2018 Book FundamentalsOfGeneralSurgery 2

Fundamentals of
General Surgery
Francesco Palazzo
Editor
With Contribution by
Michael J. Pucci
123
Fundamentals of General Surgery
Francesco Palazzo
Editor
Fundamentals of
General Surgery
With Contribution by
Michael J. Pucci
Editor
Francesco Palazzo
Department of Surgery
Sidney Kimmel Medical College
Thomas Jefferson University
Philadelphia, PA
USA
ISBN 978-3-319-75655-4 ISBN 978-3-319-75656-1 (eBook)

https://doi.org/10.1007/978-3-319-75656-1
Library of Congress Control Number: 2018941249
© Springer International Publishing AG, part of Springer Nature 2018

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To my wife, Silvia, and to my children Gaia, Giada, and Bruno;
to the many mentors who contributed to the field of General
Surgery and to the Jefferson residents, present and past, for
inspiring me to strive for clarity and excellence every single
day.
Francesco Palazzo
To my family whom have supported me in every way
to allow me to pursue my dream. To the masters and
mentors of surgery whom have inspired me to continually
strive for technical excellence. To the patients whom
entrust me with their care, and provide endless learning
opportunities for myself and our trainees. And finally,
to the resident surgeons I have the opportunity to learn
from and teach. Your endless thirst for knowledge and
mastery of surgical skills inspires and drives me to
continue to improve in all skills necessary for the
transference of surgical ability.
Michael J. Pucci
Foreword: Why Another Textbook of
Surgery?
So, why offer another textbook in the domain of Surgery? Certainly, there
have been numerous surgical textbooks published over the last few centuries.
New books continue to be added annually, as older textbooks cease to be
revised. New areas of surgical specialty are developed, and textbooks are
composed. In addition to books, we have journals, webcasts, audio guides,
blogs, newsfeeds, and many other sources of information to assist the surgical
learner. This book is designed to be different!
The intent of this book is to provide medical students, surgical physician
assistants, surgical nurse practitioners, surgical residents, and surgical fel-
lows with a novel resource—a place where they can find modern surgical
knowledge upon which to base their surgical development. This book includes
information that is typically transferred in the operating room setting, or at
the bedside, but is frequently lost or limited during current training due to
shorter work hours or due to the lesser amount of direct observation or inter-
action as part of teaching rounds, serving as a second assistant, etc. That is,
much of what is contained herein is not typically contained in other text-
books, but rather has been transmitted verbally from the master to the learner.
So, enjoy the content of this textbook. There are many chapters on the
operating room and its setup, patient positioning and skin preparation, retrac-
tors, and robotics. Contained here are useful discussions of gastrointestinal
anastomoses, laparotomy for trauma, temporary abdominal wall closure,
acceptable behavior in the operating room, and management of the operative
catastrophe. Every topic is current, important, timely, and well discussed.
In the spirit of full disclosure, I must admit to a certain bias. The two edi-
tors of this textbook are young rising star members of our faculty at the
Sidney Kimmel Medical College of Thomas Jefferson University. They both
served as chief residents at Thomas Jefferson, and they both went on to fel-
lowship training: Dr. Palazzo at the University of California—San Francisco
vii
viii Foreword: Why Another Textbook of Surgery?
(UCSF) and Dr. Pucci here at Thomas Jefferson. I have scrubbed with both of
these editors—they are superb surgeons and extraordinarily talented and car-
ing physicians. Acknowledging this bias, I nonetheless enthusiastically rec-
ommend this textbook. I have learned much from the chapters I have read.
Charles J. Yeo
Samuel D. Gross
Professor and Chairman, Department of Surgery,
Senior Vice President and Chair,
Enterprise Surgery, Jefferson Health, Jefferson University Hospital,
Philadelphia, PA, USA
Preface
It is with great excitement that we present to you the first edition of

Fundamentals of General Surgery. This book you hold in your hands—or
more likely read on a computer screen—is the result of long conversations,
reflections, and some degree of whining that have followed the many elective,
urgent, and emergent procedures we have been lucky enough to bring to
successful completion during our last several years in practice in Philadelphia.
While surgical education continues to rely on textbooks (or videos), oral
transference of information at the bedside or in the operating room, and
technical expertise demonstrated by and practiced with skilled mentors, it
seems that current limitations have made it, at times, fragmented and not
always uniformly delivered to all trainees. This book hopes to bridge the gap
that exists between surgical education and the practice of surgery for novice
and expert surgical trainees of all levels.
Herein you will find valuable information that is at times based on
evidence, and other times based on years of practice in countless procedures.
You will be able to use this when you need to take a patient to the operating
room, when you first set foot in the operating room, when you need to
independently position your first patient for a low anterior resection, but also
for when you begin to construct your first gastrointestinal or vascular
anastomoses. A sizeable portion of the book looks at sutures, knots, and
instruments we use to make our procedures possible and safe (from retractors,
to dissectors, to energy devices). Much focus is devoted to key concepts of
trauma surgery which we believe any general surgeon should be familiar
with; and an equally important portion of the book is dedicated to the
frequently unaddressed concepts of progression from resident to independent
surgeon, etiquette in the operating room, leadership and followership, and
how to manage your time successfully. In each chapter we have asked the
authors to provide a brief historical background, discuss some controversial
areas, and present a list of recommended readings.
We are proud of the fact that this book should not be consulted frantically
while preparing for the ABSITE or the American Board of Surgery qualifying
exam. What can be found in these pages is not meant to be “swallowed whole
and quick” but is meant to be carefully read, re-read, and slowly digested
alternating practice, questions to your mentors, and review of this text (and
many others) which is the only way to make knowledge easily retrievable and
long lasting.
ix
x Preface
We are indebted to the many superb authors who contributed chapters to

this book for their knowledge, their dedication, and willingness to invest their
valuable time with a new editorial concept of surgical education. We have
both read the chapters many times, have enjoyed them, and have learned
much: our deepest thanks go to all of you!
A special acknowledgment goes to Jennifer Brumbaugh, MA, who is the
medical illustrator and webmaster in the Department of Surgery at the Sidney
Kimmel Medical College of Thomas Jefferson University, and who has
worked with us on several of these chapters providing (once again) top-notch
illustrations that complement and enrich the text.
We would also like to thank the production team at Springer UK and
Springer Nature that have made this possible and deserve to be mentioned:
Melissa Morton, Leo Johnson, Prakash Jagannathan, and many others.
We hope that this book will serve the many out there entering the
fascinating world of General Surgery so that their journey can be easier and
lead to the mastery we all seek. On the other hand, for those among us who
have been navigating these waters for a few years this book may offer a new
way to teach “young dogs some of the old tricks.”
Philadelphia, PA, USA Francesco Palazzo

Philadelphia, PA, USA Michael J. Pucci
Contents
1 Fundamentals of Patient Preparation for the Operating

Room in the Twenty-First Century�� 1
Emily A. Pearsall and Robin S. McLeod
2 Fundamentals of Operating Room Setup and Surgical
Instrumentation�� 17
Katerina Dukleska, Allison A. Aka, Adam P. Johnson,
and Karen A. Chojnacki
3 Fundamentals of Sutures, Needles, Knot Tying,
and Suturing Technique�� 39
Jessica A. Latona, Sami Tannouri, Francesco Palazzo,
and Michael J. Pucci
4 Fundamentals of Patient Positioning and Skin Prep�� 65
Giulio Giambartolomei, Samuel Szomstein, Raul Rosenthal,
and Emanuele Lo Menzo
5 Fundamentals of Incisions and Skin Closures�� 83
Folasade O. Imeokparia, Michael E. Villarreal,
and Lawrence A. Shirley
6 Fundamentals of Retractors and Exposure �� 95
Michael B. Ujiki and H. Mason Hedberg
7 Fundamentals of Dissection�� 107
Neal S. McCall and Harish Lavu
8 Fundamentals of Surgical Hemostasis �� 119
Daniel J. Deziel
9 Fundamentals of Energy Utilization in the Operating Room�� 129
Amin Madani and Carmen L. Mueller
10 Fundamentals of Stapling Devices�� 137
Christina Souther and Kenric Murayama
11 Fundamentals of Drain Management�� 143
Guillaume S. Chevrollier, Francis E. Rosato,
and Ernest L. Rosato
12 Fundamentals of Flexible Endoscopy for General Surgeons��163
Robert D. Fanelli
xi
xii Contents
13 Fundamentals of Prosthetic Materials

for the Abdominal Wall �� 175
Udai S. Sibia, Adam S. Weltz, H. Reza Zahiri,
and Igor Belyansky
14 Fundamentals of Basic Laparoscopic Setup�� 189
Marc Rafols, Navid Ajabshir, and Kfir Ben-David
15 Fundamentals of Laparotomy Closure�� 207
William W. Hope and Michael J. Rosen
16 Fundamentals of Robotic Surgery�� 215
Tomoko Mizota, Victoria G. Dodge, and Dimitrios Stefanidis
17 Fundamentals of Gastrointestinal Anastomoses �� 227
Talar Tatarian, Andrew M. Brown, Michael J. Pucci, and
Francesco Palazzo
18 Fundamentals of Vascular Anastomosis�� 239
Selena G. Goss and Dawn M. Salvatore
19 Fundamentals of Exploratory Laparotomy for Trauma�� 253
Chia-jung K. Lu and Joshua A. Marks
20 Fundamentals of Temporary Abdominal Wall Closure�� 265
Shelby Resnick and Niels D. Martin
21 Fundamentals of Exploratory Thoracotomy for Trauma�� 275
Deepika Koganti and Alec C. Beekley
22 Fundamentals of Becoming a Safe and Independent Surgeon
(From First Assistant to Skilled Educator)�� 289
Nabeel R. Obeid and Konstantinos Spaniolas
23 Fundamentals of Acceptable Behavior in the Operating Room
(Etiquette) �� 297
Annie P. Ehlers and Andrew S. Wright
24 Fundamentals of the Daily Routine as a Surgeon: Philosophy,
Mentors, Coaches, and Success�� 307
Charles J. Yeo
25 Fundamentals of Managing the Operative Catastrophe�� 321
Idalid Franco, David L. Hepner, William R. Berry,
and Alexander F. Arriaga
Index�� 339
Contributors
Navid Ajabshir Mount Sinai Medical Center, Comprehensive Cancer

Center, Miami Beach, FL, USA
Allison A. Aka Department of Surgery, Sidney Kimmel Medical College,
Thomas Jefferson University, Philadelphia, PA, USA
Alexander F. Arriaga Department of Anesthesiology, Perioperative and
Pain Medicine, Harvard Medical School, Brigham and Women’s Hospital,
Boston, MA, USA
Department of Anesthesiology and Critical Care, University of Pennsylvania
Health System, Philadelphia, PA, USA
Alec C. Beekley Department of Surgery, Division of Acute Care Surgery,
Division of Bariatric Surgery, Sidney Kimmel Medical College at Thomas
Jefferson University, Philadelphia, PA, USA
Igor Belyansky Department of Surgery, Anne Arundel Medical Center,
Annapolis, MD, USA
Kfir Ben-David Mount Sinai Medical Center, Comprehensive Cancer
Center, Miami Beach, FL, USA
William R. Berry Ariadne Labs, Boston, MA, USA
Center for Surgery and Public Health, Boston, MA, USA
Department of Health Policy and Management, Harvard School of Public
Health, Boston, MA, USA
Andrew M. Brown Department of Surgery, Sidney Kimmel Medical
College, Thomas Jefferson University, Philadelphia, PA, USA
Guillaume S. Chevrollier Department of Surgery, Sidney Kimmel Medical
Karen A. Chojnacki Department of Surgery, Sidney Kimmel Medical
Daniel J. Deziel Department of Surgery, Rush University Medical Center,
Chicago, IL, USA
Victoria G. Dodge Department of Surgery, Indiana University School of
Medicine, Indianapolis, IN, USA
xiii
xiv Contributors
Katerina Dukleska Department of Surgery, Sidney Kimmel Medical

