Atlas of General Surgery E-Book

Volker Schumpelick

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 681

Veröffentlichungsjahr: 2009

Beschreibung

The ideal reference for over 150 common operations

The Atlas of General Surgery is a highly practical, how-to reference for the most frequently performed operations. For precise and quick orientation, each surgical chapter presents a brief introduction to surgical preparation, anesthesia, positioning, relevant anatomy, risks, complications, and postoperative care, and then illustrates the operative technique through excellent drawings and detailed legends.

Key features:

• Covers all common surgeries any general surgeon needs to know
• Step-by-step guide to each operative procedure
• More than 1,200 high-quality drawings demonstrate surgical anatomy and technique, with each illustration showing one operative step
• Didactic page layout allows for easy comprehension of the material
• Practical tips, tricks, and pitfalls highlight crucial information

Ideal for all surgeons in training the Atlas of General Surgery is a handy, one-volume text that provides an overview of this broad field. It also serves as a valuable reference for the bookshelf of practicing surgeons who would like to consult a rapid review before surgery.

Leseprobe

Atlas of General Surgery

Volker Schumpelick, MD

Professor and ChairmanDepartment of SurgeryUniversity Hospital AachenAachen, Germany

With the collaboration ofReinhard Kasperk and Michael Stumpf

1223 illustrations

ThiemeStuttgart • New York

Library of Congress Cataloging-in-Publication Data is available from the publisher.

This book is an authorized and revised translation of the 2nd German edition published and copyrighted 2006 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Operationsatlas Chirurgie.

Contributors:Reinhard Kasperk, MDProfessorDirector of the Surgical ClinicSt. Johannes-HospitalCatholic Clinic DuisburgDuisburg, Germany

Michael Stumpf, MDAdj. ProfessorSupervising PhysicianDepartment of SurgeryUniversity Hospital AachenAachen, Germany

Translator: Dr. Grahame Larkin, MD, East Sussex, UK

Illustrator: Gisela Tambour, Adrian Cornford, and Rose Baumann

© 2009 Georg Thieme Verlag,Rüdigerstraße 14, 70469 Stuttgart, Germanyhttp://www.thieme.deThieme New York, 333 Seventh Avenue,New York, NY 10001, USAhttp://www.thieme.com

Cover design: Thieme Publishing GroupTypesetting by Druckhaus Götz, LudwigsburgPrinted in China by Everbest Printing, Hongkong

ISBN 978-3-13-144091-4                1 2 3 4 5 6

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher's consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

Preface

Surgery can no more be learned from text books than can cycling or swimming. Similarly, hardly any other discipline is both a teaching and learning profession with such a close teacher—pupil relationship. But rarely does the young surgeon of today have the opportunity to gain enough continuous practice under supervision to the point of reaching subcortical implementation. The restrictions of working-time reduction, rare opportunities to practice techniques on laboratory animals, and the early division of surgery into subspecialties have completely changed the face of mandatory training guidelines for basic surgical operations. As a result, the young surgeon rarely gets to see many an operation, and those operations in which he has managed to gather a greater amount of personal experience are few and far between. Even surgical simulators, which are becoming increasingly available and provide excellent training opportunities, especially in the field of laparoscopic surgery, cannot convey the entire spectrum of basic surgical operations. In some specific fields they do allow manual skills and tactile coordination to be practiced, but cannot provide broad surgical expertise together with the understanding and mastering of standard operative techniques. Alongside video films, surgical atlases are therefore the most important sources of information for the young surgeon when it comes to practicing all the stages of certain operations.

The concept of this surgical atlas is directed toward presenting the most common 16 general and 150 special operations of everyday surgical practice to surgeons in training, to students as well as to qualified surgeons. In this respect, it is neither my intention with this single-volume atlas to vie with the more detailed, multi-volume surgical atlases nor to undermine the essential principle of specialization. Its content is general surgery—not that which remains after separation of the specialist disciplines, but rather that which a general surgeon from the respective specialist disciplines must learn in order to stand his ground as a surgeon.

We are glad that this concept has proven itself to the extent that an English edition is now available. The aim of this surgical atlas is to serve trainee surgeons as a reference book, to allow them to learn new things, and to arouse their curiosity to learn more. But even qualified surgeons may use the opportunity to recall a technique they have already learned and to compare standards. For easy memorization and mental preparation of the respective operations, all the operative stages are structured and schematized so that the continuity of the operation is divided into labeled and reproducible single steps. Just as racing drivers mentally prepare themselves before the race by imagining each individual leg of the race course, the surgeon should, before any operation, recall before his or her mind's eye each operative stage step by step so as to to proceed only along familiar lines at the operating table.

We are grateful to the staff of Thieme Publishers for their support during the preparation of this English edition. But above all we should also like to thank Mr. Grahame Larkin for his excellent work in translating this atlas into English. We are looking forward to an equally favorable English-speaking readership of this Atlas of General Surgery.

