PRINCIPLES OF PROF DR AMEER

ONCOLOGY & AFZAL

Head of Surgery,
North Surgical
OPERATIVE Ward,MHL.
 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
N
 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.
DEVELOPING A SURGICAL
DIAGNOSIS
It is done by:
• Complete and thorough
history
• Physical examination
• Radiographic findings
• Laboratory investigations
• Record keeping/data in an
organized form
• Differential diagnosis
ASEPTIC
TECHNIQUE:
It includes minimizing wound
contamination by pathogenic
microbes through:

Medical asepsis
Surgical asepsis
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.
 INCISIONS
Incisions are necessary for many
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.
 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.
 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 desiccate.

Only physiologic substances should come in

contact with the living tissue.
 HEMOSTASIS
Prevention of excessive blood
loss is important for :

Preserving patient’s oxygen-

carrying capacity
Increased visibility
To prevent formation of
hematomas
 HEMOSTASIS
MEANS OF PROMOTING WOUND HEMOSTASIS:

Assist natural clotting processes by applying pressure on a bleeding

vessel or a hemostat.
Use of heat(thermal coagulation).
Suture ligation.
Use of vasoconstrictive substances(epinephrine)
By applying procoagulants(commercial thrombin & collagen)
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.
 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.
DECONTAMINATION AND
DEBRIDEMENT
 DECONTAMINATION AND
DEBRIDEMENT
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 .
EDEMA CONTROL

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
EDEMA CONTROL(contd..)
It’s minimized by:

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.
 Patient General Health And Nutrition
Wound Healing is affected by:

1.Diseases inducing ●
Poorly controlled IDDM
catabolic ●
End-stage renal or hepatic disease
metabolic state ●
Malignant diseases

2.Conditions interfering
●
Severe COPD
with delivery of oxygen ●
Congestive heart failure
and nutrients to wound ●
Drug addictions (Alcohol)

3.Drugs or physical
agents that interfere with ●
Autoimmune diseases (long-term corticosteroid therapy)
immunity or wound ●
Malignancies (cytotoxic agents & radiation therapy)
healing.
 PATIENT GENERAL HEALTH
AND NUTRITION
SURGEON’S ROLE :

Evaluating and optimizing the

patient’s 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.
 SURGICAL
ONCOLOGY
 CANCER CELLS
-PSYCHOPATHS
No respect for the rights of other
cells.
Violate the democratic principles of
normal cellular organization.
Their proliferation is uncontrolled.
Ability to spread is unbounded.
Their inexorable, relentless progress
destroys first the tissue and then the
host.
PRINCIPLES OF SURGERY
– CANCER
For most solid tumors, surgery remains the definitive
treatment and the only realistic hope of cure.
Role of surgery in cancer treatment includes:

Diagnosis & staging

Removal of primary disease

Removal of metastatic disease

Palliation
 DIAGNOSIS
PHYSICAL
EXAMINATION:
Pap Smear
test for cervical and uterine cancer

Breast Exam
palpate for lumps in the breast

Testicular Exam
palpate for tumors in testes

Digital Rectal Exam

screening for prostate cancer 29
 DIAGNOSIS

TUMOR MARKERS
Carcino-Embryonic Antigens (CEA)
• detects gastrointestinal tumors

Prostate-specific Antigen (PSA)

• detects prostate cancer

Alpha-Fetoprotein test (AFP)

• detects liver or testicular cancer

Cancer Antigen 125 (CA-125)

• protein produced by ovarian cancer cells

Human Chorionic Gonadotropin (Hcg)

• present with testicular cancer
 TNM METHOD FOR
STAGING OF TUMOR
T - score: size and extent of invasion of the primary
tumor

N - score: number and location of histologically involved

regional lymph nodes

M - score: presence or absence of distant metastasis.

CATEGORISATION OF
TUMORS
 Grade
the maturity of the tumor

 Stage
the degree the tumor has spread

 Appearance
using a microscope and by visual observations
 PATHOLOGICAL BIOPSY
• Despite suggestive imaging, a
cancer is not diagnosed until
histopathological biopsy.
• Biopsies where tissue (as opposed to
cells) are provided to the pathologist
increase the accuracy of the pre-
operative diagnosis but may not always
be feasible.
• Biopsies may be undertaken
percutaneously -- for example, a core
biopsy of the breast, fine needle
aspiration of thyroid or endoscopically
such as in gastric cancer or colon cancer.
Incisional biopsy Excisional biopsy
•Removal of part of •Removal of the
a tumor for tumor and
examination surrounding
Surgical tissue
Procedures

Resectioning Exenteration
•Removal of the
•Removal of an
tumor and a
organ, tumor, and
large amount of
surrounding tissue
the surrounding
tissue
4
PATIENT SELECTION AND
TIMING OF SURGERY
• Choose the correct surgery for the correct patient
and with the tumor type and biology in mind.

• The surgery should not cause more morbidity than

the cancer and must achieve surgical goals without
compromising tumor biology.
When tumors are locally advanced, a neoadjuvant approach
with chemotherapy, radiotherapy or targeted therapy used:
 to ‘control’ the growth of a tumor,
 down-stage a tumor to render it operable, or
 because the impact of systemic disease risk may outweigh those of
local control.

Similarly, patients with metastatic disease may still require

surgery to prevent complications of the primary tumor, such
as bowel obstruction from a colon cancer.
MULTIDISCIPLINARY APPROACH
The pre-operative multidisciplinary team including:
anesthetists,
 cardiologists,
dieticians,
psychologists
social workers, and
tumor-specific specialist nurses
often assesses fitness for cancer surgery and the
psychosocial impact of surgery.
DECISION MAKING

As the management of cancer becomes more complex, it becomes

impossible for any individual clinician to have the intellectual and
technical competence that is necessary to manage all the patients
presenting with a particular type of tumour.

The formation of multidisciplinary teams represents an attempt to

make certain that each and every patient with a particular type of
cancer is managed appropriately.

Teams should not only be multidisciplinary, they should be

multiprofessional.
SURGERY IN CANCER
 Diagnosis & Staging
 Lap Ultrasound & Biopsy
 Sampling Lymph nodes

Removal of primary disease

 Removal of primary tumor + lymph node

Removal of metastatic disease

 Liver metastases - Resection
 Lung metastases – Pulmonary resection

Palliation
 By pass procedures
TREATMENT TECHNIQUES
AND PROCEDURES
Surgery:
Tumor removal through surgery.
In more than 90 percent of all cancers, surgery is used
for diagnosing and staging
In more than 60 percent of all cancers, surgery is the
primary treatment.
When feasible, the primary tumor is excised in its
entirety.
TREATMENT

RADICAL SURGERY:

Primary tumor
 Safety Margin
Lymph nodes
• GIT CA Routinely Resected
• Breast CA Excision or Irradiation
• Head & neck & skin Treated in involved

BLOCK EXCISION:
Whenever possible lymph nodes are removed in continuity with the
primary tumor.
 TREATMENT
PRECAUTIONS
i. Avoid spillage of malignant cells, local & blood

ADVANTAGES
i. Quick
ii. Effective
iii. The largest number of cures
iv. Confirms full ablation of a tumor (clear safety margin).

DISADVANTAGES AND LIMITATIONS:

i. Functional and cosmetic disabilities
ii. Not applied if fixed to a vital structure or with mets.