Annie P. Ehlers Department of Surgery, University of Wisconsin, Madison,
WI, USA
Robert D. Fanelli Department of Surgery, The Guthrie Clinic, Sayre, PA,
USA
The Geisinger Commonwealth School of Medicine, Scranton, PA, USA
Albany Medical College, Albany, NY, USA
Idalid Franco Harvard Medical School, Boston, MA, USA
Giulio Giambartolomei The Bariatric and Metabolic Institute, Cleveland
Clinic Florida, Weston, FL, USA
Selena G. Goss Department of Surgery, Sidney Kimmel Medical College,
Samuel D. Gross Professor and Chairman, Department of Surgery, Senior
Vice President and Chair, Enterprise Surgery, Jefferson Health, Jefferson
University Hospital, Philadelphia, PA, USA
David L. Hepner Department of Anesthesiology, Perioperative and Pain
Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston,
MA, USA
Ariadne Labs, Boston, MA, USA
William W. Hope New Hanover Regional Medical Center, University of
North Carolina at Chapel Hill, Wilmington, NC, USA
Folasade O. Imeokparia Department of Surgery, The Ohio State University
Wexner Medical Center, Columbus, OH, USA
Adam P. Johnson Department of Surgery, Sidney Kimmel Medical College,
Deepika Koganti Department of Surgery, Sidney Kimmel Medical College,
Jessica A. Latona Department of Surgery, Sidney Kimmel Medical College,
Harish Lavu Jefferson Pancreas, Biliary and Related Cancer Center and the
Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia,
PA, USA
Chia-jung K. Lu Department of Surgery, Division of Acute Care Surgery,
Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia,
PA, USA
Amin Madani Department of Surgery, McGill University, Montreal, QC,
Canada
Contributors xv
Joshua A. Marks Department of Surgery, Sidney Kimmel Medical College,

Niels D. Martin Trauma and Surgical Critical Care, University of
Pennsylvania, Philadelphia, PA, USA
H. Mason Hedberg Department of Surgery, University of Chicago Medicine,
Chicago, IL, USA
Neal S. McCall Department of Surgery, Sidney Kimmel Medical College,
Robin S. McLeod Zane Cohen Centre, Lunenfeld-Tanenbaum Research
Unit, Mount Sinai Hospital, Toronto, ON, Canada
Department of Surgery, The Institute of Health Policy, Management and
Evaluation, University of Toronto, Toronto, ON, Canada
Cancer Care Ontario, Toronto, ON, Canada
Emanuele Lo Menzo Research Institute, The Bariatric and Metabolic
Institute, Cleveland Clinic Florida, Weston, FL, USA
Tomoko Mizota Department of Surgery, Indiana University School of
Carmen L. Mueller Department of Surgery, McGill University, Montreal,
QC, Canada
Kenric Murayama Department of Surgery, John A Burns School of
Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
Nabeel R. Obeid Department of Surgery, Stony Brook Medicine, Stony
Brook, NY, USA
Francesco Palazzo Department of Surgery, Sidney Kimmel Medical
Emily A. Pearsall Zane Cohen Centre, Lunenfeld-Tanenbaum Research
Unit, Mount Sinai Hospital, Toronto, ON, Canada
Department of Surgery, The Institute of Health Policy, Management and
Evaluation, University of Toronto, Toronto, ON, Canada
Michael J. Pucci Department of Surgery, Sidney Kimmel Medical College,
Marc Rafols Mount Sinai Medical Center, Comprehensive Cancer Center,
Miami Beach, FL, USA
Shelby Resnick Trauma and Surgical Critical Care, University of
Pennsylvania, Philadelphia, PA, USA
Ernest L. Rosato Department of Surgery, Sidney Kimmel Medical College,
Francis E. Rosato Department of Surgery, Sidney Kimmel Medical College,
xvi Contributors
Michael J. Rosen Cleveland Clinic, Cleveland, OH, USA

Raul Rosenthal Department of Surgery, The Bariatric and Metabolic
Institute, Cleveland Clinic Florida, Weston, FL, USA
Dawn M. Salvatore Department of Surgery, Sidney Kimmel Medical
Lawrence A. Shirley Department of Surgery, The Ohio State University
Udai S. Sibia Department of Surgery, Anne Arundel Medical Center,
Annapolis, MD, USA
Christina Souther Department of Surgery, John A Burns School of
Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
Konstantinos Spaniolas Department of Surgery, Stony Brook Medicine,
Stony Brook, NY, USA
Dimitrios Stefanidis Department of Surgery, Indiana University School of
Adam Strickland Department of Surgery, Sidney Kimmel Medical College,
Samuel Szomstein The Bariatric and Metabolic Institute, Cleveland Clinic
Florida, Weston, FL, USA
Sami Tannouri Department of Surgery, Sidney Kimmel Medical College,
Talar Tatarian Department of Surgery, Sidney Kimmel Medical College,
Michael B. Ujiki Department of Surgery, Grainger Center for Innovation
and Simulation, NorthShore University HealthSystem, Evanston, IL, USA
Michael E. Villarreal Department of Surgery, The Ohio State University
Adam S. Weltz Department of Surgery, Anne Arundel Medical Center,
Annapolis, MD, USA
Andrew S. Wright Department of Surgery, University of Wisconsin,
Madison, WI, USA
Charles J. Yeo Professor and Chairman, Department of Surgery, Senior Vice
President and Chair, Enterprise Surgery, Jefferson Health, Jefferson University
Hospital, Philadelphia, PA, USA
H. Reza Zahiri Department of Surgery, Anne Arundel Medical Center,
Annapolis, MD, USA
Fundamentals of Patient
Preparation for the Operating 1
Room in the Twenty-First Century
Emily A. Pearsall and Robin S. McLeod
1.1 General Concepts Finally, preoperative education is an important

part of the preoperative work-up.
Modern surgery can be performed safely with low
mortality and morbidity rates, even in patients
having complex operations or who have signifi- 1.2 Preoperative Assessment
cant comorbidities. However, to achieve excellent and Care
results, there must be thorough evaluation and
preparation of patients. Even in patients having In all patients, a complete history and examination
emergency surgery, it is important, if possible, to is essential. In addition to understanding the pre-
ensure that patients are in optimal condition. This senting condition, it is necessary to know if the
requires a full preoperative assessment of their pri- patient has underlying comorbidities and what
mary condition, as well as their comorbidities. In medications he/she is on. There are some fairly
addition, patients may require preoperative imag- common drugs which patients are often taking
ing and appropriate laboratory testing. Depending such as anticoagulants, steroids, and diabetic medi-
on the urgency of their surgery, patients may need cations which may need to be discontinued or mod-
various interventions to optimize their condition. ified prior to surgery. As well, diagnostic imaging
should be performed to assist in the planning of the
operation. Finally, it might be worthwhile in some
E. A. Pearsall situations to delay surgery to optimize the patient’s
Zane Cohen Centre, Lunenfeld-Tanenbaum Research condition. For instance, patients presenting with an
Unit, Mount Sinai Hospital, Toronto, ON, Canada abdominal abscess who do not require emergency
Department of Surgery, University of Toronto, surgery should have the abscess drained, antibiot-
Toronto, ON, Canada ics started, and surgery performed on a semi-elec-
R. S. McLeod (*) tive basis. Similarly, in patients presenting with an
Zane Cohen Centre, Lunenfeld-Tanenbaum Research obstruction due to a stricture, it might be possible
Unit, Mount Sinai Hospital, Toronto, ON, Canada to decompress the bowel prior to undertaking
Department of Surgery, University of Toronto, surgery.
Toronto, ON, Canada With respect to imaging and laboratory tests to
Institute of Health Policy, Management and prepare patients for surgery, Choosing Wisely has
Evaluation, University of Toronto, Toronto, made a number of specific recommendations for
ON, Canada
asymptomatic patients who are undergoing non-
Cancer Care Ontario, Toronto, ON, Canada cardiac low-risk surgery [1]. In these patients, it
e-mail: robin.mcleod@cancercare.on.ca
© Springer International Publishing AG, part of Springer Nature 2018 1