Volker Schumpelick

List of Abbreviations

ASA

Acetylsalicylic acid

DC

Dynamic compression

DIP

Distal interphalangeal

DSA

Digital subtraction angiography

EEA

End-to-end anastomosis

EPT

Endoscopic papillotomy

ERC

Endoscopic retrograde cholangiography

ERCP

Endoscopic retrograde cholangiopancreatography

FFP

Fresh frozen plasma

IORT

Intraoperative radiotherapy

MCP

Metacarpophalangeal

OPSI

Overwhelming postsplenectomy infection

ORIF

Open reduction and internal fixation

PDS

Polydioxanone suture

PGA

Polyglycolic acid

PIP

Proximal interphalangeal

PTC

Percutaneous transhepatic cholangiography

PTCD

Percutaneous transhepatic cholangiodrainage

RBCC

Red blood cell concentrate

Table of Contents

General Aspects

General Aspects

1 Preliminary Remarks on the Surgical Intervention

2 Use of Scalpel, Needle Holder, Forceps, and Scissors

3 Ligation and Suture Ligation

4 Knots

5 Skin Suture

6 Drains

7 Urinary Catheter

8 Venous Access

9 Central Venous Port

10 Venous Cutdown

11 Joint Punctures

12 Pleural Punctures (Thoracentesis)

13 Urinary Bladder Puncture

14 Ascites Puncture (Paracentesis)

15 Fine-Needle Aspiration Biopsy

16 Arterial Puncture and Arterial Catheterization

Operations

Skin and Soft Tissues

17 Excision of Skin Lesions

18 Removal of Soft Tissue Tumors

19 Removal of Inguinal Lymph Node

20 Wound Management

21 Secondary Suture

22 Carbuncle of the Neck

23 Bursectomy (Elbow)

24 V-Y Advancement Flap

25 Z-plasty

26 Split-Skin Coverage

27 Ganglion (Wrist)

28 Panaritium (Felon)

29 Paronychia (Run-around)

30 Ingrown Toenail (Unguis Incarnatus; One-third Wedge Resection)

Neck

31 Removal of Cervical Lymph Node

32 Tracheotomy (Open and Percutaneous Tracheostoma)

33 Exposure of the Jugular Vein

34 Subtotal Thyroidectomy

35 Total Thyroidectomy

36 Parathyroidectomy

37 Zenker Diverticulum

Thoracic Wall and Cavity

38 Axillary Lymph-Node Clearance

39 Breast Biopsy

40 Subcutaneous Mastectomy

41 Mastectomy (Auchinclos-Patey)

42 Chest Drain

43 Median Sternotomy

44 Posterolateral Thoracotomy

45 Axillary Thoracotomy

46 Atypical Lung Resection Open

47 Atypical Thoracoscopic Lung Resection

48 Right Superior Lobectomy

49 Pneumonectomy

50 Thoracoscopic Pleurectomy

Abdominal Cavity: Diaphragm

51 Rupture of the Diaphragm

Abdominal Cavity: Esophagus

52 Hiatal Hernia Repair (Lortat-Jacob Hiatoplasty)

53 Fundoplication (Nissen-Rosetti and Toupet)

54 Laparoscopic Fundoplication

55 Cardiomyotomy for Achalasia (Gottstein-Heller)

Abdominal Cavity: Stomach

56 Percutaneous Endoscopic Gastrostomy (PEG)

57 Gastrostomy (Witzel)

58 Closure of a Perforated Ulcer

59 Oversewing of a Bleeding Peptic Ulcer

60 Gastrojejunostomy

61 Pyloroplasty (Heineke-Mikulicz, Finney, Jaboulay)

62 Selective Proximal Vagotomy

63 Truncal Vagotomy

64 Gastroduodenostomy (Billroth I)

65 Gastrojejunostomy (Billroth II)

66 Roux-en-Y Gastrojejunostomy

67 Gastrectomy and Longmire Gastric Reconstruction

68 Gastrectomy and Roux-en-Y Gastric Reconstruction

Abdominal Cavity: Gallbladder and Bile Ducts

69 Cholecystectomy

70 Laparoscopic Cholecystectomy

71 Exploration of the Common Bile Duct

72 Hepaticojejunostomy

Abdominal Cavity: Liver

73 Wedge Resection of the Liver

74 Hepatic Cyst

75 Left Hepatic Lobectomy

76 Hepatic Rupture

77 Port Catheter of the Hepatic Artery

Abdominal Cavity: Pancreas

78 Necrosectomy of the Pancreas

79 Pseudocystojejunostomy

80 Resection of the Tail of the Pancreas

Abdominal Cavity: Spleen

81 Splenectomy

82 Partial Splenectomy

83 Splenic Rupture

84 Laparoscopic Splenectomy

Abdominal Cavity: Peritoneum

85 Peritonitis and Laparostoma

86 Peritoneovenous Shunt

Abdominal Cavity: Small Intestine

87 Segmental Resection of the Small Intestine

88 Intraluminal Stenting of the Small Intestine (Dennis Tube)

89 Meckel Diverticulum

90 End Ileostomy

91 Loop Ileostomy

Abdominal Cavity: Large intestine

92 Appendectomy

93 Laparoscopic Appendectomy

94 Loop Transverse Colostomy

95 End Sigmoidostomy (Hartmann Procedure)

96 Stoma Closure

97 Colotomy and Polypectomy

98 Palliative Anastomosis between the Distal Ileum and Transverse Colon

99 Right Hemicolectomy

100 Ileocecal Resection

101 Tubular Resection of the Sigmoid Colon

102 Radical Resection of the Sigmoid Colon

103 Laparoscopic Resection of the Sigmoid Colon

104 Left Hemicolectomy

105 Anterior Rectum Resection

106 Rectum Resection

Retroperitoneum

107 Adrenalectomy

108 Laparoscopic Adrenalectomy

Proctology

109 Hemorrhoidectomy (Miles-Gabriel)

110 Perianal Abscess

111 Fistula-In-Ano (Including Sliding Flap)

112 Perianal Thrombosis

113 Lateral Sphincterotomy (Parks)

114 Pilonidal Sinus (Schrudde-Olivari)

External Genital Organs

115 Testicular Hydrocele

116 Vasectomy

Hernias

117 Local Anesthesia for Inguinal Hernia Repair

118 Dissection for Inguinal Hernia Repair

119 Inguinal Hernia Repair (Shouldice)

120 Inguinal Hernia Repair (Bassini)

121 Inguinal Hernia Repair (Lichtenstein)

122 Transinguinal Preperitoneal Mesh Repair (TIPP)

123 Preperitoneal Inguinal Hernia Repair

124 Laparoscopic Inguinal Hernia Repair

125 Femoral Hernia Repair (Crural Approach) 443

126 Femoral Hernia Repair (Inguinal Approach; Lotheissen, McVay)

127 Femoral Hernia Repair (Inguinocrural Approach)

128 Epigastric Hernia

129 Umbilical Hernia

130 Incisional Hernia

131 Spigelian Hernia

Pediatric Surgery

132 Inguinal Hernia in Children

133 Orchidopexy for Inguinal Testes (Shoemaker)

134 Circumcision

135 Pyloromyotomy (Weber-Ramstedt)

Vessels

136 Femoral Embolectomy

137 Femoral Thrombectomy

138 Crossectomy, Long Saphenous Vein Stripping, and Perforator Ligation

139. Dialysis Shunt (Cimino Arteriovenous Fistula)

Amputations

140. Finger and Toe Amputation

141. Below-Knee Amputation

142. Above-Knee Amputation

Traumatology

143 Traction Management of Fractures

144 Harvesting Cancellous Iliac Bone for Grafting

145 Septic Arthritis of the Knee

146 Fasciotomy of the Lower Leg

147 Per- and Supracondylar Fracture of the Humerus (Child)

148 Olecranon Fracture—Tension Band Wiring

149 Fracture of the Radius Shaft—ORIF Plate Fixation

150 Distal Radius Fracture—ORIF Plate Fixation

151 Distal Radius Fracture—Kirschner Wire Fixation

152 Dupuytren Fasciectomy

153 Flexor Tendon Repair

154 Extensor Tendon Repair

155 Carpal Tunnel Release

156 Pelvic External Fixation

157 Dynamic Hip Screw (DHS)

158 Proximal Femoral Nailing

159 Femoral Head Replacement (Hemiarthroplasty)

160 Femoral Shaft—ORIF Plate Fixation

161 Patella Fracture—Tension Band Wiring

162 Intramedullary Nailing of the Tibia

163 Lower Leg—External Fixation

164 Medial Malleolus—ORIF

165 Lateral Malleolus—ORIF

166 Fibular Ligament Suture and Ligament Reconstruction with a Periosteal Flap

167 Achilles Tendon Repair

Further Reading

Index

IGeneral Aspects

1 Preliminary Remarks on the Surgical Procedure

2 Use of Scalpel, Needle Holder, Forceps, and Scissors

3 Ligation and Suture Ligation

4 Knots

5 Skin Suture

6 Drains

7 Urinary Catheter

8 Venous Access

9 Central Venous Port

10 Venous Cutdown

11 Joint Punctures

12 Pleural Punctures (Thoracentesis)

13 Urinary Bladder Puncture

14 Ascites Puncture (Paracentesis)

15 Fine-Needle Aspiration Biopsy

16 Arterial Puncture and Arterial Catheterization

General Aspects

1 Preliminary Remarks on the Surgical Procedure

1 General Preoperative Investigations

The following minimal requirements must be fulfilled before a surgical operation:

Basic laboratory tests: blood count, electrolytes, coagulation studies, human immunodeficiency virus (HIV) state for elective operations

Chest X-ray and electrocardiogram (ECG) for patients over 40 years of age

Additional investigations may be required, depending on age, previous disorders, and current state of health of the patient.

