGERY SHOULD BE DONE WITH SEVERAL

DIAGNOSTIC STEPS
► THE INITIAL STEP IN PRESURGICAL EVALUATION IS THE COLLECTION OF
ACCURATE AND PERTINENT DATA USING………..
► THIS GOOD ANALYSIS SHOULD BE ORGANISED FOR HYPOTHESIS
TESTING((DIFFERENTIAL DIAGNOSIS))
 BASIC NECESSITIES FOR SURGERY

-
1-Adequate visibility, which depends on:
wax
->
as,536ic
Y

Cgls8r b.
a. Adequate access (mouth opening, retraction, surgical flaps)
Adequate light (avoid blocking chair light , or the use of headlight)
c. Surgical field free of blood or other fluids( high volume suction)
↳b ne
·
removal
design that
=

from prevent
lood
*
and
blokade
other fissue
2- Properly trained assistant
Aseptic technique -> infection control

Protocol
-
-
 Incision

► Sharp blade of proper size( Degree of sharpness , number of strokes)

► Firm continuous stroke while incising (#of strokes=tissue damage and
bleeding…..impaired wound healing)
► Avoid cutting vital structures while incising ( nerves, blood vessels,
accidental injury of the lip during the procedure)
► Blade should be hold perpendicular to the epithelium to be cut …square
wound edge…better approxiamation…low risk of ischemia and necrosis
► Incisions should be made (in the oral cavity) over healthy bone…closure
will be on intact bone…better wound support for better healing
► Near to teeth to be extracted, incisions should be in the gingival sulcus
I
* enter perpendicular with the tissue to be insised -
ji square o
#lade healing sy
Borders
the ⑤ Slone firm
5
continuous stoke 8.9C- Bone 316575-5.50*

my incision is
*
determine by anatomy and should be done over
healthy Bone Cast infected)
 *

Incision

T
scalpel
->
of
is holder
the
blade

-> pin grasp

Flap design

SURGICAL FLAP???
Flap design (prevention of flap
necrosis)

► Flap apex should not be wider than the base, unless a major artery is found
in the area
► The length of the flap should not be no more than the twice of the width
(not so strict in oral surgery)
► When possible, axial blood supply should be included in the base of the
wedth
flap Y:
X: length
► The base should not be twisted, stretched……………….ischemia…. Affect

Xofflare
supply and drainage relent inside o
wide r
*
vertical
the Base
* is always
the flap
length
*
of
inscision
not be mora salular
d
s would
Man 2 riches the
wed
apex of flap
the
Flap design(prevention of flap
dehiscence)
1 25! -481 -> Badresulti& healings & S
► By approxiamation over healthy bone, gentle handling

► It will expose underlying bone, produce pain, bone loss, increase scar
formation
Flap design(prevention of flap tearing)

► Because of flaps that produce insufficient access

► Vertical releasing incisions is the solution in the line angle of the tooth or in
the adjacent interdental papillae Y
[ Plobet & Inscision I

& access
(13g. ⑤ ~

288.8 tearing (105 8g'

Y

-
should be done
& blighly
1.5
⑤x base
 incision
outlines by surgical
Flap types -> apiece
of softtissue
↓God
subbly (Axial BS, with
prober
the purpose
and have
a
be
tissue, and
can
deep
-

of reaching
position
retained to it's original
supported by suture
and
infected our trapizoid #
corner

⑰
-T C
stiled
trianguar flap
I
-

margins 59.
· a sided 4
threecorner
flap
j984131- of
wealthy
is one
·

Herdenta
s uscular
one vertical
7
&
igbitso
S
-
-> ore
calcula+
vertical
81683 jB
-

8
Recsition
vie Ojis 88
included
angles &
in encluded jg8. adjacent &

envelope flap
x
-

->
underlyingand
fissue ·we
bore
Isulcular only)
↳perio
Tissue handling
~

normal saline as irrigation

↳ isotonic 508.5.
► It includes careful handling, excessive pulling or crushing, high chemical jo
temperature, desiccation, or the use of unphysiologic chemicals & am age L

► While using tissue forceps, the holded tissue should not be pinched too
tightly
formalines
► Avoid excessive retraction to gain better access chemicalage 8..

► Bone removal with cooling is highly mandatory Le Biopsy s1 jly id

► Protection the tissue from the heat produced by drills 2,"d-j,8
native
► Open wounds should be moistened ↓sswe (1@foreep. I
► Examples, handling with formalin should not be returned to the wound
↑ os
the Now forth,b
sliding o
- -

terroadit
*
Isild
Hemostasis WHY it is important??

heamatoma -> Poressure-tischemic

Blood ->
collection of
► Preserving oxygen carrying capacity
► Increase visibility in the surgical field
► Bleeding will lead to hematoma formation….pressure….decrease
vascularity…good culture medium…..infection….
for
Means of promoting wound
hemostasis

► Assisting natural hemostatic mechanisms by direct pressure, or placing

hemostat on a vessels (small vessels require 20 -30 seconds, but larger ones
require 5-10 minuets ), and the wound should dap rather than wipe
► Themal coagulation which require patient grounding to let the electric current
to enter the patient body, proper application of cautety tip at the interested
site, and the removal of any accumulated blood of fluid around the vessel to
be cauterized
► Suture ligation
► Placing vasoconstrictive substances such as epinephrine, or procoagulants like
thrombin or collagen
► Note: application of epinephrine 7 min preoperatively produce efficient
vasoconstriction
Means of promoting wound
hemostasis
stat
forcers
or
-> Heard suita
mos

A
3..4
50818
-
"

c)
Sunde
ligation
..

J
19
d
⑤ ↑

gi8
& 815)x
cat f Major

Bleeding 18 surveys
 Dead space management (aid"d

► Is any area left devoid of tissue after closure of wound

► Can be eliminated by:
tissue Ex superfacial one)
► Layered closure (Deepist
► Placing pressure dressing on the
L
repaired wound till fibrin or edema can
itself compress the wound (takes 12-18 hours)
► Placing packing into the wound till bleeding arrested then removed e.g.
bone cavities found after some minor oral surgical procedures
► Using drains, which will bring any bleeding to come to the surface without
collection and finally hematoma formation
 -

Decontamination and debridement

*4
Use inifigation
► By irrigation (large volumes of fluid under pressure) using antibiotic
containing fluid or normal saline

► Wound debridement is the removal from injured tissue the necrotic and
severly ischemic tissues and foreign material the impedes wound healing
Edema control

► It is the accumulation of fluid in the interstitial space because of

transudation from blood vessels and obstruction of lymphatics by fibrin
► It degree depends on : degree of tissue injury during surgery and the
amount of loose CT in the wound density edema

Example attached gingivae vs. Lips and floor of the mouth

so, edema can be controlled by minimizing tissue damage during
procedure, patient position during the few postoperative days, and
administration of corticosteroids( reduce inflammation and transudation )
I
dataton
rose
Low y

patientsin
th
is
Patient general health and nutrition

► Some chronic diseases will impair healing by decreasing nutrition supply

and oxygen to the injured wounds e.g. ESRD and poor controlled insulin
dependent diabetes
► Patient who is taking immunosuppressive drugs

► Care should be given to the malnourished patients