F. Palazzo (ed.), Fundamentals of General Surgery, https://doi.org/10.1007/978-3-319-75656-1_1
2 E. A. Pearsall and R. S. McLeod
is recommended that the following should not be should be encouraged to have a family member in
done routinely but rather selectively utilized: attendance so they are well informed and can
share information with the patient.
• Blood count, coagulation testing, and serum
biochemistry tests
• ECG, chest x-ray, ECHO cardiogram, cardiac 1.2.2 Nutritional Evaluation
stress tests, and pulmonary function tests and Supplements
• Type and screen for blood
Malnutrition is a common problem for general
surgery patients, as approximately 14% of elective
1.2.1 Patient Education GI surgical patients are at risk of malnutrition.
Several studies have shown that patients at risk of
Patient education is an essential component of malnutrition often have longer hospital stays as
preoperative care. Appropriate preoperative edu- well as an increased rate of postoperative compli-
cation has been shown to decrease patients’ anxi- cations. The European Society for Clinical
ety and fears about surgery, lessen the use of Nutrition and Metabolism released a guideline in
postoperative analgesia, reduce postoperative 2017 on clinical nutrition in surgery [7]. In addi-
complications, and decrease the length of hospi- tion to recommending a shortened fast and carbo-
tal stay [2–5]. Many patients view surgery as a hydrate drinks up to 2 h prior to surgery, they also
threatening experience with many stressful com- recommend that the nutritional status of all patients
ponents which elicit strong emotional responses should be assessed before and after surgery. The
[4, 5]. These responses can have negative reper- authors suggest that nutritional therapy, preferable
cussions for the patient in the postoperative by the enteral route, should be initiated in patients
period [3, 4]. Research, although limited, has who are malnourished or those at nutritional risk.
shown that preoperative psychosocial interven- Additionally, patients who may not be able to eat
tions also have positive effects on postoperative or may have a low oral intake prior to surgery may
psychological and physical functioning [4–6]. also benefit from nutritional therapy.
With the implementation of enhanced recov- A 2012 Cochrane review was undertaken to
ery after surgery programs, there is greater review the literature on preoperative nutritional
emphasis on self-management and early dis- support in patients undergoing gastrointestinal
charge [6]. This means that patients require more surgery. The authors found that immune-
information about what the expectations of them enhancing nutrition reduces the risk of complica-
are in hospital as well as after discharge, what tions; however, these studies included
they can expect with normal recovery, and finally well-nourished surgical patients and excluded
how to identify complications and what they those at high risk of malnutrition. Thus, immune-
should do if they occur. Patients should receive enhancing nutrition has not been proven to be
this information both verbally and in written for- beneficial for malnourished surgical patients.
mat. Ideally, this information should be provided Similarly, there was inconclusive evidence to
prior to their preadmission visit to better prepare support preoperative oral supplements and
them for the appointment and be able to have enteral nutrition. Lastly, parental nutrition
questions ready. In addition, patients should be appears to have an effect on total complications
offered a second appointment with the surgeon but not on infectious complications in malnour-
because often they forget to ask questions at their ished patients [8].
first meeting, especially if they received unex- With regards to nutritional screening, while
pected recommendations. It is also essential that the literature strongly recommends that screening
patients receive a consistent message from all should take place, there is limited information on
healthcare providers and standardized messaging the preferred screening method. Both Nutritional
in all written materials. Additionally, patients Risk Screening 2002 [see Editors’ Corner at end
1 Fundamentals of Patient Preparation for the Operating Room in the Twenty-First Century 3
of chapter] and Subjective Global Assessment are all efforts should be made for these patients to
most commonly used [9]. have a shortened fast, so diabetic patients under-
going elective surgery should be scheduled early
in the day.
1.2.3 Management of Patients
with Diabetes Mellitus
1.2.4 Smoking Cessation
With the increasing prevalence of obesity, diabe-
tes is seen more frequently in patients having sur- Smokers who undergo surgery are at greater risk
gery. Depending on the surgical procedure, for developing pulmonary and surgical-related
approximately 10–15% of patients will be dia- complications. This risk may be in the order of a
betic. These patients are at higher risk for devel- three- to sixfold increase in intraoperative pulmo-
oping complications, having a longer length of nary complications [11]. There are a number of
stay, and dying postoperatively. The poorer out- short-term and long-term risks related to smok-
comes may be due to the diabetes or the associ- ing. Short-term effects are due to increased con-
ated comorbidities. centrations of carbon monoxide and nicotine in
Patients scheduled for elective surgery should the blood. Carbon monoxide preferentially binds
be seen as soon as the date of surgery is determined to hemoglobin over oxygen. Carbon monoxide
so the patient’s status can be assessed, and if neces- also changes the structure of hemoglobin, so
sary, interventions can be implemented to optimize there is a shift in the oxygen hemoglobin curve.
the patient when he/she undergoes surgery. Together, these effects lead to decreased avail-
Random glucose levels are of no value and ability of oxygen. Nicotine increases blood pres-
should not be ordered in patients with diabetes sure, pulse rate, and systemic vascular resistance.
mellitus. Instead, the patient should have their Thus, nicotine increases the work of the heart,
HbA1c measured. Generally, individuals with a while carbon monoxide decreases the availability
HbA1c of less than 69 mmol mol−1 (i.e., 8.5% of oxygen. These harmful effects may disappear
NGSP) can be managed with fasting and simple after 48 h of stopping smoking.
manipulation of their insulin. On the other hand, The long-term effects of smoking are related to
individuals with an elevated HbA1c will likely atherosclerosis and effects on pulmonary function
require careful monitoring and manipulation of including increased mucus which may increase
their treatment. In addition to measuring HbA1c, the likelihood of infection [7]. Lastly, in addition
diabetic patients should be assessed for comor- to the effects on the cardiovascular and respira-
bidities including ordering of serum electrolytes tory systems, smoking impairs wound healing.
and an ECG [10]. This may affect the surgical wound as well as
Patients with a HbA1c below 69 mmol mol−1 increase the risk of anastomotic leaks [11].
usually can withstand fasting with minor A Cochrane Review which was published in
changes in their insulin requirements or medica- 2014 included 13 studies looking at the effect of
tion. On the other hand, individuals who have a preoperative smoking cessation programs [11].
HbA1c greater than 69 mmol mol−1, have poorly These studies were quite heterogeneous in regards
controlled diabetes, are having emergency sur- to their interventions and intensity. The authors
gery, or will be unable to take a normal diet after classified them as short and long intensive inter-
surgery may require significant changes to their ventions based on the length of time before sur-
care and should be seen by a specialist consul- gery they were instituted and the intervention.
tant [10]. Generally, the intensive strategies were started
For all diabetic patients having surgery, it is 4–8 weeks before surgery and included weekly
important that there is careful monitoring to behavioral interventions as well as nicotine
ensure there is normal glycemia and minimal dis- replacement therapy. Both the short and long
ruption of their usual routine. To accomplish this, intensive programs were effective in decreasing
smoking rates, but the results were more favorable alleviate anxiety and depression and give patients
in the long intensive program and were also sus- a sense of empowerment that they can improve
tainable. In addition, only intensive programs were their health.
effective in decreasing surgical complications (RR
0.42, 95% CI 0.27–0.65) including wound compli-
cations (RR 0.31, 95% CI 0.16–0.62). 1.2.6 Blood Conservation
The authors concluded that the optimal preop-
erative intervention intensity remains unclear, but The World Health Organization defines anemia as
based on this review, they recommend interven- an insufficient number of red blood cells (RBC) to
tions which are started 4–8 weeks before surgery meet physiologic needs [15]. The most common
and provide behavioral support as well as offer- indicator of anemia is a hemoglobin (Hb) concen-
ing nicotine replacement therapy. tration below the normal adult values, with thresh-
olds of 12.0 g/dL in women and 13.0 g/dL in men
[16]. In the general population, the prevalence of
1.2.5 Prehabilitation anemia is generally under 5%, but in the periop-
erative setting, anemia is more common. An
There is some evidence that there is an association observational study looking at data from the
between patients’ fitness before surgery and their National Surgical Quality Improvement Program
outcomes after surgery including complications, (NSQIP) identified 33.9% of 6301 non-cardiac
length of stay, and health-related quality of life surgical patients with preoperative anemia [17].
[12, 13]. Several trials assessing whether preop- Perioperative anemia appears to be multifactorial.
erative exercise programs (“prehabilitation”) have The most obvious causes can be associated with
been performed and have shown mixed results. A the disease for which surgery is required, such as
recent systematic review and meta- analysis of gastrointestinal bleeding leading to chronic blood
nine studies [13] focusing on abdominal surgeries loss, nutritional deficiency from decreased oral
found that preoperative exercise was associated intake, or hematologic toxicities from chemother-
with a 41% decrease in postoperative complica- apy treatments. The anemia of chronic disease
tions and a 1.6-day reduction in LOS. However, also plays an important role.
the studies which were included were of “very Perioperative anemia has been shown to have
low quality,” due to improper allocation conceal- negative effects on surgical outcomes. In the
ment, randomization strategies at high risk of NSQIP analysis, the postoperative infection rate
bias, and biased outcome assessment. There are increased from 2.6% to 5% with increasing
also other studies which have not shown a benefit degrees of anemia [17]. Overall, 92% of postop-
including a study of patients over the age of erative infections occurred in anemic patients.
60 years having colorectal surgery [14]. Low preoperative and postoperative hemoglobin
While there may be some benefit to prehabili- levels were independent risk factors of increased
tation programs, there are some limitations to mortality, postoperative pneumonias, and length
their adoption. In particular, these programs may of stay [17]. Furthermore, another meta-analysis
delay surgery for 4–6 weeks. This may not be found that allogeneic blood transfusion was sig-
possible, particularly in patients who are having nificantly associated with a higher risk of
surgery for a cancer diagnosis where a delay postoperative infection (OR 3.45, 95% CI 1.43–
might not be advantageous or patients who are 15.15) [18].
receiving other treatments such as neoadjuvant A number of non-transfusion strategies have
therapy in that interval. been suggested to correct preoperative anemia
At the current time, there is insufficient evi- and hopefully lower its consequences. The peri-
dence to recommend prehabilitation programs, operative use of erythropoietin in colorectal can-
but it is an area of interest. Not only may this cer surgery was summarized in a Cochrane
increase patient physical well-being but also may Review in 2009 [19]. Four randomized controlled
trials were included. No difference was observed reduces the rates of infectious postoperative
in the proportion of patients requiring RBC trans- complications such as surgical site infections,
fusions. The authors concluded that there was deep intra-abdominal infections, and anasto-
insufficient evidence to recommend the use of motic dehiscence. These theories, however,
erythropoietin in colorectal cancer surgery. have been based largely on clinical experience
The use of perioperative iron supplementation and expert opinion.
has been shown to decrease the need for RBC In the recent years, the value for MBP in
transfusion either alone or in combination with patients having elective colonic and rectal sur-
erythropoietin or autologous blood donation. In a gery has been challenged. MBP is generally safe
randomized controlled trial, 49 patients sched- but has been associated with serious complica-
uled for colorectal surgery were randomized to tions in patients with existing cardiac and renal
ferrous sulfate or no supplements for 2 weeks disease as well as previously healthy patients.
prior to surgery. Preoperative iron led to higher Furthermore, most patients find taking a MBP to
hemoglobin and ferritin levels at admission and be unpleasant. A meta-analysis published by
decreased likelihood of requiring blood transfu- Slim et al. in 2009 included 14 trials in which
sion, along with a 66% cost reduction [20]. 4859 patients were randomized to MBP or no
Another study compared intravenous iron sup- MBP. The pooled results revealed no significant
plementation, and no difference was observed in differences in anastomotic leakage rates (OR
either hemoglobin level at admission or the need 1.12, 95% CI [0.824, 1.532], p = 0.46) or superfi-
for blood transfusion [21]. cial SSI (9.5% in the MBP group vs. 8.3% in the
In an attempt to reduce transfusion-related no MBP group; OR 1.17, 95% CI [0.96, 1.44],
morbidity by limiting the exposure to allogeneic p = 0.11) [23].
blood, preoperative autologous donation has More recently, there has been laboratory evi-
been used. A Cochrane Review included 14 tri- dence that the combination of oral antibiotics and
als. Preoperative autologous blood donation was intravenous antibiotics reduces the risk of anasto-
associated with a reduction in the relative risk of motic leaks as well as SSI. The WHO found
receiving allogeneic blood transfusion by 68% moderate quality evidence for prescribing MBP
(RR 0.32 [95% CI 0.22–0.47]). However, the risk and oral antibiotics to reduce SSIs in colorectal
of receiving any blood transfusion was increased surgery [24]. Their systematic review of 11 RCTs
(RR 1.24 [95% CI 1.02–1.510). The rate of post- compared MBP with oral antibiotics to MBP
operative infection was not different between alone and found an OR 0.56 (95% CI 0.37–0.83).
autologous and allogeneic blood transfusion Numerous oral antibiotic regimens have been
groups (RR 0.70 [95% CI 0.34–1.43]) [22]. studied but usually a combination of an amino-
Moreover, preoperative blood donation would glycoside (neomycin) with erythromycin or met-
appear to be difficult to use in gastrointestinal ronidazole is prescribed.
surgery where a significant proportion of patients Thus, while more evidence is required, it is
present with anemia. possible that MBP with a combination of oral
and intravenous antibiotics may be the preferred
option.
1.2.7 Mechanical Bowel Preparation
Mechanical bowel preparation (MBP) before 1.2.8 Stoma Siting