2 Absolute Contraindications

Patient in a general inoperable state

Informed consent for elective operations not recorded in the notes (must be available at least 1 day prior to surgery)

3 Relative Contraindications

Relative contraindications arise from a disproportion between the threat posed by the presenting illness, the extent of the planned operation, and the risk arising from nonintervention. This dispro-portion is highly dependent upon local and temporal factors.

Contraindications relating in particular to video-assisted endoscopic operations are constantly undergoing change. Some degree of restraint has particularly been necessary with regard to oncological and septic operations.

4 General Patient Information and Consent

Information regarding the course of events: length of hospital stay, any necessary period of intensive care, drains, necessity of active cooperation with physiotherapy, breathing exercises, and so forth

Cessation of certain unhealthful practices during hospital stay, especially smoking (if necessary, enter a remark in the patient's notes or on the consent form)

General points regarding patient information and consent for the operation:

– Wound healing problems, wound breakdown

– Perioperative hemorrhage

– Allogeneic blood transfusion, possibility of donating autologous blood before the operation

– Adhesion-related ileus

– Scar formation/incisional hernia

– Thromboembolic event

– For laparoscopic operations: intraoperative conversion to open surgery may become necessary and is not regarded as a complication.

The remarks in the following chapters regarding the frequency of postoperative complications are to be understood as an orientation and are based on averages reported in the literature.

5 Perioperative Standards

Preoperative

Prophylaxis against thrombosis: compression stockings, early mobilization, heparin administration

Consider perioperative antibiotic prophylaxis/therapy and, if necessary, initiate.

Following trauma: consider tetanus prophylaxis.

Ensure nothing by mouth for at least 6 hours before surgery, possibly longer for gastric stenosis or bowel paralysis; alternatively, or if in doubt, insert a nasogastric tube.

Before surgery for malignancies, consider ordering a frozen section in the pathology laboratory before the operation and clarify, for example, when there is suspicion of a lymphoma or sarcoma, whether a native specimen is required.

If indicated or available: plan for IORT.

Practice with the patient any necessary important physiotherapy and breathing exercises before surgery.

Insert a central line before surgery. X-ray verification of its position is possible, and if necessary parenteral nutrition can be initiated preoperatively.

Organize availability of blood substitutes (RBCC, FFP, concentrated platelets, autologous blood).

Shave the operative site or use chemical depilation.

Intraoperative

Take culture samples (also from traumatic wounds).

Use an instant or digital camera for photodocumentation.

Whenever the abdomen is opened, the opportunity should be taken to perform a short, but full, exploratory palpation, if this is possible without any relevant additional risk.

Postoperative

Prophylaxis against thrombosis: see earlier

Prophylaxis against stress ulcer: antacids, H2 blockers, H-pump blockers, early enteral nutrition

Dietary progression: indicators include reflux via the nasogastric tube, auscultation for bowel sounds, passing of stool and/or wind, abdominal ultrasound. Procedure: first allow sips of water or tea, then free drink, then yogurt/zwieback/white bread, and finally normal diet.

Monitor the postoperative course using ultrasound: retention of fluids, free intra-abdominal fluid, peristaltic movement, dilatation of hollow organs.

Postoperative retention (seroma, hematoma, bilioma, abscess) can be punctured under ultrasound guidance and, if necessary, drained percutaneously (Sonnenberg, Otto, or similar catheters), provided the clinical condition of the patient is stable.

Remove subcutaneous suction drains on postoperative day 2.

Remove sutures in the region of the face or neck after 4 to 6 days, otherwise remove sutures after 10 to 12 days.

Inform the patient about the possibility of a posthospital rehabilitation program and, if necessary, plan it under cooperation with the social service staff.

Explain the necessity and course of any, possibly long-term, postoperative follow-up care, such as cancer aftercare.

Inform patients about self-aid groups.

6 Laparoscopic Interventions

Umbilical disinfection overnight

Perioperative insertion of nasogastric tube and urinary catheter

Endoscopic surgery may require special positioning measures, which may differ from conventional methods. Usually a feet down (reversed Trendelenburg) position of 10 to 20 degrees is appropriate for surgery of the upper abdomen and, conversely, a Trendelenburg position of 10 to 20 degrees head down for operations of the lower abdomen. Corresponding positions are required for exposure of lateral regions of the abdominal cavity. Changes of position are often necessary several times during the operation and demand a stable fixation of the patient on the operating table.

2 Use of Scalpel, Needle Holder, Forceps, and Scissors

Scalpel

The scalpel is held with three fingers, using the thumb and middle finger to actually hold the instrument, while the index finger, placed on the back of the knife, steadies the instrument. A skin incision is made by using the belly of the scalpel while the contralateral hand places the skin to be incised under tension and stabilizes it. The movements of the knife should be harmonic and continuous, avoiding several repeated attempts. The knife requires very little pressure for the incision.

Forceps and needle holder

As a rule, the length of the instrument should match the depth of the operative field. The strength of the tip of the instrument, on the other hand, depends on the stability of the structures to be handled, which in turn determines the needle size. Toothed (surgical) forceps are generally used only for skin and fascia sutures. Otherwise, nontoothed (anatomical) forceps, with straight or angled tips, are more favorable. Forceps should always be pressed together lightly, only so much as to allow the tissue structure to be lightly grasped. Any unnecessary firm squeezing of the blades should be avoided. A distinction is made between locking and nonlocking needle holders. The nonlocking needle holder, which the authors usually use, places greater demands on the handling technique than does the locking needle holder. A secure command of the needle requires a continuously adjusted closing pressure on both handle limbs (a). The needle holder is opened in a controlled manner with the use of the little finger, which requires practice. Curved needles are generally favored; therefore, the path of the needle through the tissue must also be curved to produce a small punctiform hole rather than a long tear. Given the stable connection between the needle and needle holder, the hand must also follow this curve. Furthermore, it is advantageous not to mount the needle too far back (i.e., at the threaded end). The locking needle holder is held and used like scissors, with the thumb and ring finger, while the index and middle fingers guide the instrument (b).

Scissors

The scissors are best operated with the thumb and ring finger, while the index and middle fingers control the instrument.

3 Ligation and Suture Ligation

Simple ligation

For the simple ligature, the thread may be passed around the tip of the hemostat, which holds the structure to be ligated, directly by hand in a superficial operating field or with the aid of a curved clamp, as shown here, in a deeper operating field. The size of the thread is chosen relative to the lumen of the tissue to be ligated. When tightening the first knot, care should be taken to open the hemostat slowly and not with a jerk; otherwise, the tissue to be ligated could easily retract, especially if it is under traction.

Suture ligation I

The suture ligature is used to tie structures that are somewhat more voluminous or on the other hand larger vessels, especially arteries, as depicted. The suture ligation ensures a safer fixation of the knot. It should be placed 1 to 2 mm below the temporarily closed clamp and not beside it.

