器械和打结英文版课件

BasicSurgicalInstruments

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KnotsTyingDepartmentofHepatobiliarySurgeryTheFirstAffiliatedHospitalXi’anJiaotongUniversityXinZhengMD,PHDObjectiveRecognizingthebasicsurgicalinstrumentsHowtousetheinstrumentsKnotstyingScalpelThebladecomesinmultipleshapesandsizes,sodoesthehandle.BelliedbladeScalpelLoadingthebladerequiresthehelpofsomeinstruments,suchastheneedleholder,andalsohandlewithgreatcareasthebladesareverysharp.(Practiseattachinganddetachingthebladeusinganeedleholder.Neverhandlethebladedirectly.)ScalpelA:Fiddlebowhold.Thescalpelisheldlikeasteakknife,theindexfingerguidesthebladewhilethehandleisheldbetweenthethumbandmiddlefingerScalpelC:Thescalpelhandleisheldlikeapencil,makingthecuttingbellyapproximate45degreestotheskinsurfaceduringtheincision.ScalpelB:thescalpelhandleisheldlikegrabbingsomethingScalpelD:reversethesharpedgeScissorsTissueScissors(thinandsharp);SutureScissors;Stitch-CuttingScissors;Straight(shallow);curved(deep);ScissorsTouchthesuture.Slidethescissordown.Incline45degree.Cut.hemostatorclamphemostatorclampDifferentkindsofclamps;Straightclamp(superficial)Kellyclamp(internal,deep)Mosquitoclamp(small)Kocher

clamp(thick)Angledclamp(duct)hemostatorclampDissecttissueclampbloodvesselshelptopullouttheneedleclampthicktissuehelpknottingForceps

Teethforceps;smoothforceps;Holdgentlybetweenthumbandfingers,themiddlefingerplayingthepivotalroleNeedleHolder&Needle&SutureHoldtheneedleinthetipofthejawsabouttwo-thirdsofthewayalongitscircumference.NeedleHolder&Needle&SutureGrasptheneedleholdersintheseway(axle)NeedleHolder&Needle&SutureHandtohanddeliverNeedleHolder&Needle&SutureDifferentkindsofneedle/suture;IntersectingsurfaceSuture:absorbableandnon-absorbabletowelcliportowelclamp

thisinstrumentsisusedtofixsteriledrapesinpositionSpongeclamp

orRingforcepsgraspdressingssterilizeordisinfectionclampintestineRetractor

ThyroidretractorAbdominalretractorSkinhooksDeepretractorself-retainingretractorRetractor

self-retainingretractorAppendixretractorOtherclampsIntestinalclampAppendixclamporBabcockforcepsOtherclampsRat-toothforcepsorAllistissueforcepsNontraumatichemostaticforcepssuctionstaplerandcloserStaplegunCloserCauterycutcoagulationBasicSurgicalInstrumentsSimple\square\extraunijunction\surgical\false\slip

knot1.Simpleknot:incompletebasicunit2.Squareknot:completedcommonknot3.Surgeon’sorFrictionknot:completedtensionknotSimpleKnots/Right-handedtechnique.

Whitestrandloopedaround2or3fingersofrighthandwithdistalendheldbetweenthumbandindexfinger.SimpleKnots/Right-handedtechnique.

Purplestrandheldinlefthandbroughttowardtheoperatortocrossoverthewhitestrand.Continuehandmotionbyflexingdistalphalanxofrightmiddlefingertobringitbeneathwhitestrand.SimpleKnots/Right-handedtechnique.

Asthemiddlefingerisextendedandtherighthandpronated,thewhitestrandisbroughtbeneaththepurplestrand.SimpleKnots/Right-handedtechnique.

Horizontaltensionappliedwiththerighthandawayfromandthelefthandtowardtheopposite.Thisisthefirsthalfhitchofthesquareknot.SimpleKnots/Right-handedtechnique.

Whitestrandheldbetweenthumbandmiddlefingerofrighthandwithloopoverextendedindexfinger.Purplestrandheldbetweenthumbandindexfingeroflefthand.SimpleKnots/Right-handedtechnique.