elective colorectal surgery has been the stan-
dard in surgical practice for over a century. An ileostomy or colostomy is frequently required
Surgeons believed that MBP decreases intralu- in patients having surgery for benign or malig-
minal fecal mass and presumably decreases nant indications. The stoma may be permanent or
bacterial load in the bowel. It is argued that a temporary. Preoperative marking of the stoma is
decrease in fecal load and bacterial contents essential since how well the stoma functions may
have a profound effect on outcome and the gical complications leading to reduced length
patient’s acceptance of it. When siting a stoma, it of hospital stay.
should be placed away from scars and creases Early research in the role of preoperative fast-
and in a location where the patient can visualize ing determined that for passive regurgitation and
it adequately when he/she is sitting or lying. If pulmonary aspiration to occur during anesthesia,
not, the patient may have difficulty changing the a certain gastric volume must be present. It has
appliance. Both stoma placement and siting of been assumed that a minimum of 200 mL of
incisions are extremely important both in the residual volume is required for regurgitation [31,
short term as well as the long term since if the 32]. Numerous studies have reported that in most
stoma is permanent, it may require revision in the patients, the preoperative mean gastric fluid vol-
future [25]. ume is in the range of 10–30 mL, and 120 mL is
Siting of the stoma should be performed prior rarely exceeded irrespective of intake of clear
to surgery and should include education on how liquids.
to look after the stoma. Optimally this should be With regards to carbohydrate drinks, the
given by a trained enterostomal therapist. While majority of the evidence has shown no benefit,
education has always been important, it has even but some studies have shown modest effects for
more relevance now since patients’ hospital stays reduced length of stay, postoperative insulin
are shorter, and thus, there is less time for them to resistance, return to GI function, and patient
get comfortable with a stoma [26]. well-being [33]. As well, none of the studies
found that carbohydrate drinks increased the risk
of postoperative complications such as aspira-
1.2.9 Fasting tion. Thus, they concluded that while there is no
strong evidence to support its use in terms of
Despite many institutions still requiring patients improved surgical outcomes, there is no evidence
to be “NPO after midnight,” there is strong evi- for potential postoperative complications, and
dence that favors reducing preoperative fasting carbohydrate drinks may be encouraged as it may
times and is supported by numerous worldwide improve the tolerability of the presurgical period.
guidelines. The current guidelines all support a There is much debate regarding carbohydrate
fast of 6 h following a light meal at night [27–29]. loading in diabetic patients. Unfortunately, there
The recommendations are based on the estimated is limited evidence available to support or refute
physiologic gastric emptying time for healthy a recommendation on this. To date, only one
patients which is relatively short and thus will not study has assessed preoperative carbohydrate
increase the risk of pulmonary aspiration [30]. loading in type 2 diabetes patients [34]. This
Furthermore, rather than prohibiting oral study was of low quality, comparing 25 patients
intake, current guideline recommendations with diabetes to 10 healthy controls. The patients
encourage patients to consume drinks high in in the experimental group were given a
carbohydrates up to 2–3 h prior to surgery carbohydrate- rich drink (400 ml, 12.5% with
[30]. Clear fluids may include coffee and tea 1.5 g of paracetamol). The authors found that
(without milk) but preferably should be drinks peak glucose was higher in diabetic patients
that are high in carbohydrates (i.e., apple juice (13.4 ± 0.5 vs. 7.6 ± 0.5 mm; P < 0.01); however,
and pulp-free orange juice). This may improve glucose concentrations were back to baseline at
patient outcomes by minimizing the adverse 180 min for diabetic patients compared to
effects of starvation and decreasing the effects 120 min in the control group (P < 0.01). Gastric
of surgical stress. Additionally, it has been half-emptying time (T50) was also significantly
hypothesized that carbohydrate drinks may different with it occurring at 49.8 ± 2.2 min in
reduce insulin resistance and glycogen deple- diabetics compared to 58.6 ± 3.7 min in the con-
tion and may attenuate loss of muscle mass, trol (P < 0.05). Despite these differences, the
hunger, thirst, anxiety, nausea, as well as sur- authors concluded that type 2 diabetic patients
showed no signs of delayed gastric emptying sug- with the sign out phase. The handoff of patients
gesting that the use of carbohydrate drinks may has been shown to be important especially in
be safely administered prior to surgery. patients who have had a complex procedure or
Despite the lack of evidence, preoperative have multiple comorbidities. In a follow-up
assessment of individuals for gastroesophageal study, Haynes and colleagues surveyed providers
reflux disease, dysphagia symptoms, or other and found that the attitudes of the individuals
gastrointestinal motility disorders is recom- correlated with the degree of improvement in
mended because these individuals might be at care [37].
higher risk for reflux and aspiration [29].
1.3.2 S
urgical Site Infection
1.3 Preparation on the Day Prevention
of Surgery
Surgical site infections (SSIs) are the most com-
1.3.1 Surgical Checklist mon and expensive healthcare-associated infec-
tions leading to increased morbidity and mortality
Surgical checklists have been adopted by most and increased hospital stays. However, evidence-
hospitals. Checklists include items which are based initiatives have been shown to prevent
essential to all parts of the work load in the oper- more than 50% of SSIs [38]. There are four
ating room. The goal is to increase communica- essential components which have strong evi-
tion among all individuals who are part of the dence to support their use to decrease surgical
surgical team including anesthesiologists, nurses, site infections: antibiotic prophylaxis, mainte-
and surgeons and optimize the care and safety of nance of normothermia before and throughout
patients. There are three phases to the checklist the surgical procedure, adequate skin prepara-
including the “sign in” phase which should occur tion, and avoidance of shaving.
before the patient is anaesthetized, the “time out”
phase before the incision is made, and the “sign 1.3.2.1 Antibiotic Prophylaxis
out” phase before the patient leaves the operating Table 1.1 outlines the preferred choice of antibi-
room. Haynes et al. were able to show a signifi- otics for different general surgical procedures.
cant reduction in mortality (1.5% vs 0.8%) and The benefit of antimicrobial prophylaxis varies
complications (11% vs 7%) following the imple- depending on the procedure. Antibiotics are often
mentation of the checklist in eight hospitals not recommended for clean surgeries unless post-
across the world [35]. operative infections would have severe conse-
In the Haynes study, hospitals in developing quences. When choosing a regimen, the narrowest
nations had the greatest improvement in out- antimicrobial spectrum should be used to mini-
comes which may be the reason why a subse- mize the risk of Clostridium difficile infections
quent study in Ontario, Canada, did not identify and the emergence of antibiotic resistance.
any improvement following the adoption of the While cephalosporins are the preferred antibi-
checklist [36]. The checklist consists of a list of otics for many procedures, another drug is often
items which pertain to all aspects of the opera- substituted if the patient has a history of a peni-
tion. Simply confirming that these items are in cillin allergy. Instead, a detailed allergy history as
place may not lead to improved outcome. Rather, outlined in the Cefazolin Safety Checklist
the value of the checklist may be that it fosters (Fig. 1.1) should be obtained because in most
improved communication among all members of instances, cephalosporins can be prescribed with-
the surgical team. In addition, the checklist has out significant risk. Severe anaphylactic type 1
three phases, and in many instances, not all reactions are not common in patients receiving
phases are completed which may decrease its antibiotics: 0.01–0.05% in patients receiving
utility. In particular, there may not be compliance penicillin and 0.0001–0.1% for cephalosporins.
Table 1.1 Considerations in the preoperative assessment Additionally, re-dosing of antibiotics for pro-
and management of patients undergoing general surgery
longed procedures is necessary to maintain ade-
procedures
quate tissue concentration (Table 1.2). Thus,
A. Preoperative assessment should include the
following:
additional intraoperative doses are recommended
1. History and physical examination at intervals approximating two times the half-life
2. Appropriate imaging and diagnostic tests of the antibiotic or if there is significant blood
B. Preoperative interventions that should be loss (>1.5 L). Finally, antibiotics should not be
considered depending on the patient status and routinely continued postoperatively. They do not
surgical procedure decrease the risk of a SSI but can increase the risk
1. Smoking cessation
of Clostridium difficile infections (Table 1.3).
2. Prehabilitation
3. Blood conservation
4. Nutritional assessment 1.3.2.2 Normothermia
5. Management of the diabetic patient General and neuraxial anesthesia impair thermo-
6. Mechanical bowel preparation regulatory control. As a result, nearly all
7. Stoma siting (in patients where a stoma may be unwarmed surgical patients become hypothermic
required) if active measures are not taken to maintain nor-
8. Preoperative fasting mothermia. The typical rate of heat loss leads to
C. Patient education a drop in body temperature of 1–1.5 °C during
D. Preparation on the day of surgery
the first hour of general anesthesia. Hypothermia
1. Surgical checklists
2. Strategies to decrease the risk of surgical site
increases the risk of surgical site infections
infections (SSI) through one of two mechanisms. First, thermo-
3. Venous thromboembolic prevention regulatory vasoconstriction reduces subcutane-
ous oxygen tension, and secondly, mild core
A significant allergy is defined as a prior allergic hypothermia impairs immune function through
reaction (or positive skin testing) with resultant impairment of T-cell-mediated antibody produc-
hospitalization or anaphylaxis (hypotension, tion and neutrophil oxidative killing. Mild peri-
laryngeal edema, wheezing, angioedema, urti- operative hypothermia has also been causally
caria). If the patient did suffer this type of reac- linked to numerous complications including
tion, he/she should not receive the same drug or increased blood loss, adverse cardiac events, and
another penicillin. The rate of cross-reactivity prolonged post-anesthetic recovery and hospital-
between penicillin and cephalosporins is approx- ization. In the review by the WHO guidelines,
imately 10%, so if the patient has a history of a pre- and intraoperative body warming signifi-
severe reaction, an alternative antibiotic should cantly reduced SSIs compared to no warming
be prescribed such as vancomycin. However, (OR, 0.33; 95% CI, 0.14–0.62) [26]. Normal core
non-severe reactions/side effects such as mild temperature should be maintained during surgery
maculopapular rash and gastrointestinal upset are through the use of active measures including
not reasons for prescribing clindamycin or warmed intravenous fluids, inspired gases, forced
vancomycin. air warming, and ensuring that irrigation fluids
To reduce surgical site infections, antibiotic used in a surgical procedure are at or slightly
prophylaxis must attain adequate tissue concen- above body temperature before use. The OR
tration at the time of incision and be maintained should be kept in the range of 20 °C, a c ompromise
during the procedure. To achieve this objective, between what is acceptable for the patient and
antibiotics directed against the most common tolerable for the surgical team. In addition, mea-
contaminating bacteria must be administered sures should be taken preoperatively to maintain
within 60 min before incision at the correct dose. the patient’s temperature at 36 °C or above. This
Vancomycin and fluoroquinolones require a lon- may require warmed blankets while patients wait
ger infusion time and need to be initiated earlier in the holding area and ensuring they are covered
to ensure completion within 60 min of incision. in the operating room prior to induction.
Fig. 1.1 Cefazolin Have you had

safety checklist No an allergic Yes
reaction to
penicillin?
Have you taken penicillin, a

Use penicillin or Yes penicillin like drug (i.e.
cephalosporin amoxicillin), or cephalosporin
since then without a reaction?
No/
unsure
Yes Did you ONLY experience GI

upset (nauea, vomiting, diarhea)
as a result of your allergy?
No/
unsure
Any 1 of:
1. Did you have skin testing that confirmed an allergy?
2. Did you develop hives as a result of your allergy?
3. Did you expereince difficulty breathing, wheezing, swelling of the tongue,
or require a breathing tube (intubation) as a result of your allergy?
4. Did you expereince a loss of consciousness as a result of your penicillin
allergy?
5. Did you require hospitalization as a result of your penicilliin allergy?
Yes
DO NOT ADMINISTER
PENICILLIN OR CEPHALOSPORIN
1.3.2.3 Preoperative Skin Preparation trial which included 849 patients who underwent
Chlorhexidine alcohol should be used to clean clean-contaminated surgery (colorectal, small
the skin in most patients [see Chap. 4]. The intestinal, gastroesophageal, biliary, thoracic,
exceptions are procedures where there is contact gynecologic, urologic) confirmed these results: SSI
with the eyes, the middle ear, mucous mem- rates of 9.5% in the chlorhexidine alcohol group vs
branes, and meninges (including lumbar punc- 16.1% in the povidone-iodine group. However,
ture). In addition, it should be avoided in infants while this solution is more effective, there is a small
less than 2 months old. risk of fire with the 70% alcohol which can be miti-
A 2010 meta-analysis of 6 studies containing gated by ensuring there is no pooling of the alcohol
5031 patients undergoing clean-contaminated and time is left for it to dry [40].
general or gynecological surgery showed that Bathing or showering prior to surgery to clean
chlorhexidine alcohol was more effective than the skin is considered good clinical practice.
povidone-iodine in reducing the risk of SSIs However, there is no definitive evidence to sup-
(pooled odds ratio 0.68, 95% CI 0.50–0.94, port the use of antimicrobial soap (chlorhexidine)
p = 0.019) [39]. A more recent large, multicenter compared to plain soap to reduce SSIs.
10
Table 1.2 Recommended antibiotics for prophylaxis of general surgery proceduresa

Surgical procedure Recommended agents B-lactam allergy recommended agents
Breast surgery Cefazolin Vancomycin
Gastroduodenal/esophageal/distal pancreatic resection Cefazolin Vancomycin + aminoglycoside
Percutaneous endoscopic gastrostomy (PEG) Cefazolin Vancomycin + aminoglycoside
Biliary tract—laparoscopic procedure—elective low risk None None
Biliary tract—laparoscopic procedure—high-risk emergency, inserting prosthetic Cefazolin Vancomycin + aminoglycoside
device, diabetes, risk of intraoperative gallbladder rupture/conversion to open, age
>70 years, ASA ≥3, reintervention within 1 month, acute cholecystitis, obstructive
jaundice, CBD stones, nonfunctional GB, pregnancy, immunosuppression
Biliary tract—open procedure
Liver resection
Colorectal, small bowel, appendectomy Cefazolin + metronidazole Vancomycin + aminoglycoside + metronidazole
Pancreaticoduodenectomy If risk of Gram-negative
resistance, add aminoglycoside
Hernia repair—hernioplasty, herniorrhaphy Cefazolin Vancomycin
Low-risk anorectal procedures: hemorrhoidectomy, fistulotomy, sphincterotomy None None
Head and neck procedures: clean with no incision through oral/nasal/pharyngeal None None
mucosa (e.g., parotidectomy, thyroidectomy, and submandibular gland excision)
Head and neck procedures: clean with placement of prosthetic material (excludes Cefazolin Vancomycin + metronidazole
tympanostomy tubes)
Head and neck procedures: clean-contaminated (incision through oral/pharyngeal Cefazolin + metronidazole Vancomycin + aminoglycoside + metronidazole
mucosa): cancer surgery and other clean-contaminated procedures with the
exception of tonsillectomy and functional endoscopic sinus procedures
a
Adapted from Best Practice in Surgery http://www.bestpracticeinsurgery.ca
E. A. Pearsall and R. S. McLeod
Table 1.3 Recommended dosing and re-dosing of antimicrobial prophylaxisa

Pediatric dose (max dose should
not exceed the recommended adult Intraoperative re-dosing
Agent Adult dose dose) normal renal function
Cefazolin 2 g 30 mg/kg IV (max dose: 2 g) q4 h if CrCl >30 mL/
3 g if weight ≥120 kg min (Max 6 g/24 h)
Aminoglycoside:b 1.5–2 mg/kg (round to 2.5 mg/kg Repeat once at 3 h if
gentamicin or tobramycin nearest 20 mg) CrCl >60 mL/min
Metronidazole 500 mg 15 mg/kg Neonates <1200 g: 8 h
7.5 mg/kg
Vancomycinc,d 15 mg/kg round 15 mg/kg (max dose: 1 g) 8 h, if CrCl >50 mL/
nearest 250 mg (max min
2 g/dose)
Administer ≤1 g over
60 min
>1 g–1.5 g over 90 min
>1.5 g over 120 min
a
Adapted from Best Practice in Surgery http://www.bestpracticeinsurgery.ca
b
Dose based on actual body weight (ABW) unless obese. If ABW >20% above ideal body weight (IBW), use Dosing
Weight = IBW + 0.4*(ABW – IBW); IBW Men: 50 kg + 2.3 kg (× inches above 60 in.); IBW Women: 45.5 kg + 2.3
kg (× inches above 60 in.)
c
Dose should be based on total body weight
d
If tourniquet is used, entire dose should be infused prior to inflation
1.3.2.4 Preoperative Hair Removal develop DVT including prolonged stasis during
Preoperative preparation for surgery has tradi- the procedure and possibly postoperatively if the
tionally included the removal of body hair from patient cannot or does not ambulate and increased
the intended surgical site. However, several lines coagulability. It is estimated that between 15%
of evidence have challenged this practice, and and 30% of patients having a general surgical
current data suggest that hair removal might procedure will develop asymptomatic DVTs in
increase SSI rates [41–43]. A Cochrane Review the absence of prophylaxis [44–47]. The more
conducted by Tanner et al. included six trials sinister complication, pulmonary embolism, is
totalling 972 participants comparing hair removal said to occur in 1–3% of patients [48]. Factors
(shaving, clipping, or depilatory cream) with no which further increase the risk include age, obe-
hair removal and found no statistically significant sity, history of varicose veins and thromboembo-
difference in SSI rates. However, three trials with lism, cancer diagnosis, inflammatory bowel
1343 participants compared clipping to shaving disease, and medications including hormone
and showed significantly more SSIs associated replacement.
with shaving (RR 2.09, 95% CI 1.15–3.80). Thus, In 1975, a randomized controlled trial demon-
the authors concluded that when it is necessary to strated that low-dose heparin significantly
remove hair, clippers are associated with fewer reduced the rates of asymptomatic DVT, symp-
SSIs than razors [44]. tomatic DVT, and fatal PE [48]. Since then, hun-
dreds of randomized controlled trials,
meta-analyses, systematic reviews, and guidelines
1.3.3 Venous Thromboembolic on thromboprophylaxis in major abdominal gen-
Prophylaxis eral surgery have been published [45–47].
Despite the overwhelming evidence that throm-
Patients undergoing surgery are at risk for devel- boprophylaxis is an essential component of the
oping deep venous thrombosis (DVT) following postoperative care of general surgery patients,
surgery. Several factors make patients prone to there is evidence that prophylaxis is not used as
consistently as recommended nor as often as sur- guidelines recommend delaying administration