Suture ligation II

After suture ligation, the thread is knotted once on the side of the ligation and, after passing it around, knotted again on the opposite side, as shown in the illustration. Equal traction should be applied to both ends of the thread when knotting to avoid a lateral tear-out.

Double suture ligation I

The double suture ligature allows an even more secure fixation of the tissue. Here, it is very important to ensure that the second passage of the needle through the tissue is placed close to the first, leaving only a narrow segment of the ligated tissue not grasped by the ligature. After the second passage of the needle, the thread should not be pulled further through the tissue, particularly with this double suture ligation. This could result in an undesired “sawing effect”, especially with the polyfilament absorbable suture material that is commonly used today.

Double suture ligation II

The clamp should be opened very carefully while the double suture ligation is pulled tight. It has proven useful, especially with somewhat more voluminous tissue structures, to place the knot directly below the blade of the hemostat and not to the side of it.

4 Knots

Index finger technique I

As a rule, the surgeon should be capable of tying knots with both hands. This saves cumbersome and time-consuming maneuvers when switching hands. The size of the suture material used depends on the thickness of the layers to be adapted. Suture sizes of 3–0to 5–0 are usually used for skin sutures, which are usually exclusively of monofilament suture material.

Index finger technique II

When learning the technique of knotting, one should as a rule get used to regarding one strand as the “pulled strand” and the other as the “knot strand.” The knot strand is held by the hand performing the knot. In the illustrated figure, this is the left hand.

Index finger technique III

After throwing the knot, the ends of the suture should be tightened carefully and not overtightened. Blanching of the tissue regions beneath the suture is an indication of ischemia and is thus detrimental to any uncomplicated wound healing. At the moment the knot is pulled together, the fingers securing the suture ends and the knot itself must lie in a straight line. If this is not the case, a lateral pull will be exerted on the knot at the moment it is tightened, which will easily result in the suture cutting out of fine tissue structures.

Middle finger technique I

Secure locking of the thread requires several consecutive knots. It is important to exchange the pulled strand at least once between the consecutive knots.

Middle finger technique II

The middle finger knotting technique is often regarded as easier to perform. It does, however, require wider turning movements of the knotting hand.

Middle finger technique III

The total number of knots thrown depends on the suture material used and the suture size. Especially when using monofilament sutures, the general rule should always be to place 1 to 2 knots more than the suture size.

Middle finger technique IV

Again, when tightening each consecutive knot, one should carefully align the fixation points of the hands with the knot.

Instrument knotting

Knotting with the aid of the needle holder saves suture material but affords only little tacticle sensation when knotting. It is therefore generally only used for superficial and relatively resistant structures such as the fascia or skin. For the first knot, the suture should be looped twice around the tip of the needle holder. One or two further knots, thrown in opposite directions, will then adequately lock the suture.

5 Skin Suture

Interrupted suture

For many patients, the skin suture is the surgeon's trademark. The principle aim of all skin sutures is to achieve healing by primary intention and with minimal scar formation. The precondition for this is the flush edge-to-edge apposition of epidermis and subdermis without tension. The skin margins should be well perfused; cavities and pockets are to be avoided. The general rule is that the distance between each stitch mark corresponds to the width of the suture (i.e., stitch distance and suture width form a square). The interrupted suture is the commonest, and also the easiest, form of suture union. The suture is consecutively drawn through the wound margins, which are stabilized by forceps. For this purpose, the needle should pass perpendicularly through the skin and obliquely through the subdermis. The distance of the suture from the wound margin and the depth of the stitch must be identical at both wound margins. The threads should be knotted with little tension to avoid tissue ischemia (i.e., there should be no blanching beneath the suture).

Continuous suture

The continuous, or running, suture saves time but is technically more demanding because it presupposes a good approximation of the wound margins and suture guidance by the assistant. The continuous suture can be placed as (a) a simple Kirschner stitch or as (b) a locking “boatsman” stitch.

Donati vertical mattress suture

The mattress suture produces excellent approximation of the wound margins. With the Donati vertical mattress suture, the thread is visible on either wound margin. The excellent approximation, however, is only achieved if width and depth of the suture loops of the forehand and backhand stitches are exactly symmetrical and also if the four entry and exit points lie in a straight line, perpendicular to the wound. The closer the backstitch is placed to the epidermis, the better is the wound closure.

Allgöver vertical mattress suture

With this modification of the mattress suture, the thread is only visible on one side of the wound. On the other side, the suture only grasps the subdermis and parts of the dermis. Otherwise, the same conditions apply as for the Donati suture to achieve a good cosmetic result. The removal of this suture, however, is more difficult if entry and exit points are placed too close together and the suture is also pulled together too tightly.

Continuous subcuticular suture

With the continuous subcuticular suture, the thread exits the skin only at the beginning and end of the wound. The suture runs entirely within the dermis and allows an excellent approximation by an exact complementary run of the thread through the two wound margins. The thread is secured at either end with a plastic clip.

Interrupted subcuticular suture

Interrupted subcuticular sutures using absorbable 5–0 or 6–0 PGA allow good approximation of the skin, especially in children. Removal of sutures is therefore unnecessary. It is, however, recommended to relieve these sutures of any wound tension by the additional application of surgical tapes.

Skin staples

The fastest way to close a wound is by using an automatic stapling device, which inserts and bends square metal staples into the wound margins. The wound margins must be grasped symmetrically with toothed forceps and slightly everted at the moment the staples are placed. This suture line requires good coordination between the surgeon and assistant.

Surgical tapes (Steri-Strips)

Modern surgical tapes are capable of approximating and holding together wound margins without tension. They are only seldom indicated as a sole measure because they easily peal off when soaked through. They are commonly used as a supportive measure or for very superficial wounds.

Removal of sutures

For removal, the suture is lifted slightly with forceps, cut on one side, close to the skin, and then extracted. This avoids drawing the contaminated outside parts of the suture through the stitch path. The best time for removing skin sutures is determined by the local conditions of the wound as well as the site of the suture. Skin sutures on the face and neck can be removed on day 5, whereas skin sutures in other regions may remain for 6 to 14 days, depending on their location.

Removal of staples

Staples are removed with the appropriate special pliers. They bend open the skin staples into the shape of an M so that the intracutaneous parts separate and release the scar.

6 Drains

Suction drain

This drain exerts a continual suction and is primarily used in the region of the subdermis and muscle clefts. A bottle is connected to the tube of the drain in a closed system and has a suction bellow, which gives an indication of the remaining negative pressure and expands visibly when this negative pressure is lost. Because the plastic material of the suction drain is relatively stiff, it should not be used near vulnerable tissue. A suction drain usually remains in situ for 48 hours.

Drain fixation

Every drain should be secured to the skin to avoid any accidental dislocation and to prevent it from continually slipping in and out. For this reason, it is important that the fixation suture does not have a long bridge between the skin and drain.

Abdominal drains

Abdominal drains are placed either to serve as indicators or to evacuate fluids. They provide early warning of any complications (postoperative hemorrhages, anastomotic leaks, infections) or of draining blood and wound secretion. These drains function by overflow, with certain forms constructed to support the transportation of secretion by capillary forces. Nowadays, very flexible plastic materials, such as silicone, latex, and polyurethane, are usually used. Stiff materials, such as rubber, pose a considerable risk of arrosion, even after a relatively short time. Conventional forms of drains include (a) the tube drain with side openings, (b) the Penrose drain with and without an inserted gauze ribbon, (c) the easy-flow drain, (d) the easy-flow sheet drain, and (e) the Jackson-Pratt drain in its various modifications.

