Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Fundamentals of Surgical Practice
The Surgical Patient
Approach to the surgical patient
The paediatric patient
Surgical Techniques
Tissue Handling
Suture and suture technique
Prophylaxis
Basic Surgical Procedures
Wound management
Specific lacerations and wounds
Burns
Foreign bodies
Cellulitis and abscess
Excision and biopsies
Tissue Handling
 



Technique

When making an incision:

1 Plan the incision to give adequate exposure.
2 Stabilize the skin with one hand and, using the belly of the scalpel blade, open the skin in a continuous motion (Figure 4.1).
Figure 4.1
Figure 4.1

3 Deepen the wound to reach the target organ, using the whole length of the incision. Do not shorten the incision with each layer. If time permits, ensure that haemostasis is achieved as the operation proceeds. In an emergency situation, this can be done once the situation and the patient are stabilized.
4 Close the operation wound in layers with non-absorbable sutures. Braided materials may provide a focus for infection and should not be used in potentially contaminated wounds. Bring the wound edges together loosely, but without gaps, taking a “bite” of about 1 cm of tissue on either side, and leaving an interval of 1 cm between each stitch (Figure 4.2).
Figure 4.2
Figure 4.2

A potentially contaminated wound is best left open lightly packed with damp saline soaked gauze and the suture closed as delayed primary closure after 2–5 days (Figure 4.3).

Figure 4.3
Figure 4.3



Haemostasis
Minimizing blood loss is essential and is of the highest priority in patients who are medically compromised by anaemia or chronic illness.

As the risks of transfusion (from infections such as malaria, Chagas, hepatitis and HIV) have increased, the challenge of establishing a safe and consistent blood supply has been highlighted. Minimizing blood loss is part of excellent surgical technique and safe medical practice. Meticulous haemostasis at all stages of operative procedures, decreased operative times and improved surgical skill and knowledge will all help to decrease blood loss and minimize the need for blood replacement or transfusion.

Technique

:: Control initial oozing of blood from the cut surfaces by pressure over gauze
:: Control individual bleeding vessels with cautery or suture ligation using fine suture; when tying off bleeders, cut the ligature short
:: Avoid diathermy near the skin where it may cause damage and devitalize tissue
:: When tying off a large vessel, or to ensure that the suture will not come off the end of a vessel, use a suture ligature. This involves passing the needle through the vessel before securing the tie around the vessel (Figure 4.4). Place a second free tie below the suture ligature.

 

Figure 4.4
Figure 4.4



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  Kep Points  
Handle tissues gently


Prevent bleeding. Minimizing blood loss minimizes the need for blood replacement or transfusion. This is especially important in areas where a safe and consistent blood supply is in doubt.