geons think it is being used in their patients. An of prophylaxis for 6–8 h (post-insertion of an epi-
audit of 123,000 patients hospitalized in the dural catheter) [50]. The ASRA also recommends
United States found that the majority received no that VTE prophylaxis may be given 2 h after
prophylaxis [49]. Among general surgical removal of an epidural catheter. In obese patients,
patients, 78% received no prophylaxis, and 83% in whom the BMI is less than 50, the above rec-
did not receive a prophylaxis option recom- ommendations can be followed. However, for
mended by the sixth American College of Chest individuals with a BMI greater than 50, the dose
Physicians (ACCP) Consensus Guidelines on the should be increased. There is no Level 1 evidence
Prevention of Venous Thromboembolism [49]. on the effectiveness of thromboprophylaxis in
There are a number of options for decreasing bariatric surgery. However, the American Society
the risk including intermittent pneumatic com- for Metabolic and Bariatric Surgery recommends
pression, low-dose unfractionated, and low- that perioperative thromboprophylaxis should be
molecular heparin. Which intervention is chosen given [51]. Furthermore, indirect evidence sug-
depends on the risk of developing a VTE. In addi- gests that dosing should be weight based. In
tion, all patients having surgery should be encour- patients with renal dysfunction, dose modifica-
aged to ambulate as soon after surgery as possible tion also is required.
and frequently thereafter. Thromboprophylaxis is Patients with cancer undergoing major
not required in low-risk patients (<0.5%). This abdominal or pelvic surgery and are at high risk
includes all patients having outpatient surgery (6%) should receive unfractionated or low-
and minor procedures such as anorectal proce- molecular heparin plus mechanical prophylaxis.
dures, inguinal hernia repairs, and laparoscopic In addition, there is evidence that asymptomatic
cholecystectomy, unless patients have other risk DVT can be reduced by extending prophylaxis to
factors. In addition, patients having breast proce- about 1 month after surgery [50].
dures do not require prophylaxis and, in fact,
should not receive prophylaxis unless there are Editors’ Comments
other risk factors because of the risk of wound
hematomas [46, 47]. • The preparation of the patient for the day of
Other general surgery patients having elective surgery has undergone significant changes
or emergency abdominal surgery, whether it is during the last several years and since we were
performed open or laparoscopically and their disin training. The implementation of ERAS
ease is benign or malignant and are at moderate pathways has dramatically affected the way
risk (3%), should receive low-molecular-weight patients are educated for what expects them in
heparin, unfractionated heparin, or mechanical the perioperative period; additionally, the way
prophylaxis with intermittent pneumatic com- that fluids and pain medications (NSAIDS and
pression. For individuals receiving unfractionated opiates) are managed perioperatively has
or low-molecular heparin, thromboprophylaxis determined a significant reduction in length of
should be started preoperatively at the time of the stay and faster return to regular activities of
“time out” and continued until discharge. This daily living.
recommendation is based on evidence from • Several calculators are in existence to help the
numerous RCTs and meta-analyses in patients medical practitioner estimate risk p reoperatively.
undergoing major abdominal surgery over a These apply to the overall risk of the surgical
40-year period which have demonstrated a consis- intervention (ACS-SQIP risk calculator:
tent 70% or greater relative risk reduction in DVT h t t p s : / / r i s k c a l c u l a t o r. fa c s . o rg /
as well as a similar decrease in PE [46, 47]. RiskCalculator/), to potential risk of develop-
While most patients should receive a preoper- ing a DVT in the perioperative period (Caprini
ative dose of heparin, the American Society of risk score: http://venousdisease.com/dvt-risk-
Regional Anaesthesia and Pain Medicine (ASRA) assessment-online/).
• Pain management continues to evolve, and 9. Karateke F, Ikiz GZ, Kuvvetli A, Menekse E, Das K,
Ozyazici S, Atalay BG, Ozdogan M. Evaluation of
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Ireland. Peri-operative management of the sur-
when started preoperatively. gical patient with diabetes 2015. Anaesthesia.
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compliance with prophylaxis guidelines for venous
Fundamentals of Operating Room
Setup and Surgical 2
Instrumentation
Katerina Dukleska, Allison A. Aka,
Adam P. Johnson, and Karen A. Chojnacki
2.1 Introduction cient operation for the patient. However, it is

important to remember that there are a number of
Caring for a patient in the operating room requires other staff that support the flow of the OR, includ-
an integrated system of healthcare professionals ing those responsible for sterilizing equipment,
with the primary goal to safely bring the patient the environmental staff, etc. The focus in this sec-
through a surgical procedure. This is a principle tion will be to provide an overview of the staff in
that is initiated in the preoperative setting and is the OR and to define the sterile field.
carried through the operation and to the postop-
erative setting. The goal of this chapter is to intro- 2.1.1.1 Sterile Versus Non-sterile
duce the reader to basic information about the Members of the OR Team
operating room and the operating team. We will In general, team members who are sterile during
also discuss fundamental concepts and the proper an operation include:
use of equipment related to open, laparoscopic,
and endoscopic surgery. 1. The surgeon who will be performing the pro-
cedure, along with his or her assistants. These
assistants could be residents, physician’s
2.1.1 Introduction to the Operating assistants, medical students, or nurse
Room Team practitioners.
2. The scrub nurse or scrub technician who is in
The operating room (OR) is one of the most charge of the sterile instruments.
dynamic locations in a hospital. Those who enter
into this atmosphere must be well trained and The non-sterile group includes:
prepared for any potential emergent situation that
may arise. The main OR team is made up of phy- 1. The anesthesia team, made up of an anesthesi-
sicians, nurses, and technicians who all play ologist who may be supervising a resident or
essential roles in order to achieve a safe and effi- certified registered nurse anesthetist. They are
responsible for airway management and intra-
operative life support.
K. Dukleska · A. A. Aka · A. P. Johnson
K. A. Chojnacki (*) 2. A circulating nurse who oversees OR docu-
Department of Surgery, Sidney Kimmel Medical mentation, obtaining needed equipment, and
College, Thomas Jefferson University, overall nursing care for the patient undergoing
Philadelphia, PA, USA the procedure.
e-mail: Karen.Chojnacki@jefferson.edu

18 K. Dukleska et al.
2.1.1.2 The Sterile Field 2.1.2 Introduction to Operating

The importance of a sterile field is paramount, as Room Equipment
it prevents surgical site infections. Multiple steps
are utilized in an effort to minimize surgical site The basic physical layout of the OR is depen-
infections, including patient evaluation and their dent on the specific requirements of the opera-
overall risk, sterilization of OR instruments, tion at hand. There are common components
environmental cleaning, the use of antibiotic pro- that are present in essentially all instances.
phylaxis, and the use of aseptic technique. The These include the OR table, anesthesia machine
goal of aseptic technique is to minimize patho- for the provision of oxygen and inhaled anesthe-
genic contamination by isolating the operative sia, intraoperative hemodynamic monitors, illu-
field from the non-sterile environment. Once mination, electrocautery, suction, back table,
properly gowned and gloved, or “scrubbed,” a Mayo stand, kick bucket, instrumentation, etc.
sterile OR team member is theoretically void of (Fig. 2.1). The setup of all of these components
pathogen colonization. Furthermore, sterile sur- is driven by the requirements for patient posi-
gical drapes are used to establish an aseptic bar- tioning and need for any additional specialized
rier to minimize the passage of pathogens from equipment.
the non-sterile areas of the operating room. Only
individuals that are “scrubbed” can handle the 2.1.2.1 Anesthesia Setup
sterile drapes, which should not be rearranged The anesthesia machine and anesthesia team
once placed. Only the top of the draped area is are typically positioned at the head of the OR
considered sterile. Similarly, instruments that are table. This allows for the team to have an unob-
opened onto the sterile field are done so by meth- structed view of the patient’s airway, easy
ods that maintain sterility. All members of the access to the anesthesia machine, access to
operative team are tasked with maintaining the monitoring equipment, etc. The determination
sterile field. If contamination is identified, it is on the type of anesthesia is highly case spe-
everyone’s duty to speak up and identify appro- cific, and the anesthetic plan should be dis-
priate actions to maintain sterility [1, 2]. cussed preoperatively.
Fig. 2.1 Typical OR components include OR table, light sources, anesthesia machine, etc. A historical picture from the
1960s shows that some of the equipment in the OR hasn’t changed
2 Fundamentals of Operating Room Setup and Surgical Instrumentation 19
2.1.2.2 Operating Room Table It is important to be mindful where the base of

Upon entry into the OR room, patients typically the bed is for all operations, especially in
start in a supine position and are safely secured to instances as mentioned above or in foregut or
the OR table with arms extended, thus allowing colorectal procedures. For example, for laparo-
the anesthesia team to then safely secure the air- scopic foregut surgery, such as during laparo-
way. For operations that are long and require spe- scopic paraesophageal hernia repair, the patient
cialized patient positioning, knowledge of how to is typically placed in a lithotomy position, and
maneuver the OR table is essential. Moreover, the operating surgeon stands in between the
the OR table can be broken into modular parts, patient’s legs. Therefore, it is imperative to be
and additional extensions can be added as needed. mindful of the location of the base of the OR
In the event of the need to use specialized equip- table so as to not interfere with the operation at
ment, such as X-ray or fluoroscopy during an hand.
operation, it is important to understand the loca- After successful induction of anesthesia, it is
tion of the bed stand. For example, when fluoros- essential to further position the patient safely and
copy is used for intraoperative cholangiography, appropriately for the specific case at hand.
it is oftentimes necessary to flip the bed in the General principles to keep in mind while posi-
opposite direction. This allows for the bottom tioning a patient include:
hand of the C-arm to safely be placed under the
bed to allow the surgeon to maneuver the patient • Avoiding hyperextension of the arms to avoid
and C-arm in order to successfully perform a brachial plexus injury
cholangiogram (Fig. 2.2). Some OR tables have • Care when positioning the patient in lithotomy
the ability to be automatically adjusted where to avoid peroneal nerve injury
they can slide up or down on the base of the bed. • Adequately securing the patient to the bed
This is another way to successfully perform chol- when extreme table positions are expected,
angiography without having to change the direc- such as in bariatric or some laparoscopic
tion of the bed. cases
Fig. 2.2 Positioning of the OR table base in relation to bottom of the C-arm and allows the movement of the
how the C-arm is positioned for a laparoscopic cholecys- equipment to be unobstructed
tectomy. Note the base of the OR bed does not obstruct the
More specific details regarding patient posi- soiled lap pads and to remove them from the ster-
tioning can be found in the Fundamentals of ile field.
Patient Positioning and Skin Prep chapter Illumination during surgery is provided by
(Chap. 4). overall illumination, which is generally attached
to the OR ceiling to allow for movement of the
2.1.2.3 Electrosurgical and Powered overhead lights. This allows for the lights to be
Devices adjusted during the procedure.
Most operating rooms are equipped with electro-
surgical devices and other powered devices. Care 2.1.2.5 Specialized Equipment
should be taken to avoid injury to the patient and The ability to perform certain cases in an OR
staff when using this equipment. may require specialized equipment. For example,
The most commonly utilized electrosurgical it is important to have equipment specifically tai-
device in the OR is the “electrocautery” device, lored to laparoscopic surgery as such components
commonly known as the Bovie. Electrosurgical may not typically be part of every OR. The oper-
units work by generating heat and vaporization ation at hand will guide the team in determining
of intracellular contents, which results in coagu- what needs to be available.
lation and hemostasis. The Bovie requires close Additional specialized equipment includes an
supervision since it has been associated with endoscopy tower when it is required intraopera-
patient injury and even surgical fires. This risk tively. The location of the endoscopy tower will
increases when alcohol-based skin preparation depend on what it will be used for (i.e., EGD ver-
products are used or the dispersive electrode is sus colonoscopy) and the patient’s positioning.
not appropriately placed. The purpose of the dis- For example, when performing an EGD as in the
persive electrode is to ground the patient, and it case for a percutaneous endoscopic gastrostomy
should be attached on dry, hairless skin on a tube, the endoscopy tower should be located on
location over large muscle mass (e.g., patient’s the operating surgeon’s right side.
thigh) and not be adjacent to metal. More details When the use of the C-arm is necessary, as in
on energy devices in the operating room can be during intraoperative cholangiography, in the
found in the Fundamentals of Energy Utilization beginning of the procedure, it should be located at
in the Operating Room in (Chapter 9). the patient’s feet. During the preparation stage,
Powered devices include drills and powered the surgeon should be mindful to securely and
saws. For example, when performing lower safely tuck the patient’s right arm and to ensure
extremity amputations, the bone saw is commonly the bed stand is flipped or the patient is on a slid-
used. These devices must be very carefully used ing bed. This will allow for the C-arm to be placed
so as to avoid injury to the patient or staff. Powered in the appropriate position in a way that it is not
saws and drills aerosolize body fluids; therefore, obstructed by the patient or other OR equipment.
one must be cautious and wear appropriate per-
sonal protective equipment to minimize potential
infectious exposure. 2.1.3 B
asics of Personal Protective
Equipment
2.1.2.4 Additional OR Components
During the operation, the sterile instruments that The American College of Surgeons released a
are required for the case are stored on the back statement in 2016 regarding appropriate operat-
table. The Mayo stand is an extension of the back ing room attire [3]. The goal was to balance sur-
table. The surgical scrub utilizes the Mayo stand geon comfort, professionalism, and infection
to place instruments and equipment commonly control. The following recommendations are
used during the operation at hand for easy and most important for those new to the operating
quick access. The kick bucket is used to place room:
• OR scrubs should be changed at least daily. 2.2 Technical Considerations