Semiopen drain

Semiopen drainage systems have a connection point between the in situ drain tube and the collection system on the outside. The possibility of exchanging the system quickly is an advantage, with the disadvantage being the risk of contamination.

Closed drains

Closed drainage systems eliminate any risk of contamination from accidental disconnection. One disadvantage, however, is the necessity of having to insert the drainage system from the outside.

Drainage areas of the abdominal cavity

In the supine patient, fluids collect at the most dependent sites of the abdominal cavity (a). These are, in particular, the pouch of Douglas, both subphrenic spaces, the subhepatic region, and the right and left paracolic gutters. A further cavity at risk of retention is the omental bursa (b).

Chest drain

The chest drain has a valve function, allowing secretions, blood, or air to escape from the pleural cavity while preventing additional air from entering the pleural space. Unlike other drains, chest drains must be thick walled so as not to collapse under the various pressures that arise. The drain must be well secured to the chest wall. With chest drains, suitable clamps must always be readily available to close them in an emergency should they become accidentally disconnected. External suction of 15 to 20 cm H2O may be applied to the drain to assist its function of evacuation. Incidentally, the opening pressure of the chest drain is defined by the distance between the water level in the drainage bottle and the opening of the tube below the fluid level.

7 Urinary Catheter

Transurethral Catheter

Conventional Catheter Types: Nélaton, Tiemann, Mercier as a single-use catheter, and Foley as the most common form of indwelling catheter. Material: rubber or silicone, soft to semistiff.

1 Indications

There are various indications for the insertion of a urinary catheter, including the following:

Acute urinary retention

Intra-and postoperative fluid balance

Examination of sediment, urine culture, and cystography

Retrograde filling to exclude a defect

Aspects of care (e.g., incontinence)

We distinguish between the transurethral catheter, as the most common form, and the suprapubic catheter.

2 Technique

The introduction of the catheter in females is usually unproblematic, whereas in males it is difficult due to the S-shaped bend of the urethra and the penile bulb.

Catheter Insertion: Under sterile conditions and with the patient supine, the meatus is cleaned and the lubricant introduced into the urethra and onto the catheter tip.

Catheter Length: Female 8 to 25 cm, male 40 cm

Different forms of urinary catheter tips: (a) Tiemann, (b) Mercier, (c) Nélaton, (d) Foley not inflated, (e) Foley inflated.

In the female, direct insertion under vision after gently spreading the labia. In the male, introduction of the catheter while straightening and lifting the shaft (a). On passing the external sphincter, lower the extended shaft. After 25 to 30 cm, urine returns if the catheter has been placed correctly. The catheter balloon is inflated with 5 to 10 mL sterile water; drainage is via a closed sterile collecting system (b).

Technique of urinary catheterization in the male: (a) insertion of the catheter, (b) position after inflation of the catheter balloon.

3 Complications

Ascending infection with long-term use, injury to the urethra during insertion (via falsa), impassability in the presence of a large prostate requiring cystoscopic guidance, pressure ulcers during long-term catheter placement.

Suprapubic Catheter

1 Indications

Long-term indwelling catheters should be inserted using the suprapubic technique and not the transurethral method to avoid a chronic ascending infection. Advantages include improved subjective toleration, less pain, the possibility of bladder training through catheter control and plugging by the patient, and reduced risk of infection due to the greater degree of soft tissue coverage.

2 Technique

Puncture of the bladder after filling with 300 to 500 mL of sterile solution via a transurethral catheter. If necessary, confirmation of a distended bladder and location of the best puncture site with the aid of ultrasound. The puncture site is 3 to 4 cm above the pubic symphysis with the bladder distended (a).

Caution: Watch out for altered anatomy secondary to previous surgery and scar formation

After positive puncture of the bladder, aspirate urine and thread a plastic catheter through the hollow cannula (Cystofix) until it is reliably in the bladder. The catheter is secured with tape and by the inflated balloon at the catheter tip (b). Then remove the Cystofix cannula, which is released by splitting the two halves from the catheter.

Caution: Watch out for damage to the catheter by the sharp edges and tip of the cannula

(a) Bladder puncture using hollow cannula.

(b) Technique of suprapubic bladder puncture.

3 Complications

Injury to the bladder mucosa, failed puncture attempt due to altered anatomy (ultrasound), damage to the catheter by the sharp edges of the cannula, intramural or possibly intestinal misplacement due to poor visualization–confirmation of catheter position by verifying urine flow.

8 Venous Access

Peripheral Venous Access (Indwelling Venous Cannula)

1 Indications

Administration of intravenous infusion solutions, short-term infusion therapy. No high-calorie nutrition!

2 Access

Short-term peripheral venous access is usually provided by an in-dwelling venous cannula. Puncture sites are the arm veins. An in-dwelling venous cannula is unsuitable for administering hypertonic solutions (e.g., parenteral nutrition) or longer lasting (> 3 days) infusions. They exclusively serve the short-term perioperative administration of fluid or acute venous access. A central-venous line (see later discussion) should be chosen if infusions are required for a longer period because it also offers the advantage of measuring central venous pressure. In all other cases, the venous cannula is the most common form of venous access.

Indwelling venous cannula, technique of insertion. (a) Cannula, (b) puncture of the vein, (c) withdrawal of the steel mandrin, (d) fixation of the cannula, connection of the infusion.

3 Technique

After producing venous stasis of the upper arm, identify a congested vein by palpation and inspection, and tangentially insert the in-dwelling venous cannula at an obtuse angle. Advance the cannula and withdraw the needle lying within. Connect to the infusion system and secure with an adhesive strip.

4 Complications

Perforation and tearing of the posterior wall of the vein, failed puncture attempt, dislocation by arm movements (splint immobilization), infection. Such cases require immediate removal and local wound care (e.g., alcohol dressings).

Central Venous Access (Vena Cava Catheter)

1 Indications

Indications for central venous access include the following:

Parenteral nutrition with high-calorie solutions

Measurement of central venous pressure

Emergency access in the presence of collapsed peripheral veins

Long-term infusion therapy

2 Access

Typical access sites are the subclavian, internal jugular, external jugular, femoral, and cubital veins.

3 Technique

Well-considered indication and aseptic technique. After puncture of the vein, insert a fine guidewire (after Seldinger) through a wide-bore cannula. Withdraw the cannula and thread the catheter over the guidewire as far as the level of entry into the vena cava. A venous cutdown (see below) is only seldom required for this. The technique will now be described using as examples the two commonest accesses to the superior vena cava (i.e., the subclavian catheter and the internal jugular catheter).

Subclavian Vein Catheter: Puncture the vein below the clavicle at the junction of the middle to lateral third, at an angle of 45 degrees in the direction of the spine (junction of cervical/thoracic spine). Aspiration of venous blood confirms the correct position.

Caution: Watch out for pleural puncture

Insert a flexible guidewire (Seldinger wire) through the cannula.