Withpurplestrandsupportedinlefthand,thedistalphalanxofrightindexfingerpassesunderthewhitestrandtoplaceitovertipofrightindexfingerSimpleKnots/Right-handedtechnique.

Thenthewhitestrandispulledthroughloopinpreparationforapplyingtension.SimpleKnots/Right-handedtechnique.

Thiscompletesthesecondhalfhitchofthesquareknot.Therighthanddrawntowardandlefthandawayfromtheoperator.Finaltensionshouldbeasnearlyhorizontalaspossible.TWO-HANDTECHNIQUEWhitestrandplacedoverextendedindexfingeroflefthandactingasbridge,andheldinpalmoflefthand.Purplestrandheldinrighthand.TWO-HANDTECHNIQUEPurplestrandheldinrighthandbroughtbetweenleftthumbandindexfinger.TWO-HANDTECHNIQUELefthandturnedinwardbypronation,andthumbswungunderwhitestrandtoformfirstloop.TWO-HANDTECHNIQUEPurplestrandcrossedoverwhiteandheldbetweenthumbandindexfingeroflefthand.TWO-HANDTECHNIQUERighthandreleasespurplestrand.Thenlefthandsupinated,withthumbandindexfingerstillgraspingpurplestrand,tobringpurplestrandthroughthewhiteloop.Regrasppurplestrandwithrighthand.TWO-HANDTECHNIQUEPurplestrandreleasedbylefthandandgraspedbyright.Horizontaltensionisappliedwithlefthandtowardandrighthandawayfromoperator.Thiscompletesfirsthalfhitch.TWO-HANDTECHNIQUELeftindexfingerreleasedfromwhitestrandandlefthandagainsupinatedtoloopwhitestrandoverleftthumb.TWO-HANDTECHNIQUEPurplestrandheldinrighthandisangledslightlytotheleft.Purplestrandbroughttowardtheoperatorwiththerighthandandplacedbetweenleftthumbandindexfinger.Purplestrandcrossesoverwhitestrand.TWO-HANDTECHNIQUEByfurthersupinatinglefthand,whitestrandslidesontoleftindexfingertoformaloopaspurplestrandisgraspedbetweenleftindexfingerandthumb.TWO-HANDTECHNIQUELefthandrotatedinwardbypronationwiththumbcarryingpurplestrandthroughloopofwhitestrand.Purplestrandisgraspedbetweenrightthumbandindexfinger.TWO-HANDTECHNIQUEHorizontaltensionappliedwithlefthandawayfromandrighthandtowardtheoperator.Thiscompletesthesecondhalfhitch.TWO-HANDTECHNIQUEThefinaltensiononthefinalthrowshouldbeasnearlyhorizontalaspossible.INSTRUMENTTIEShortpurplestrandliesfreely.Longwhiteendofstrandheldbetweenthumbandindexfingeroflefthand.Loopformedbyplacingneedleholderonsideofstrandawayfromtheoperator.INSTRUMENTTIENeedleholderinrighthandgraspsshortpurpleendofstrand.INSTRUMENTTIEFirsthalfhitchcompletedbypullingneedleholdertowardoperatorwithrighthandanddrawingwhitestrandawayfromoperator.Needleholderisreleasedfrompurplestrand.INSTRUMENTTIEShortpurplestrandliesfreelyagain.Longwhiteendofstrandheldbetweenthumbandindexfingeroflefthand.Loopformedbyplacingneedleholderundersideofstrandtowardtheoperator.INSTRUMENTTIEEndofthepurplestrandgraspedbytheneedleholder,purplestrandisdrawnthroughloopinthewhitestrandawayfromtheoperator.INSTRUMENTTIESquareknotcompletedbyhorizontaltensionappliedwithlefthandholdingwhitestrandtowardoperatorandpurplestrandinneedleholderawayfromoperator.Finaltensionshouldbeasnearlyhorizontalaspossible.DEEPTIEStrandloopedaroundhookinplasticcuponPracticeBoardwithindexfingerofrighthandwhichholdspurplestrandinpalmofhand.Whitestrandheldinlefthand.DEEPTIEPurplestrandheldinrighthandbroughtbetweenleftthumbandindexfinger.Lefthandturnedinwardbypronation,andthumbswungunderwhitestrandtoformthefirstloop.DEEPTIEByplacingindexfingeroflefthandonwhitestrand,advancetheloopintothecavity.DEEPTIEHorizontaltensionappliedbypushingdownonwhitestrandwithleftindexfingerwhilemaintainingcountertensionwithindexfingerofrighthandonpurplestrand.DEEPTIEPurplestrandloopedoverandunderwhitestrandwithrighthand.DEEPTIEPurplestrandloopedaroundwhitestrandtoformsecondloop.Thisthrowisadvancedintothedepthsofthecavity.DEEPTIEHorizontaltensionappliedbypushingdownonpurplestrandwithrightindexfingerwhilemaintainingcountertensiononwhitestrandwithleftindexfinger.Finaltensionshouldbeasnearlyhorizontalaspossible.LIGATIONAROUNDHEMOSTATICCLAMPWhensufficienttissuehasbeenclearedawaytopermiteasypassageofthesutureligature,thewhitestrandheldintherighthandispassedbehindtheclamp.LIGATIONAROUNDHEMOSTATICCLAMPLefthandgraspsfreeendofthestrandandgentlyadvancesitbehindclampuntilbothendsareofequallength.LIGATIONAROUNDHEMOSTATICCLAMPToprepareforplacingtheknotsquare,thewhitestrandistransferredtotherighthandandthepurplestrandtothelefthand,thuscrossingthewhitestrandoverthepurple.LIGATIONAROUNDHEMOSTATICCLAMPAsthefirstthrowoftheknotiscompleted,theassistantremovestheclamp.Thismaneuverpermitsanytissuethatmayhavebeenbunchedintheclamptobesecurelycrushedbythefirstthrow.Thesecondthrowofthesquareknotisthencompletedwitheitheratwo-handorone-handtechniqueaspreviouslyillustrated.Attentions1.Thecompletedknotmustbefirm,andsotiedthatslippingisvirtuallyimpossible.2.Theknotmustbeassmallaspossibletopreventanexcessiveamountoftissuereactionwhenabsorbablesuturesareused,ortominimizeforeignbodyreactiontononabsorbablesutures.Endsshouldbecutasshortaspossible.3.Intyinganyknot,frictionbetweenstrands(“sawing”)mustbeavoidedasthiscanweakentheintegrityofthesuture.4.Careshouldbetakentoavoiddamagetothesuturematerialwhenhandling.Avoidthecrushingorcrimpingapplicationofsurgicalinstruments,suchasneedleholdersandforceps,tothestrandexceptwhengraspingthefreeendofthesutureduringaninstrumenttie.5.Excessivetensionappliedbythesurgeonwillcausebreakingofthesutureandmaycuttissue.6.Suturesusedforapproximationshouldnotbetiedtootightly,becausethismaycontributetotissuestrangulation.7.Afterthefirstloopistied,itisnecessarytomaintaintractionononeendofthestrandtoavoidlooseningofthethrowifbeingtiedunderanytension.8.Finaltensiononfinalthrowshouldbeasnearlyhorizontalaspossible9.Thesurgeonshouldnothesitatetochangestanceorpositioninrelationtothepatientinordertoplaceaknotsecurelyandflat.10.Extratiesdonotaddtothestrengthofaproperlytiedknot.Theyonlycontributetoitsbulk.SURGEON’SKNOTWhitestrandplacedoverextendedindexfingeroflefthandandheldinpalmoflefthand.Purplestrandheldbetweenthumbandindexfingerofrighthand.SURGEON’SKNOTPurplestrandcrossedoverwhitestrandbymovingrighthandawayfromoperatoratanangletotheleft.Thumbandindexfingeroflefthandpinchedtoformloopinthewhitestrandoverindexfinger.SURGEON’SKNOTLefthandturnedinwardbypronation,andloopofwhitestrandslippedontoleftthumb.Purplestrandgraspedbetweenthumbandindexfingeroflefthand.Releaserighthand.SURGEON’SKNOTLefthandrotatedbysupinationextendingleftindexfingertopasspurplestrandthroughloop.Regrasppurplestrandwithrighthand.SURGEON’SKNOTTheloopisslidontothethumbofthe