• OR scrubs should not be worn at any time out-
side of the hospital perimeter. 2.2.1 Basics of Instrumentation
• Scrubs and hats worn during dirty or contami- and Equipment for Open
nated cases should be changed prior to subse- Operative Technique
quent cases even if not visibly soiled.
• Masks should not be worn dangling at any Being a successful and efficient surgeon requires
time. training and knowledge about foot positioning,
• OR scrubs should not be worn in the hospital hand movements, and efficient use of instru-
facility outside of the OR area without a ments. In general, an ergonomic position for
clean lab coat or appropriate cover over them. open surgery is with the shoulders and elbows
relaxed, elbows in a flexed position, and the
The use of personal protective equipment is wrists should not be bent. For most major open
required not only to prevent contamination of the abdominal operations, the surgeon stands on the
sterile surgical field but also to protect clinicians patient’s right side; however, this can vary
from contact with patient bodily fluids [4]. Full depending on the type of surgery and the required
sterile attire includes: exposure.
There are numerous instruments that are uti-
• Surgical cap/bouffant—This should be worn lized during open surgery to assist with dissec-
at all times in the OR and any other designated tion, exposure, and suturing, some of which are
areas. highly specialized for certain operations. The
• Surgical mask—Different masks are often avail- appendix of this book includes the most com-
able for the OR. Selection of a mask varies based monly utilized instruments during open surgery
on personal preference and level of risk of air- along with a description of their proper use and
borne pathogens. While wearing a mask, the air handling.
flow is directed posteriorly; thus it is not recom- Personal special equipment, in addition to the
mended to turn one’s back on the sterile field. personal protective equipment, utilized by sur-
• Surgical gown—In order to maintain sterility, geons in open surgery includes:
gowns are often donned with assistance. They
must be properly secured prior to participation • Headlights provide additional illumination to
in the surgical procedure. the operative field, particularly focused within
• Eye protection—The eyes are a surgeon’s the line of sight of the surgeon. The proper use
most important tools. Corrective lenses are not of a headlight can provide improved visualiza-
sufficient protection without the addition of tion, particularly in deep surgical areas, such
side guards. Masks with eye shields or dispos- as the pelvis. Improper positioning or body
able visors are highly recommended. ergonomics can result in fatigue and injury
during lengthy cases; therefore, practice
Additional protective equipment possibly uti- outside of the operating room or with short
lized in specialized procedures includes: procedures is recommended prior to pro-
longed use.
• Body exhaust suit—A full body suit and hood • Surgical magnification can either be achieved
sometimes used in orthopedic procedures, via surgeon eyewear (i.e., loupes) or through a
such as joint replacements. free-standing microscope. These are particu-
• Lead gown—The use of lead is highly recom- larly useful for delicate operations or micro-
mended during procedures that implement surgery that requires fine anastomoses, such as
ionizing radiation, such as plain X-ray or during vascular procedures. Loupes are cus-
fluoroscopy. tom fit to a surgeon’s visual acuity and focal
length, and using another surgeon’s equipment they are ergonomic and allow for the surgeon and
is not recommended. The use of magnification assistant to have an unobstructed view. When the
severely limits a surgeon’s peripheral vision use of energy devices is necessary, it is important
and visual field. The surgeon and the OR team to be mindful of where the equipment is placed.
need to be aware of these limitations in the sur- For example, during a laparoscopic cholecystec-
geon’s visual field, especially when passing tomy, if using a foot pedal to control the cautery,
instruments and sharps (needles and scalpels). it needs to be located on the patient’s left side
where the primary surgeon is located. This equip-
For most open abdominal cases, the patient is ment should be placed in the appropriate place
positioned on the operating room table in the prior to prepping the patient and establishing the
supine position with both arms out. In addition to sterile field.
the surgeon being on the patient’s right, the assis- As with open surgery, specialized equipment is
tant is located on the patient’s left side. In these required to gain entry into the abdomen along with
instances, the scrub assistant is located on the specific instruments to perform the procedure. The
right side along with the surgeon and ensures ste- appendix of this book contains information about
rility of the instruments, and the operative field is some general concepts pertinent to laparoscopic
maintained. For major abdominal cases, the surgery and commonly used instruments.
Mayo stand and scrub assistant are generally
located to the right of the operating surgeon.
2.3 Future Directions
2.2.2 Basics of Setup Surgery is an ever-evolving field with surgical

for Laparoscopic and Robotic innovation driving development of new equip-
Surgery ment and instrumentation. Surgeons are always
looking for ways to best utilize the operating
When positioning a patient for laparoscopic sur- room using minimally invasive techniques—lap-
gery, one has to be mindful of appropriate patient aroscopic, endoscopic, robotic, natural orifice, or
positioning and of ideal positioning of the equip- hybrid approaches. However, despite this focus
ment that will be used. For example, when perform- on advancing surgery while minimizing trauma
ing laparoscopic appendectomy, both the surgeon to the patient, the fundamental goal of surgery
and assistant are located on the patient’s left side. continues to be rooted in its beginnings: to pro-
This means that the left arm must be safely and vide safe and effective care to patients.
securely tucked to allow for two individuals to com-
fortably stand on the same side. Conversely, when Take-Home Points
performing a diagnostic laparoscopy and there is an
intent to inspect the entire small bowel and large • The operating room is a dynamic environ-
bowel, it is ideal to tuck both arms to allow for any ment, and, in order to safely bring the patient
positioning of the surgeon and assistant. For opera- through an operation, a team approach is
tions that will require extreme patient positions, for required.
example, in morbidly obese patients who undergo a • Understanding of commonly found equipment
laparoscopic Roux-en-Y gastric bypass, safely in the OR and its proper use is important to
securing the patient is of paramount importance in ensure there is no harm to the patient or staff.
order to avoid any injury. A similar approach needs • Maintaining the sterile field is the responsibil-
to be employed during robotic surgery. The surgeon ity of the entire OR team, especially of the
must be mindful of the position of the OR table, the “scrubbed” personnel.
robot itself, and the console. • Proper use of instruments for open surgery is
In regard to the location of the equipment, the necessary to ensure integrity of the tissue that
monitors should always be placed in a way that is handled.
• Understanding laparoscopic instruments and the goal of the operation in mind. Essentially, the
their proper use allows for increased efficiency location of the incision should allow you to per-
and safety during laparoscopic surgery. form the operation safely and should provide you
• Surgical endoscopy is becoming increasingly with adequate exposure. In general, reusable scal-
utilized and becoming an integrated compo- pels include a handle and blade. First, the blade. It
nent in many general surgical procedures. comes in different sizes, with the most common
sizes used in surgery being the 10, 11, 15, and
rarely the 20 blade. The belly of the blade should
R Instrument Appendix:
O be in contact with the surface that is being cut. As
OR Instruments for Open Surgery a general rule, when making an incision, one
always cuts away from oneself or from the non-
Scalpels (Fig. 2.3) dominant to the dominant side. The handle which
safely holds the blade also comes in different
The scalpel is one of the synonymous instruments sizes. The size of the handle used is dependent on
that is associated with surgery. Perhaps the most the location where the incision will be made. Of
important decision to make prior to using the scal- note, some surgeons sometimes use the scalpel for
pel is the decision for where the incision will be sharp dissection which necessitates the use of a
placed. This should be a deliberate decision with longer handle (as in abdominal cases).
a b
a b c a b c d
Fig. 2.3 (a) Left to right, different varieties of knife han- to right, different varieties of blade numbers: A, number
dles: A, Bard-Parker knife handle #3; B, Bard-Parker 10 blade; B, number 11 blade; C, number 15 blade; D,
knife handle #4; C, Bard-Parker knife handle #7. (b) Left number 20 blade
Scissors (Figs. 2.4 and 2.5) the distal phalanx of your thumb and ring finger,
and attempt to use your dominant hand if possi-
Scissors come in multiple varieties, and depend- ble. Scissors used for dissection include the
ing on the type, they are used in various settings. Metzenbaum scissor, which can be used for sharp
They have a bias for right-handed individuals. dissection as in lysis of adhesions. Potts scissors
When using a scissor, place only about a half of are generally used in vascular surgery to extend
a b c d e f g
Fig. 2.4 Left to right, (a) Mayo scissor, straight; (b) Mayo scissor, curved; (c) Metzenbaum dissecting scissor, straight;
(d) Metzenbaum dissecting scissor, curved; (e) Potts scissor; (f) tenotomy scissor; (g) Iris scissor
a b c
Fig. 2.5 Left to right, (a) straight versus curved Mayo scissor; (b) straight versus curved Metzenbaum scissor; (c) Potts
scissor, open
the arteriotomy or venotomy. In contract, scis- Needle Holders (Fig. 2.8)

sors, such as the straight and curved Mayo, are
used for cutting suture or bowel during gastroin- The type, size, and weight of the needle holder are
testinal anastomoses. One should avoid the use of determined by the needle and suture. For exam-
finer instruments, such as the Metzenbaum scis- ple, larger and heavier needle holders are required
sor, to cut suture as it will dull the instrument. for large needles, such as the ones used for fascial
closure. Conversely, small needles that are used
for vascular anastomoses require finer and lighter
Forceps (Figs. 2.6 and 2.7) needle drivers, such as the Castroviejo. When
loading the needle on to the needle holder, it is
The general principle for how forceps work is by important to remember that a circular motion
grasping tissue in between two opposing sur- requires pronation and supination of the surgeon’s
faces. Deciding on which forceps to use depends wrist. This is necessary in order to prevent tissue
on the task at hand. In general, forceps come in trauma at the site of the needle point’s entry.
two varieties, smooth and toothed. Forceps that
are smooth cause crushing tissue trauma, and in
instances as such, the use of toothed forceps is Retractors (Figs. 2.9 and 2.10)
preferable. An example is when handling skin,
toothed Adson forceps are preferred so as to min- Much like other instruments, retractors come in
imize tissue trauma. different varieties, and their use is determined by
a b c d e f g
Fig. 2.6 Left to right, commonly used tissue forceps or Adson tissue forceps with teeth; (f) Adson tissue forceps
pickups: (a) Bonney tissue forceps; (b) Russian tissue for- without teeth; (g) Adson-Brown tissue forceps
ceps; (c) DeBakey forceps; (d) Gerald tissue forceps; (e)
a b c d
Fig. 2.7 Left to right, (a) Bonney tissue forceps; (b) Russian tissue forceps; (c) DeBakey tissue forceps; (d) Adson
tissue forceps
a b c d
Fig. 2.8 Left to right, (a and b) Mayo-Hegar needle driver, two different sizes; (c) Ryder needle driver; (d) Castroviejo
needle driver
a
e f g h i j k
b
c
d
Fig. 2.9 Left to right, different varieties of handheld retractor, (f) Richardson-Eastman retractor, (g) S-retractor,
retractors. (a) Harrington or Sweetheart retractor, (b) (h) Cushing vein retractor, (i) Senn retractor, (j) Rake
Deaver, (c) Kelly retractor, (d) Eastman, (e) Richardson retractor, (k) Army-Navy
c d
Fig. 2.10 Left to right, (a and b) Balfour self-retraining retractor, (c) Weitlaner self-retaining retractor, (d) Gelpi
the task at hand. They can be handheld or self- Suction (Fig. 2.11)