After withdrawal of the introduction cannula, thread the catheter over the guidewire, if necessary, after prior dilation.

Remove the wire while securing the catheter in its correct position in the vessel.

Obtain confirmation by X-ray or image intensifier (the tip of the catheter should lie at the level of the superior vena cava).

Secure the catheter with a suture, sterile dressing.

Caution: X-ray confirmation is obligatory before starting infusion to confirm both the position of catheter and to rule out pneumothorax, a failed puncture attempt, and a rolled-up catheter.

Subclavian vein catheterization. (a) Puncture site below the clavicle at the junction of middle to lateral third. (b) Puncture of the vessel with a wide-bore cannula. (c) Introduction of a flexible guidewire (Seldinger wire) via the cannula. (d) After removal of the introduction cannula, advancement of the catheter over the guidewire.

Internal Jugular Vein Catheter: Puncture under sterile conditions and local anesthetic with the patient supine and the head end slightly lowered. Prior ultrasound confirmation of the course of the vein will facilitate the procedure. Palpate the common carotid artery with the index and middle fingers of the left hand. Infiltrate the local anesthetic in the middle of the sternocleidomastoid muscle, beginning at the crossing of the external jugular vein, in the direction of the internal jugular vein, which lies immediately lateral to the common carotid artery. Obtain verification by aspiration. Insert the puncture cannula at an angle of 45 degrees to the axis of the body, lateral to the palpated artery. Aspiration of venous blood confirms the correct position. Proceed as with the subclavian vein catheter.

Puncture site of the internal jugular vein.

4 Catheter Care

Care includes daily change of the dressing under aseptic conditions, no contamination of the connections, and reinsertion of the catheter via a different site should fever of unknown origin or infection of the skin puncture site arise. When removing the catheter, always check its integrity and order bacteriological examination of the catheter tip.

5 Complications

Thrombosis of the vena cava, embolus, phlebitis, sepsis, pneumothorax, hemothorax, arterial puncture, hematoma, vessel perforation, heart perforation, air embolus, catheter embolus, damage to the brachial plexus or recurrent nerve, arrhythmias if positioned too low in the right atrium.

In the case of a patient with a vena cava catheter and fever of an unknown origin, you should replace the catheter.

9 Central Venous Port

1 Indications

Need for long-term central-venous access (e.g., short-bowel syndrome, precarious condition of the veins, chemotherapy)

2 Preparation for Operation

Consider duplex ultrasonography of the neck veins

3 Specific Risks, Patient Information, and Consent

Infection of the port, complications of hemorrhage, pneumothorax, catheter dislocation

4 Anesthesia

Usually local anesthetic

5 Positioning

Supine, image intensifier, X-ray table

6 Approach

Puncture of the subclavian or internal jugular vein or, alternatively, open insertion via the cephalic vein in the deltopectoral groove (Mohrenheim fossa)

7 Operative Steps

Local anesthetic

Puncture of the subclavian vein and introduction of the guide-wire; alternatively, open exposure of the cephalic vein in the deltopectoral groove and direct insertion of the plastic port catheter after venotomy

Verification of position under image intensifier

Dilatation using Seldinger technique and insertion of the port catheter

Infraclavicular skin incision and dissection of an epifascial pocket for the port reservoir

Connection and placement of the catheter without kinking

Fixation of the reservoir with nonabsorbable sutures onto the fascia

Renewed image intensifier check

Wound closure

X-ray follow-up

8 Relevant Anatomy, Serious Risks, Tricks

Consider using the jugular vein for puncture or open insertion via the cephalic vein.

Ensure adequate fixation of the reservoir to the fascia.

Caution: Dislocation

Ensure a harmonic course of the port catheter (kinking causes leaks)

9 Measures for Specific Complications

For pneumothorax consider inserting a chest drain.

Infection requires port removal.

10 Postoperative Care

Documentation of radiological follow-up

Wound check

Immediate use of the port is possible

The correct position of the port system after insertion of the tube into the right subclavian vein.

10 Venous Cutdown

The venous cutdown has lost some of its significance due to percutaneous catheterization of the vena cava, but there are still indications for its use today.

1 Indications

Failed search for peripheral or central veins for catheterization, placement of a port system.

2 Access

Peripheral veins that rapidly become large-caliber veins

Usual sites for venous cutdown.

3 Technique

The skin incision is done on the supine patient after preparing and draping and applying local anesthetic. The vein is identified and two loops are passed around it. The plastic catheter is inserted via a skin tunnel, which lies approx. 3 to 5 cm distal to the final entry point. The vein is punctured between the two loops and a catheter is inserted through the opening. If puncture of the vein is unsuccessful, one ligature is tied distally and the catheter is introduced via a fish-mouth incision. Once the catheter is in position, the proximal ligature is tied snugly to secure the vein over the catheter. The wound is closed and a sterile dressing applied.

The advantage of entering the vein only via a puncture is that blood will still flow around the catheter, whereas thrombosis of the vein due to the ligature is inevitable following the fish-mouth incision.

If the catheter is in the wrong position, it can be corrected under image intensification or replaced.

4 Complications

Thrombophlebitis, sepsis, wound infection, failed catheter placement

Technique of venous cutdown: (a) Infiltration anesthesia. (b) Identification of the vein. (c) Blunt dissection to expose the vein. (d) Passing of loop around vein proximally and ligation distally. (e) Incision of the vein. (f) Insertion of a catheter after subcutaneous tunneling. (g) Fixation of the catheter by snug ligation of the cranial loop, skin sutures.

11 Joint Punctures

1 Indications

Diagnostic examination and therapy of joint effusions, application of medications

2 Technique

Always perform joint puncture under sterile conditions, use local anesthetic if required, and select an adequate cannula size and length. Make a stab incision before inserting large cannulas to avoid spilling epithelial material into the circulatory system. Consider using an image intensifier.

3 Approach

Approach for Shoulder Joint: If at all possible, puncture is performed with the patient sitting with the arm abducted 10 degrees.

The posterior approach is through the deltoid muscle below the acromion in the direction of the coracoid process.

The anterior approach is vertical, in the direction of the head of the humerus.

Approach for Elbow Joint: Puncture is performed with the patient supine or sitting with the elbow flexed to 90 degrees.

The lateral approach is posterior to the radial epicondyle, above the head of the radius.

The posterior approach is directly through the triceps tendon, immediately above the tip of the olecranon.

Approach for Wrist: The lower arm is pronated and resting on a firm surface.

Over the extensor aspect, distal to the radial styloid process between the extensor indicis and extensor pollicis longus tendons.

Approach for Hip Joint: The puncture is performed with the patient supine and the hip extended.

The lateral approach is distal to the greater trochanter, ventral to the femur, and parallel to the neck of the femur.

The anterior approach is caudal to the inguinal ligament, two fingerbreadths lateral to the femoral artery, perpendicular in a dorsal direction.

Caution: Watch our for the femoral neurovascular bundle

Approach for Knee Joint: The puncture is performed with the patient supine and the knee almost fully extended (160 degrees).

Suprapatellar recess. The insertion is in the medial or superolateral quadrant, one fingerbreadth superior to the patellar margin. The direction of the needle is obliquely in a dorsal and distal direction, parallel to the posterior aspect of the patella. Perform a prior stab incision of the skin when using a large-bore cannula.

