Basic Principles of surgery.

Dr. F.J. Owotade

 Human tissues have genetically determined properties that make their response to injury predictable. The principles of surgery are based on proven techniques that help to optimize the healing environment.

Basic necessities for surgery.

1. Adequate visibility. 2. Assistance. Adequate visibility is based on Adequate access- mouth opening, surgical exposure,
retraction

Adequate light Surgical field free of excess blood and other fluids.

Aseptic technique.
The details will be discussed at a later lecture, however the principles will be outlined. Medical asepsis is the attempt to keep patients, health care staff and objects free from infectious agents and surgical asepsis describes the efforts aimed at preventing microbes from gaining access into surgically created wounds.

Universal precautions are applied to prevent sepsis and efforts fall under the following headings. 1. Instrument sterilization. 2. Operatory disinfection. 3. Surgical staff preparation. Hand and arm preparation. Clean technique. Sterile technique.

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.

Flap design
Principles of flap design help to prevent: 1. Flap necrosis. 2. Flap dehiscence 3. Flap tearing.

Preventing flap necrosis.

1. The tip should never be wider than the base unless a major artery is present at the base. 2. The length of a flap should be no more than twice the width. In the oral cavity, the length should never exceed the width. 3. When possible, include an axial blood supply in the base. 4. The base should not be twisted, stretched or grabbed with instruments that can interrupt or destroy the blood supply.

Preventing flap dehiscence

Approximate the edges over healthy bone, handling the edges gently and minimizing tension. Dehiscence exposes underlying bone leading to pain, infection and scarring.

Preventing flap tearing.

Make incisions long enough to give adequate access. Make more than one releasing incision if more access is needed.

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.

 Avoid excessive pulling forces to retract tissue. Use copious irrigation when drilling or cutting bone. Protect soft tissue when drilling or cutting.

Hemostasis.
No effort should be spared to minimize blood loss. Wound hemostasis can be obtained by: Assist natural clotting processes by applying pressure on a bleeding vessel or a hemostat. Use of heat- thermal coagulation. Suture ligation. Pressure on the wound. Use of vasoconstrictors.

1.

2. 3. 4. 5.

Dead space management.

Defined as an area that remains devoid of tissue after wound closure. Dead spaces are usually filled with blood which delays healing and predisposes to infection. Can be managed in 4 ways. 1. Suture all tissue planes. 2. Pressure dressing. 3. Packing. 4. Use of drains.

Decontamination and debridement.

Copious irrigation during and after surgery removes debris and reduce the bacteria count and minimizes the likelihood of infection. Necrotic, foreign and devitalized tissue should be removed.

Oedema control.
Results from the collection of fluid in the interstitial spaces due to the transudation from damaged vessels and lymphatics obstructed by fibrin. More severe in areas with loose connective tissue. Oedema is minimized by: 1. Careful and gentle tissue handling 2. Use of ice packs. 3. Short term steroids.

PREVENTING AND MANAGING MEDICAL EMERGENCIES. Serious medical emergencies are rare in the dental clinic. However, the dental personnel should be able to recognize and promptly and adequately manage whenever such situations occur. Prevention of medical emergencies is the cornerstone to their management.

The first step in prevention is risk assessment. This involves: 1. Adequate medical history. 2. Review of systems. 3. Physical examination with vital signs.

Preparation for emergencies.

Basic life support- An important component of continuing education

List of medical emergencies

Hypersensitivity reactions. Chest discomfort. Respiratory difficulty. Altered consciousness

Respiratory difficulty.
Asthma Hyperventilation. Chronic obstructive pulmonary disease. Foreign body aspiration.

Altered consciousness.
Vasovagal syncope. Orthostatic hypotension. Seizure. Local anesthetic toxicity. Diabetes mellitus. Thyroid storm. Adrenal insufficiency. Cardiovascular compromise.