retaining retractors. An example of commonly uti-
lized handheld retractors that are utilized in general Visualization of the operative field is important,
surgery include the Army-Navy and Richardson which is accomplished through the use of suction
retractors. Similarly, self-retaining retractors, such devices. Sizes of the suction tip depend on the
as the Bookwalter and Balfour, are commonly uti- area and type of tissue being worked on. The
lized during large abdominal procedures. There commonly used Yankauer aspirates through the
are also smaller self-retaining retractors, such as tip end and is either disposable plastic or reusable
the Weitlaner, which are used during open proce- metal. A Poole sucker has multiple ports all along
dures, such as an inguinal hernia repair. the side and is used to quickly aspirate a large
a b c d e
Fig. 2.11 Left to right, (a) Yankauer suction; (b) Andrews suction; (c) Poole suction; (d) Frazier suction; (e) Poole
suction broken down into its components
volume of fluid, such as after irrigating the areas, and with or without teeth depending on the
abdominal cavity with liters of saline. Smaller power of the grip desired. Tissue type and desired
tips include the Andrews or Frazier, usually used outcome are some of the factors that determine
in pediatric or vascular cases. Suction on Frazier clamp choice. Babcocks are used to grasp bowel
tips are controlled by a small hole on the handle. firmly while causing the least amount of damage,
whereas a Kocher has multiple serrations that
allow for strong grasping of fascia.
Clamps (Figs. 2.12, 2.13, 2.14, 2.15, 2.16,

and 2.17)
Basics of Instrumentation
Clamps are used to hold objects in place and/or to and Equipment for Laparoscopic
maintain control of tissue, such as cutting off Surgery
blood flow to an area of interest. They can be
either straight or curved, perforating or non- Laparoscopic procedures require surgical skills
perforating, fine-tipped for more precise clamp- that include dexterity, efficiency, and the ability
ing or broad for thicker or more generalized to operate in a three-dimensional environment
a b c
Fig. 2.12 Left to right, (a) curved Crile; (b) straight Crile; (c) mosquito
a b c
Fig. 2.13 (a and c) Perforating towel clip; (b and d) non-perforating towel clip
a b c
Fig. 2.14 (a and c) Straight Kelly clamp; (b and d) curved Kelly clamp
a b
Fig. 2.15 (a) Kocher

clamp; (b and c) Kocher
clamp details
a b
Fig. 2.16 (a) Right angle, two different sizes; (b) right angle details
a b c
Fig. 2.17 Left to right, (a and c) Allis clamp; (b and d) Babcock clamp
a b
Fig. 2.18 Laparoscopic tower that includes the necessary ing the case. The surgeon can vary the insufflation pressure
hardware during a laparoscopic case. (a) Broad overview by adjusting the preset pressure. (c) Transmitter that allows
of components located on the tower. (b) Insufflator mea- for signal to be sent to other monitors in the room. (d)
sures the pressure and the flow of gas that is provided dur- Camera connection. (e) Light source connection
that is usually visualized in two dimensions. In Imaging System

addition to patient and surgeon positioning, one
must be cognizant of equipment positioning in The imaging system consists of the laparoscope,
order to facilitate the expeditious progression of camera, video monitor(s), and light source. In gen-
the operation. The equipment that is required to eral, the sterile components of this system include
carry out a laparoscopic case, such as the com- the laparoscope, camera, and fiber-optic cord that
ponents of the imaging system or insufflator, is connects the laparoscope to the light source.
oftentimes located on a laparoscopic tower Most modern laparoscopes utilize a rod-lens
(Fig. 2.18). For the remainder of this section, system that was initially discovered by Harold
basic laparoscopic equipment and the funda- H. Hopkins in the late 1950s. This was coupled
mentals of proper use will be discussed. A more with fiber-optic transmission technology by Karl
detailed overview of instruments used in laparo- Storz in the 1960s. Since then, the rod-lens system
scopic surgery can be found in the appendix of has revolutionized laparoscopy [5, 6]. Significant
this book. advances have been made that allow for a number
of laparoscope options, and therefore, not surpris- a target object, and the camera is focused to
ingly, laparoscope selection is largely surgeon the clearest image.
dependent. The ultimate goal when selecting a • Illumination adjustments allow for the inten-
laparoscope is to maintain adequate visualization sity of the light to be increased or decreased.
of the operative field. Laparoscopes can vary in a • Optical zoom allows for closer viewing of the
number of ways, as described below. operative field without loss of resolution of
the image.
• Size—The diameter (or size) of the laparo-
scope can vary from 0.88 mm to 12 mm. The Monitors come in a variety of sizes and reso-
larger the diameter of the laparoscope, the bet- lutions. Using a high-resolution monitor with a
ter the visualization. The most commonly uti- camera with similar capabilities optimizes the
lized laparoscopes are 5 mm and 10 mm. quality of the image.
• Angle—The angle of laparoscope can vary The light source can vary by type and voltage.
from 0 to 70°. A laparoscope that is 0° allows The current industry standard is a Xenon lamp
for a panoramic view, i.e., provides a view of with an output of 300 W. The laparoscope is con-
the field that is directly ahead. In contrast, an nected to the light source through a fiber-optic
angled laparoscope allows one to view a struc- cable. Any breakage in the fiber-optic cable
ture from different viewpoints without the results in decreased light transfer from the light
necessity to change between ports. The most source to the laparoscope, which results in
commonly utilized angles are 30° and 45°. An decreased light being transferred to the operative
important tip to remember when using an field. Always be mindful of the fiber-optic cable
angled laparoscope is to point the angle away once the illumination is turned on, regardless of
and not toward the area of interest [7]. whether or not it is connected to the laparoscope.
It generates a significant amount of heat that has
Significant advances in camera designs have been known to start fires or burn holes through
occurred as laparoscopy has become more popular. the sterile drapes and can lead to patient injury.
Perhaps the most notable advance in enhanced Other necessary equipment for laparoscopic
imaging in laparoscopy has been the introduction surgery includes:
of the charged-coupled device (CCD) chip camera
and digital video imaging (i.e., high- definition • Insufflator—The insufflator is necessary to
imaging). In the future, improvements in three- obtain pneumoperitoneum that allows for a
dimensional imaging will address depth perception, successful laparoscopic case to be carried out.
which is lost with two-dimensional imaging. There Several options are available for the type of
are a number of features and controls that one must gas used to insufflate, the most common being
be familiar when it comes to the laparoscopic cam- carbon dioxide. Carbon dioxide is preferen-
era. Controls present on the camera are manufac- tially used since it is nonflammable, colorless,
turer specific but, in general, include: and odorless. And, in general, it is safely
absorbed and excreted. Insufflator tubing con-
• White balance allows for the color that is pro- nects the insufflator to the instrument (i.e., tro-
duced by the camera to be adjusted to the car or Veress needle) that will facilitate the
color of the light source. It is important to delivery of the gas into the abdominal cavity.
white balance the camera against a white • Trocars or ports are used to pierce the abdomi-
object, such as a lap sponge, prior to use. nal wall and serve as a conduit that allows for
• Focus allows for a clear image to be viewed. the entry of laparoscopic instruments into the
Prior to inserting the camera into the abdomi- abdominal cavity. They can vary in size and be
nal cavity, the camera is held 5 cm away from either cutting or blunt. Trocars can have
additional features, such as a side port, which establish pneumoperitoneum in the 1940s [8, 11].
allows for pneumoperitoneum to be main- It is a spring-loaded needle that is 12–15 cm long
tained if the insufflator tubing is changed with an external diameter of 2 mm. It consists of
between ports [7]. a two-cannula system. The outer cannula has a
beveled needle that is sharp to cut through the
abdominal wall. The inner cannula is nested
I nstrumentation for Obtaining Access within the outer cannula and has a spring-loaded
to the Abdominal Cavity stylet with a dull tip. When the Veress needle is
passed through tissue, direct pressure on the tip
When initially planning the location for initial of the needle pushes the dull stylet into the outer
access for an abdominal laparoscopic procedure, cannula. Once the needle tip enters a space, such
first, survey the abdomen for scars from prior sur- as the peritoneal cavity, the dull inner stylet
gery or for any masses. Second, keep the planned springs forward and protects any underlying
operation and the operative field in mind. The tissue.
most common site for initial entry and trocar Optical trocars are a relatively new technique
placement is the umbilicus. The amount of soft that utilizes the conventional trocar and cannula
tissue between the skin and the fascia is less com- push-through design. These units are designed in
pared to other areas in the abdomen in this loca- such a way that the trocar is hollow and allows
tion. It is also possible to hide a scar in an existing for a 0° laparoscope to be inserted and locked
skin crease for improved cosmesis. Another com- along with the trocar. It can then be used to visu-
mon entry location is in the left upper quadrant in alize entry into the abdominal cavity as the trocar
a location known as Palmer’s point, which is pierces sequential abdominal wall layers. This
located 3 cm below the left subcostal border in system is generally used after the abdominal cav-
the midclavicular line [8]. Instruments com- ity has been insufflated [10, 12].
monly used to obtain access for laparoscopic sur-
gery will be briefly described next. For more
specific details, refer to Chap. 14—Fundamentals ips for “Driving” the Camera During
T
of Laparoscopic Surgery. Laparoscopic Surgery
First described by Dr. Harrith M. Hasson in the
1970s, the open technique for laparoscopic access All of the components of the imaging system are
is preferred by some as it is believed to minimize put together to allow the visualization of an
complications such as gas embolism, major vessel image. Once access to the abdominal cavity is
or visceral injury, or insufflation of the preperito- obtained, proper use of the imaging equipment to
neal space [9]. The cannula itself is usually fitted provide adequate visualization during the opera-
with a cone-shaped sleeve and an outer secondary tion is of paramount importance. Here are a few
sleeve that allows for stay sutures to be placed to pearls for proper handling of the camera and
secure the port. It is primed with a blunt obturator laparoscope and for effective “driving” of the
to prevent injury to underlying structures. The camera:
Hasson cannula is inserted into the abdomen with
the blunt obturator in place, and stay sutures • Practice holding the camera. In general, the
secure the cannula to the fascia on either side to non-dominant hand should cradle the camera
seal the opening in the abdominal wall and to pre- and laparoscope. The buttons of the camera
vent gas leak during the procedure [10]. should always point up.
The Veress is used to obtain access to the • The light cord is attached to the laparoscope,
abdominal cavity during laparoscopic surgery and in the neutral position, it points up. This is
with the closed technique. The Veress needle was especially important to remember when using
first discovered in the 1930s by Janos Veres, and an angled laparoscope, since the direction of
it was Raoul Palmer who introduced the use of the light cord corresponds to the direction of
the Veress needle in laparoscopic surgery to the viewing angle.
• When “driving” the camera, a good rule to bilities. The blue button has two features: cover-
keep in mind is the rule of opposites. To view ing the port will insufflate air, while pushing the
an image to the right, the camera is moved to button infuses water. Pushing the red button pro-
the left. Or to view an image that is up, the vides suction. A biopsy port allows for the pas-
camera is pointed down. Moreover, the cam- sage of biopsy forceps or other instruments
era should be moved toward the object of through the insertion shaft. Camera buttons allow
interest to provide a closer view. Movement of the operator to obtain pictures or videos.
the camera out (or into the trocar) will result in The insertion tube is a flexible cord that is
the ability to get a panoramic view of the field. manually manipulated by the operator by push-
• When using an angled laparoscope, move- ing, pulling, and torqueing. The deflectable tip at
ment of the light handle results in a change of the distal end of the cord has the capability of flex-
the angle. Therefore, when the light handle is ing side to side and up and down via controls on
in the neutral position, i.e., pointing up, the the handpiece. The tip also contains the port sites
viewing angle is down. When the light handle for multiple applications, including a water noz-
points up, the viewing angle points down. zle for irrigation, an air nozzle for insufflation, a
• The lens can fog once the laparoscope is suction channel, a light source, and objective lens.
inserted into the abdominal cavity. This occurs The umbilical cord is a flexible tube that con-
due to the temperature difference between the tains all of the channels (air/water, suction, and
outside environment and the intra-abdominal light source) that connect to the tower that houses
cavity. This can be avoided by warming the the video processor and displays screen. The
lens tip in warm water or with the use of anti- proximal end of this cord is directly inserted to
fog solutions [12]. the tower. A video processor cord connects the
umbilical cord to the image processor. A water
bottle and suction tubing are connected to the
Basics of Instrumentation umbilical cord to allow for irrigation and
and Equipment for Endoscopy aspiration.
Endoscopy in general surgery has many applica-