The puncture is performed with the patient supine and the lower leg on a firm surface.

Approach for Ankle Joint: Begin two fingerbreadths proximal to the tip of the lateral malleolus, at the level of the joint space between the lateral malleolus and the tendon of the extensor digitorum longus. The needle is directed toward the medial margin of the foot.

4 Complications

Infection (empyema)

All joint punctures must be performed under sterile conditions.

12 Pleural Punctures (Thoracentesis)

Thoracentesis drains the pleural space of fluids or air (i.e., to treat a pneumothorax, seropneumothorax, hemothorax, or pleural empyema). Simple aspiration without inserting a catheter is sufficient for the short-term aspiration of fluid (pleural effusion) and, less often, also for a minor pneumothorax. The insertion of a catheter, usually in the form of a chest drain, is required for larger findings and the long-term need of prolonged pleural drainage.

1 Indications

Investigations and therapy of pleural effusions (hemo-, sero-, chylothorax)

Emergency drainage of a pneumothorax

Drug administration

2 Approach

Puncture is usually performed with the patient seated, but if the patient's general medical condition is poor, a supine position is also possible.

Approach for Pleural Effusion: Posterior or midaxillary line, depending on site [percussion, auscultation, ultrasound, chest X-ray, thorax computed tomography (CT); mark the puncture site]. Typical puncture site is the seventh to eighth intercostal space in the posterior axillary line.

Approach for Pneumothorax: In the second intercostal space anteriorly in the midclavicular line

Pleural puncture: Too high → punctio sicca or pneumothorax, too low → intra-abdominal injury. Needle is introduced close to the superior border of the rib.

3 Technique

Technique for Pleural Effusion: Under sterile conditions, local anesthetic is infiltrated into the skin, subdermis, periosteum, and pleura, along with simultaneous aspiration to detect fluid. Insert a large-bore puncture cannula over the superior border of the rib to protect the intercostal neurovascular bundle lying at the inferior border. If necessary a plastic catheter may be threaded through the cannula into the pleural cavity (cava catheter set; reduced risk of pulmonary injury). The end of the needle or catheter is connected to a three-way system to which a 50 mL syringe and a drainage system are attached. In this case, aspiration of fluid or air is done by hand. In many institutions, single-use kits are available with vacuum bottles (blood sampling kit).

Bacteriological and cytological examination of the aspirated fluid and determination of tumor markers for bronchial carcinoma.

The system must be completely closed because any penetration of air will result in a pneumothorax. After completion of the puncture, apply a sterile dressing and do an X-ray follow-up.

Technique for Pneumothorax: Emergency release of pressure

Technique for pleural puncture. (a) Puncture site with the patient sitting. (b) Protection of the intercostal neurovascular bundle by entering over the superior border of the rib.

(c) Drainage via a draining system with three-way tap, aspiration using a syringe in the illustrated position. The syringe is emptied after switching the three-way tap toward the connected draining system.

4 Complications

Pneumothorax, hemothorax, pleural empyema, hematoma of the thoracic wall

Pleural puncture: air-tight system

Chest Drain

See p. 16

13 Urinary Bladder Puncture

1 Indications

Acute urinary retention if catheterization is not possible (e.g., in the presence of strictures)

Urine culture

Prolonged drainage via a suprapubic catheter (see p. 19 f)

2 Approach

Begin two fingerbreadths above the symphysis pubis in the midline, after palpation or percussion to ensure that the bladder is full (if necessary, have the patient drink large amounts of fluids and/or give diuretics). Ultrasound guidance is also a possibility.

3 Technique

Under sterile conditions and local anesthetic, inject ~4 cm down, perpendicular to the abdominal wall, two fingerbreadths above the symphysis pubis using an ~5 cm long size 1 cannula with syringe attached. The injection is directed obliquely and cranially. Advance the needle under aspiration until clear urine returns.

4 Complications

Hemorrhage, injury to intra-abdominal organs, infection, phlegmon

Puncture site for suprapubic bladder puncture. A full bladder is a prerequisite.

14 Ascites Puncture (Paracentesis)

1 Indications

For the diagnostic assessment of tumor cells

Therapeutic, to relieve abdominal pressure (paracentesis)

Drug instillation (e.g., chemotherapeutic agents for peritoneal carcinosis)

2 Approach

Begin at the junction of the middle to lateral third of the line between the left anterior superior iliac spine and the umbilicus, under ultrasound guidance if possible, especially after previous surgery.

3 Technique

Under sterile conditions and using local anesthetic, a trial puncture is performed using a no. 1 cannula; if clear ascites fluid is encountered, insert a large-bore drainage cannula or consider threading in a catheter. Drainage via an infusion system is accomplished passively by the increased intra-abdominal pressure; suction is not required.

Caution: Watch out for syncope due to sudden decompression of the intra-abdominal pressure; allow the ascites to drain out slowly, no more than1.5 L in 24 hours.

Perform bacteriological, cytological, and biochemical examination of the aspirated fluid for specific weight, glucose, protein, cholesterol, L-lactate dehydrogenase, white cells, red cells, hemoglobin, and possibly fibrin split products if the placement of a peritoneovenous shunt is planned.

4 Complications

Hemorrhage, intestinal injury, peritonitis

Puncture site for ascites puncture

15 Fine-Needle Aspiration Biopsy

1 Indications

Cytological and bacteriological investigations of the thyroid gland, lymph nodes, prostate, lung, liver, pancreas, kidney, and so forth

2 Approach

The puncture can be done percutaneously under ultrasound or computed tomographic (CT) guidance. Alternatively it can be performed intraoperatively, if necessary, also under ultrasound guidance.

3 Technique

Puncture of the area in question (e.g., pancreas, liver metastasis) with a very thin cannula, if possible in several planes under visual control or with palpation (intraoperatively), or alternatively percutaneously under ultrasound or CT guidance. Preparation of smears for cytological evaluation. Use special puncture needles to take samples (e.g., Trucut for the pancreas to gain representative tissue samples in the puncture cylinder).

4 Complications

Very rare (injury to organs, hemorrhage)

Fine-needle puncture of the head of the pancreas for suspected tumor, percutaneously under ultrasound or computed tomographic guidance or intraoperatively.

16 Arterial Puncture and Arterial Catheterization

Arterial Puncture

1 Indications

Blood gas analysis

Insertion of catheters for angiography, heart catheterization, dialysis, measurement of blood pressure

Intra-arterial injection of medications

2 Approach

Puncture of the radial or femoral artery

3 Technique

Coagulation studies, ensure correct anatomical location

The puncture cannula is inserted under sterile conditions, aiming at a point below the fingertips palpating the artery. A pulsating flow of bright red blood is encountered on correct placement of the cannula. Manual compression of the puncture site is maintained for 5 to 10 minutes after removing the cannula; consider using a sandbag or pressure dressing.

4 Complications

Inguinal hematoma, false aneurysm, arteriovenous fistula, retroperitoneal hematoma secondary to unrecognized injury of the posterior wall (operative revision may be necessary)

Cannulation of the radial artery. (a) Puncture of the artery, (b) advancement of the plastic cannula and subsequent removal of the steel needle, and (c) connection of a short extension with a three-way tap.

