December 12, 2017
All kinds of sticky situations can be avoided by following a simple set of rules during the various steps of surgery, from the incision to the last suture.
Tailor the length of the incision to the surgery at hand. For example, many surgeons have evolved from a full open arthrotomy of the stifle to a mini-arthrotomy. Others only make a few stab incisions when they perform arthroscopy. Conversely, it is essentially impossible to perform a thorough laparotomy through a conservative midline incision. Abdominal incisions should extend for the xiphoid to the pelvic inlet.
Anticipate both predictable and non-predictable complications when your surgery is ever so slightly out of the ordinary. Think of solutions ahead of time. Always have a Plan B and even a Plan C in mind in case something doesn’t unfold as planned. Some complications are predictable, such as bleeding, tearing, and anesthetic headaches. Other complications are more difficult to predict, and that’s where experience is invaluable.
For example, the equipment you were planning on using may be mysteriously missing or not sterile, or you may have dropped it on the floor. Sometimes, a new lesion may be found intraop. Or, you might perform a laparotomy to remove a foreign body and find a mass in the intestine or a gallbladder mucocele.
Ensure you are comfortable performing unexpected procedures. For example, what was thought to be an enterotomy may turn into a resection and anastomosis. A “simple” cystotomy may require a urethrostomy.
If you think you may need help from an in-house colleague, ensure they are aware and available to help. Consider teaming with a local colleague for future situations. If you think that you might encounter a sticky situation, a referral may help you avoid getting in over your head.
Use aseptic technique during surgery for your patient’s safety. A cap and a mask, as well as an appropriately sized drape, should be used to limit contamination. Every square inch of the patient should be covered by the drape. Disposable drapes are inexpensive, so it’s hard to justify using miniature drapes.
Ensure all the instruments you will need are prepared the day before surgery. It can be ever so slightly frustrating when the instrument you need is not wrapped and sterilized. A checklist is a great way to avoid such surprises.
On that note, pouches are fragile, so don’t toss them around. Double wrap instruments and protect sharp edges to avoid poorly timed punctures. Cloth drapes or metal trays, as opposed to a pouch or even paper drapes, may be a wise choice for sharp instruments.
Always use the right instrument for the right procedure. It is arguably very difficult to perform a thorough exploratory laparotomy without the unmatchable retraction of a Balfour retractor.
Monitor every parameter you have access to for your patient’s sake. It’s surprising that at some practices, CO2 or blood pressure monitoring is available but not used.
If any parameter appears too high or too low, be prepared to take appropriate measures to correct it as soon as possible to avoid an emergency situation. Recording parameters on a chart is a great way to observe trends and avoid surprises.
Familiarize yourself with the procedure being performed to minimize anesthesia time. Remember to administer medications at the right time. For example, cefazolin should be given IV, 30 minutes before the skin incision (10 milligrams per pound), which means it is typically given at the time of induction. For longer procedures, cefazolin is then given every 90 minutes as long as the patient is under anesthesia.
Biopsy any lesion that may be significant. If a surgery turns into a “negative” laparotomy because you cannot visualize an obvious problem, such as an intestinal foreign body, always take full thickness biopsies of every level of the intestine. Depending on the situation, you might also need to biopsy the liver, the stomach, the mesenteric lymph nodes, and other organs.
Using the correct type of suture material can dramatically affect post-op healing. For example, absorbable monofilament suture is preferred in the intestine.
Besides the intestine, braided sutures are not considered appropriate in the skin. There are few locations where braided sutures are recommended, such as the mouth and the nares. Using soft braided sutures is more comfortable for the patient.
Every organ and every patient require a specific suture size. Fine suture material is reserved for ophthalmic and urethral surgery. The size of the suture material should be proportional to the weight of the patient during closure of the linea. Along with proper suture placement, this decreases the risk of dehiscence.
The needle also must be appropriate and chosen wisely. Tapered needles should be reserved for hollow viscus, such as the intestine and the bladder. Cutting or reverse cutting needles should be reserved for tough organs such as joints, the linea, or the skin.
Use the correct suture pattern with an adequate number of knots, depending on the type of tissue being closed. Countless studies have demonstrated that there are very few locations where you cannot use continued sutures. It is therefore perfectly acceptable to use continuous patterns in the linea, the bladder, the intestine, and the skin.
This offers multiple benefits, including using less suture material, fewer knots, and therefore, less foreign material left inside the patient. A continuous suture is faster, which reduces surgery time as well as anesthesia time. Simple interrupted sutures are great to reconstruct a large skin incision or even to reinforce a continuous suture (for example in the bladder or the intestine).
Any surgery lover can implement all of these suggestions easily. Following basic rules will undoubtedly decrease complications and improve your success rate.
Dr. Phil Zeltzman is a board-certified veterinary surgeon and author. His traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. Visit his websites at DrPhilZeltzman.com and VeterinariansInParadise.com.
Nikki Schneck, a technician near Pottsville, Pa., and Kelly Serfas, a certified veterinary technician in Bethlehem, Pa., also contributed to this article.
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