Basic Principles of Surgery

Dr. Mustan Barış SİVRİ

Department of Oral&Maxillofacial Surgery
 Basic Principles
• In surgical operations, a controlled injury is made. Injury response in human tissues are mostly
genomically predetermined, so can be predicted to a degree.
• We should know the principles of the surgery in order to render a successful treatment, and to manage
the possible postoperative complications.
• Even with the minor procedures, the clinician should apply all the evidence-based principles and full
systemic control and management of all the patients.
• We should evaluate and handle the patient as a whole biological system, any kind of treatment is not
apart from the whole system.
• So, anamnesis and psychology management carries a paramount role as a first step.
• Assistant holds a critical role, too, so should be trained accordingly.
• Before attempting any kind of surgically indicated procedure, clinician should first evaluate the patient
about
-whether the anesthesia is indicated or not,
-systemic condition, precautions, regulations, complications, postoperative term,
-risks and benefits of the procedure,
-good quality and up-to-date radiographs.
• Please have your standard set of anamnesis questions and examination routine, and apply them in
every patient (please repeat for the patients that you have not seen for a while).
• The clinican should plan and perform the procedure as a foundation to further treatments, if there is a
possibility of staged treatment.
 Basic Necessities
• Other than sterilization, two principal requirements for surgery are;
-Visibility,
-Assistance.
• Visibility:
-Adequate Access: patient’s interincisal opening, surgical exposure, instruments and armamentarium, retraction
-Adequate Light: sometimes a headlamp helps, but not necessary all the time. Assistant should not obstruct the light.
-Surgical field free of blood, fluids, debris: High-performance suctioning, small tip (depends), clever and simultaneous
aspiration.
• Assistant: Properly trained and focused assistant provides invaluable help. Poor assistance will hinder the quality
of surgery, at minimum make it lenghty than it should be, and distract the surgeon’s attention.
• Sterilization/Aseptic Technique: These principals are a must for preventing cross-contaminations and minimizing
wound contamination by pathogenic microorganisms.
 Incisions/Flap design
• When using a scalpel, the surgeon must remain focused on the location of the blade to
avoid inadvertently cutting structures such as the lips when moving the scalpel into and
out of the mouth. (Warn the patient if necessary)
• If the clinical situation necessitates a surgical flap:
-The blade should be new and sharp
-Non-hesitant, continuous line of incision
-Avoid important anatomical structures
-Perpendicular incision
-Proper design, place and angle: Plan the tissue closure (suturation), do not place the
incision over damaged bone.
Flap design
• Surgical flaps are made to gain surgical access to an
area. The clinician should prevent necrosis, dehisence
and tearing, which are the primary complications of
surgery.
• Flap necrosis: The architecture should be designed in
order to maintain efficient blood supply to the flap
tissue.
-Sides should be parallel or be converging from the base to
apex of the flap.
-Width of the base should be grater than the height.
-The base of the flaps should not be damaged with
excessive moves or instrumentation.
Flap design
• Flap Dehiscence: causes bone exposure, pain, bone loss,
infection.
-placing the edges of the flap over healthy bone
-gently handling edges, not suturing under tension
• Flap Tearing:
-most commonly occurs with unadequately prepared flaps with
insufficient access.
-placing a minimal incision does not equal to minimally invasive
surgery all the time.
-a properly prepared and sutured long incision heals just as quickly
as a short one most of the time, so it is mostly preferable to prepare
a sufficiently large access in order to gain visibility, avoid tearing,
and have a shorter operation time (but the incision and the extension
of the flap exposure should not be more than necessary-means
extra trauma).
-the incision can be lengthened or a vertical releasing incision can
Dehiscence
Tissue handling
• Handling the tissues plays a critical role in the success, outcomes and postoperative period of any surgical
operation.
• Excessive pulling, crushing, extremes of temperature, desiccation, or the use of unphysiologic chemicals easily
damages tissue.
• All the instruments should be used gently, especially in the soft tissue.
• Tissues should not be overaggressively retracted to gain greater surgical access (also very uncomfortable for
patients even anesthetized).
• When bone is cut (osteotomy), copious amounts of irrigation should be used to decrease the amount of bone
damage from frictional heat. (Soft tissue should also be protected)
• Tissue should not be allowed to desiccate; open wounds should be frequently moistened or covered with a wet
sponge if the surgeon will not be working on them for a while.
• Only physiologic and sterile substances should come in contact with living tissue.
• Gentle and physiologic tissue handling is rewarded with grateful patients with less frequent complications.
Hemostasis

• The clinician should obtain reasonable hemostasis during the operation

and complete hemostasis at the end of every type of surgical procedure.
• During the surgery, uncontrolled bleeding creates decreased visibility,
particularly in oral and maxillofacial architecture.
• Another problem with bleeding is hematomas, which occurs mostly in
major surgeries. Hematomas place pressure and tension on wounds
and sutures, decrease vascularity, and act as a culture media for
potential wound infections.
Hemostasis
• Assisting natural hemostatic mechanisms: using a gauze sponge to place pressure on bleeding vessels or
placing a hemostat on a vessel. These methods cause stasis of blood in vessels, which promotes coagulation. A
few small vessels generally require pressure for only 20 to 30 seconds, whereas larger vessels require 5 to 10
minutes of continuous pressure.
• Thermal coagulation: use of heat to cause the ends of cut vessels to fuse; by holding the vessel with a metal
instrument such as a hemostat or by touching the vessel directly with an electrocautery tip.
-Patient must be grounded, all the metals should be taken off
-Cautery tip or any metal instrument it touches should not be in contact with any part of the patient orher than the site
of the bleeding
-Any blood or fluid should be aspirated before the cauterization for effective heat transfer and vessel closure.
• Suture ligation: If a bleeding vessel can be seen or located, it can be ligated directly or indirectly.
• Applying local hemostatic agents, procoagulants: thrombin, collagen, vasoconstrictors (mild effect), Ankaferd,
oxidised cellulose, fibrin sealant, Tranexamic acid, gelatin sponge, etc.
Edema Control
• Edema occurs after surgery as a result of tissue injury. Edema is an accumulation of
fluid in the interstitial space.
• The greater the amount of tissue injury, the greater is the amount of edema
• The looser the connective tissue that is contained in the injured region, the more edema
that occurs.
• The clinician can control the amount of postsurgical edema by performing surgery in a
manner that minimizes tissue damage.
• Patient positioning in the early postoperative period head elevated above during the first
few postoperative days.
• Short-term, high-dose systemic corticosteroids (only if extreme edema is expected)