Arterial Catheterization

1 Indications

Invasive measurement of blood pressure in high-risk patents under intensive care, blood gas analysis, long-term drug instillation

2 Approach

Radial, femoral, brachial, and dorsal pedal arteries

3 Technique

Under sterile conditions with the patient supine, the artery is palpated and a thin cannula is inserted at a 45 degree angle. Continue to proceed as with the Seldinger technique (see Chapter 8, Venous Access). Assess circulation of the extremity.

Radial artery catheterization is contraindicated without conducting an Allen test beforehand. The Allen test provides information regarding the patency of the superficial palmar arch by alternately compressing the ulnar and radial arteries. Radial artery catheterization is contraindicated if, on complete compression and occlusion of the radial artery, there is inadequate perfusion of the fingers and loss of pulsation from the ulnar artery. The technique of radial artery catheterization corresponds to that of vascular cannulation using the Seldinger technique (see p. 23).

4 Complications

See Chapter 10, Venous Cutdown.

Risk of gangrene in the presence of arteriosclerotic vessels, which could result in amputation

Mark the arterial catheter clearly “Do not use for the administration of medications”.

Allen test to confirm arterial supply to the hand

IIOperations

Skin and Soft Tissues

Neck

Thoracic Wall and Cavity

Abdominal Cavity: Diaphragm

Abdominal Cavity: Esophagus

Abdominal Cavity: Stomach

Abdominal Cavity: Gallbladder and Bile Ducts

Abdominal Cavity: Liver

Abdominal Cavity: Pancreas

Abdominal Cavity: Spleen

Abdominal Cavity: Peritoneum

Abdominal Cavity: Small Intestine

Abdominal Cavity: Large Intestine

Retroperitoneum

Proctology

External Genital Organs

Hernias

Pediatric Surgery

Vessels

Amputations

Traumatology

Skin and Soft Tissues

17 Excision of Skin Lesions

1 Indications

Elective: Any circumscribed skin alteration whose benign or malignant nature and origin are uncertain, including biopsy for diffuse or multiple lesions

2 Preoperative Preparation

Preoperative Investigations: Consider ultrasound, depending on the suspected underlying disorder.

3 Specific Risks, Patient Information, and Consent

Possible need for plastic reconstruction of the excision area using advancement flap or skin graft

Subsequent wider excision

Subsequent lymph node dissection for malignancies

Wound breakdown

Hemorrhage

Injury to deeper structures (e.g., nerves)

4 Anesthesia

Local anesthetic, general anesthetic (intubation) when plastic reconstruction using larger flaps is necessary

5 Positioning

Depends on site of lesion

6 Approach

Elliptical excision with due regard to relaxed skin tension lines, adjacent structures, safety margins, cosmetic aspects, and potential extension of the operation

7 Operative Steps

Incision

Relaxed skin tension lines

Excision

Mobilization of the wound margins

Subcutaneous suture

Skin closure

8 Relevant Anatomy, Serious Risks, Tricks

Perfect scar formation is only possible with tension-free wound closure; skin margins should be sufficiently mobilized.

If coverage is not possible, despite maximum mobilization of the skin margins and after performing a possible relaxing incision, use a mesh graft or a full-thickness skin graft.

9 Measures for Specific Complications

After wound breakdown, first consider open wound treatment, with secondary suture after a few days or even later scar revision after at least 3 months.

10 Postoperative Care

Medical Aftercare: Drainage is necessary for larger wounds (consider a minidrain). Remove the drain on postoperative day 2.

Mobilization: If necessary, temporary rest period/restricted movement, especially after plastic surgery reconstruction

Physiotherapy: Only rarely necessary

Time Off Work: 3 to 7 days; longer after larger excisions

Operative Technique

Incision

Relaxed skin tension lines

Excision

Mobilization of the wound margins

Subcutaneous suture

Skin closure

Incision

Skin lesions, particularly their pigmented forms, are a common indication for outpatient surgery. Their removal should be low in complications, painless, and cosmetically acceptable, all of which require correct incision, aseptic technique, and atraumatic skin closure as preconditions.

Cases of malignancy will require wider excisions and usually reconstruction using advancement flaps or free skin grafts. Only the simple removal of a skin lesion is presented here. The direction of the incision should run as parallel as possible to the Langer skin lines (relaxed skin tension lines).

Relaxed skin tension lines

To determine the direction of the skin tension lines, the skin can be pushed together bimanually in the direction of both axes so that subsequent folds appear.

Excision

The excision of the skin lesion is achieved by an elliptical incision around the tumor. Skin and subcutaneous tissue are dissected down to the fascia level. Safety margins lie between 0.2 and 2.0 cm, depending on the benign or malignant nature of the lesion.

Mobilization of the wound margins

Mobilization of both wound margins is required to achieve skin approximation. This is achieved by undermining using scissors, partly by blunt and partly by sharp dissection.

Subcutaneous suture

Once the skin margins have been sufficiently mobilized, the insertion of a drain may be necessary. The subdermis is closed using absorbable 3–0 PGA sutures for approximation.

Skin closure

The epidermis can be closed with surgical tape (Steri-Strips, 3M, St. Paul, MN), interrupted sutures, or staples.

18 Removal of Soft Tissue Tumors

1 Indications

Elective: Any space-occupying lesion whose benign or malignant nature is uncertain

The diagnosis of a suspected soft tissue sarcoma (hard, rapidly growing tumor, especially of the extremities) should first be confirmed by an incisional biopsy (paraffin section), later by a compartment resection.

Plan the skin incision so it may later be included in the compartment resection.

Alternative Procedures: Biopsy under ultrasound or computed tomographic (CT) guidance or incisional biopsy for larger space-occupying lesions

2 Preoperative Preparation

Preoperative Investigations: Ultrasound, CT, possibly magnetic resonance imaging (MRI), and further diagnostic examinations depending on the suspected underlying disease

3 Specific Risks, Patient Information, and Consent

Possible need for revision surgery in the event of malignancy

Injury to adjacent structures, especially vessels and nerves

4 Anesthesia

Local anesthetic, general (mask or intubation) anesthesia or spinal/ peridural anesthesia for more deeply located tumors

5 Positioning

Depends on site of lesion

6 Approach

Directly over the palpable lesion, with due consideration for relaxed skin tension lines, adjacent structures, safety margins, cosmetic aspects, and potential extension of the operation

7 Operative Steps

Approach

Dissection down to the fascial plane

Skin closure

8 Relevant Anatomy, Serious Risks, Tricks

Simultaneous removal of the overlying skin if the lesion lies directly under the skin

Avoid opening any tumor capsule (exception being an incisional biopsy).

9 Measures for Specific Complications

Should considerable bleeding occur while one is dissecting a tumor of the extremities, provisional control of the hemorrhage should initially be achieved by compression, followed by proximal and distal control of the vessels.

10 Postoperative Care

Medical Aftercare: Remove drain on postoperative day 2.

Mobilization: Immediately, with the degree of mobilization depending on the finding

Physiotherapy: Usually not necessary

Time Off Work: 1 to 2 weeks

Operative Technique

Approach

Dissection down to the fascial plane

Skin closure

Approach