tions and can be used in abdominal or thoracic
The Endoscopy Tower
procedures. This section will provide a brief
overview of the common components of endo-
The endoscopy tower consists of an image pro-
scopes used for upper and lower endoscopy.
cessor and display screen, a light source and air
insufflator, water irrigation, and energy source.
The Endoscope Once all equipment is positioned and connected
appropriately, check that the insufflation, irriga-
The endoscope is comprised of three main parts: tion, and suction are working properly before
The handpiece is used to control the direction beginning the procedure [13].
the tip of the insertion tube is facing, which aids
in visualization as well as maneuvering the scope
as it traverses a lumen. A large and small wheel is R Instruments Used
O
used to either maneuver the tip up-down or left- in Laparoscopic Surgery
right, respectively. Turning of the wheel leads to
tip angulation in the opposite direction on the Laparoscopes (Fig. 2.19)
monitor. For example, turning the large wheel up
causes the endoscopic tip to be directed down- Laparoscopes come in many varieties, as dis-
ward and vice versa. The wheels can be locked in cussed in the Fundamentals of operating room
a desired position to aid in diagnostic or thera- setup and surgical instrumentation chapter.
peutic maneuvers, such as obtaining a biopsy. Illustrated here are 10 mm laparoscopes, both at
Buttons on the handpiece control different capa- various angles.
a c
b
d
Fig. 2.19 Top to bottom, (a and c) 0° laparoscope, (b and d) 30° laparoscope
Fig. 2.20 Top to

bottom, laparoscopic a
graspers; (a) bowel
grasper; (b) Clinch
grasper; (c) Maryland
dissector b
Laparoscopic Graspers (Figs. 2.20

a
and 2.21)
Most laparoscopic instruments have a 360° rotat-

ing knob to turn the tip of the instrument in order b
to maintain the wrist in the most ergonomically
neutral position. Electrocautery sources can be
plugged into the metal port on the handle, which
are usually controlled via a foot pedal. The atrau- c
matic bowel grasper is used to handle more deli-
cate tissue, such as when running the bowel. One
should use the majority of the jaw to grasp the
anti-mesenteric side to minimize damage. Using
just the tip of the grasper can cause more damage
secondary to the increased pressure exerted by the Fig. 2.21 Top to bottom, (a) Cinch grasper; (b) atrau-
matic bowel grasper; (c) Maryland dissector
smaller surface area. A hand-to- hand or hand-
over-hand technique can be utilized to accomplish
this task. Clinch graspers are usually toothed and that has a pointed tip can be utilized to dissect
ratcheted, with a locking mechanism. This could through more fine tissues and is commonly used
be used to grasp and retract thicker or heavier tis- when dissecting around the cystic duct and artery
sue, such as omentum. The Maryland dissector during a laparoscopic cholecystectomy.
uction Devices and Cautery

S Trocars and Obturator (Fig. 2.23)
(Fig. 2.22)
Once inserted through the abdominal wall, tro-
There are a variety of instruments that exist that cars (commonly referred to as ports) are left in
allow for the utilization of electrocautery during place to allow for the passage of laparoscopic
laparoscopic procedures. Illustrated here is the instruments. Once this first port is placed, either
spatula, in which the metal shaft is insulated so as through open or Veress technique, the laparo-
to protect the surrounding tissue. Suction cannu- scope can be introduced intra-abdominally to
lae come in variety of sizes. The tip doubles as a help visualize the placement of subsequent ports.
suction and irrigator when connected to the To place a port, a twisting motion along with con-
appropriate adaptor and tubing. This adaptor usu- stant, steady pressure is applied to the trocar
ally has two buttons: red for suction and blue for with the obturator insert. This allows the pointed
irrigation. The combination of suction and the obturator tip to dissect through the abdominal
blunt tip can also be utilized to dissect tissue. wall layers. The tip should be visualized with the
Fig. 2.22 Top to

bottom, (a) insulated a
spatula cautery with
suction cannula; (b)
insulated spatula cautery
with suction cannula b
separated in individual
components; (c)
laparoscopic suction
cannula in two different
sizes c
a c
Fig. 2.23 Top to bottom, laparoscopic trocars; (a) 12 mm trocar with obturator; (b) 5 mm trocar with obturator; (c)
5 mm trocar and obturator
Fig. 2.24 Carter-
Thomason laparoscopic
port closure device with
cone-shaped guides in
two different sizes
laparoscope as it enters into the abdominal cavity Marks JM, Dunkin B. Principles of flexible endoscopy for
so as to avoid injury to organs, such as the bowel, surgeons. New York: Springer; 2013.
Vilos GA, et al. Laparoscopic entry: a review of tech-
liver, or spleen. The obturator is removed once niques, technologies, and complications. J Obstet
the trocar is in place, and a laparoscopic instru- Gynaecol Can. 2007;29(5):433–65.
ment can then be introduced. Ideally, the trocar ACS. Statement on operating room attire. Bulletin of the
should be able to freely move in any direction so American College of Surgeons. 2016.
as to allow for an optimal operative field.
References
Port Closure Device (Fig. 2.24) 1. Kennedy L. Implementing AORN recommended prac-

tices for sterile technique. AORN J. 2013;98(1):14–26.
2. Schulmann K, et al. The patient with multiple intes-
Large port sites, particularly 10 mm or greater, usu- tinal polyps. Best Pract Res Clin Gastroenterol.
ally require that the fascia be closed after port 2007;21(3):409–26.
removal. Port closure devices are particularly use- 3. ACS. Statement on operating room attire. Bulletin of
ful when it would be difficult to close the fascial the American College of Surgeons. 2016 [cited 2017
April 17].
defect by hand, such as in an obese patient. The 4. Spruce L, Wood A. Clinical issues – December 2016.
Carter-Thomason system uses a cone-shaped obtu- AORN J. 2016;104(6):593–600.
rator that is placed into the port site. A free suture is 5. Morgenstern L. Harold Hopkins (1918–1995): Let
grasped by the tip of the suture passer and then there be light…. Surgical Innov. 2004;11(4):291–2.
6. Lau WY, Leow CK, Li AKC. History of endo-
introduced into one of the two holes in the cone. scopic and laparoscopic surgery. World J Surg.
The laparoscope is used to visualize the sharp 1997;21:444–53.
suture passer as it pierces one side of the fascial 7. Mishra RK, Mishra R. Textbook of practical laparo-
defect. Once the sharp tip is in the abdomen, the scopic surgery. New Delhi: Jaypee Brothers; 2013.
8. Palmer R. Safety in laparoscopy. J Reprod Med.
suture is released, and the suture passer is removed 1974;13(1):1–5.
and then placed into the opposite hole in the cone. 9. Hasson HM. A modified instrument and
Again, the sharp tip is visualized as it pierces the method for laparoscopy. Am J Obstet Gynecol.
opposite side of the defect and grabs the free suture 1971;110(6):886–7.
10. Vilos GA, et al. Laparoscopic entry: a review of tech-
to pull it back out so the free ends of the suture can niques, technologies, and complications. J Obstet
be tied down to close the fascial defect. Gynaecol Can. 2007;29(5):433–65.
11. Szabó I, László A. Veres needle: in memoriam of the
100th birthday anniversary of Dr János Veres, the
inventor. Am J Obstet Gynecol. 2004;191(1):352–3.
Suggested Readings 12. Scott-Conner CEH. The Sages manual: fundamen-
tals of laparoscopy, thoracoscopy and GI endoscopy.
Scott-Conner CEH. The Sages manual: fundamentals New York: Springer; 2006.
of laparoscopy, thoracoscopy and GI endoscopy. 13. Marks JM, Dunkin B. Principles of flexible endos-
New York: Springer; 2006. copy for surgeons. New York: Springer; 2013.
Fundamentals of Sutures, Needles,
Knot Tying, and Suturing 3
Technique
Jessica A. Latona, Sami Tannouri,
Francesco Palazzo, and Michael J. Pucci
3.1 Sutures and Needles wounds and tendency to cause suppuration.

With the advent of antisepsis, Joseph Lister
3.1.1 Historical Background/ applied this system to suture material. Believing
Introduction that germs embedded in the silk suture were
responsible for infection, he began sterilizing
3.1.1.1 Suture History the strands in carbolic acid. When he continued
Sutures were used by Egyptians and Syrians as finding evidence of inflammation at surgical
far back as 2000 BC. The materials used as sites, he began to believe that it was the rough
suture have evolved through the years and con- material that made up the fiber and he searched
tinue to evolve today. Some of the historical for a better material [2].
materials used for suture include linen, cotton, It was Lister who reintroduced catgut rein-
hemp, flax, tree bark, wire made of gold, silver, forced with chemical coating and antisepsis into
or steel, animal or human hair, vegetable fibers, practice and is responsible for the development
animal tendons and intestines [1]. Today, sutur- of sterile absorbable sutures. He studied and
ing material is so refined that there are even wrote about the properties and outcomes of his
suture and needles designed for a singular innovation extensively. Due to his work, catgut
purpose! suture gained popularity for its strength, flexibil-
Catgut has been used since the fifteenth cen- ity, and absorbability toward the end of the nine-
tury. It was named after the string chords of a teenth century [2].
musical instrument called a “kit” [1]. By the Catgut suture had numerous properties that
twentieth century, cotton, linen, and silk were were problematic: variability in strength, unpre-
used regularly. Historically, silk was established dictable rate of absorption, intense inflammatory
as the premier suture material because it was reaction, a nidus for infection, tendency to fray,
noted to heal quickly with few disadvantages, and weakening of knots. William Halstead spoke
the result of security even with a small knot. The out strongly against using catgut and by the early
main problem with silk was its persistence in twentieth century, silk had once again become
the suture material of choice even for vascular
J. A. Latona · S. Tannouri · F. Palazzo anastomoses [1].
M. J. Pucci (*) It wasn’t until 1960 that experimentation with
Department of Surgery, Sidney Kimmel Medical
synthetic materials began in order to develop a
College, Thomas Jefferson University,
Philadelphia, PA, USA suture with more desirable properties. The first
e-mail: michael.pucci@jefferson.edu synthetic suture material (Dexon) was introduced

40 J. A. Latona et al.
in 1970. Dexon was a polyglycolic acid polymer hand-held needle was further refined by Jacques-
similar to catgut, but with better performance Louis Reverdin in the nineteenth century and was
with respect to tissue reactivity and a more uni- popular for over a hundred years. In the 1920s, it
form response to tissue, strength, and rate of was discovered that a strong connection between
absorption. The second absorbable suture to be the suture and needle could minimize tissue trauma
introduced in 1974 was polyglactin (more com- [3]. This led to the development of “atraumatic”
monly known as Vicryl) [1]. needles that form the basis for the modern needle
used today. The variety of needle sizes, shapes,
3.1.1.2 Needle History points, and eyes grew tremendously and expanded
Much like suture material, needles are not specific the functionality of the needle in surgery.
to surgery and are one of man’s oldest tools. Eye Suture and needles are the most basic surgical
needles were first recorded in use in 50,000– equipment. Our aim is to provide information on
30,000 BC and there are remnants of needles made the physical properties of suture and needles so
of bone, antlers, and tusks dating from as far back that residents feel comfortable calling for the
as 20,000 BC. Needles manufactured from met- proper suture for a task.
als emerged around 4000 BC, but the application
of needles in surgery began in 600 BC. Initially,
suture needles were straight and generally hand- 3.1.2 General Concepts
held. Because anatomic structures had to be
deformed to allow for entry and exit of the needle, 3.1.2.1 Anatomy of/Dissecting a Suture
they were primarily used for skin closure [1]. Package
As one could imagine, needle puncture was not Looking at a suture package can be confusing to
uncommon. It was the simultaneous realization that the new-comer. Figure 3.1 diagrams representa-
transmission of infection could occur with needle tive suture packages from the major manufactur-
puncture and Lister’s introduction of aseptic tech- ers. The information contained on a suture
nique that prompted a need for “no-touch” needles package includes suture material, construction,
[1]. Ambroise Paré designed curved needles. His strand size, strand length, suture color, needle
Strand size
Strand length
Needle Code
Needle length
Needle Curvature
Type of Point
Actual Needle Size
Brand Name
Suture Material
Strand color
Suture Construction
Product Code
Expiration Date
Fig. 3.1 Representative suture packages from major manufacturers. The properties of each suture are outlined in the
color corresponding to each element listed on the left
3 Fundamentals of Sutures, Needles, Knot Tying, and Suturing Technique 41
point type, needle curve, needle length, and nee- Monofilament suture is made of a single strand
dle color. These properties will be described in compared to multifilament suture which is cre-
detail in the following sections. By the time you ated from multiple strands being twisted or
finish reading this chapter, you should be braided together. Monofilament construction
equipped with the knowledge to not only navi- generates less tissue reaction and harbors fewer
gate this information, but also to confidently bacteria. It can be more difficult to handle
select an appropriate suture and needle combina- because of its elasticity (more likely to return to
tion for use. original shape and length after being stretched)
and memory (the ability to return to its original
3.1.2.2 Suture shape after tying). Monofilament suture also pos-
Suture materials differ based on their construc- sesses less knot strength and loses tensile strength
tion, size, and ability to be “absorbed” or undergo at any point that it is grasped by an instrument.
degradation after a certain amount of time within Multifilament or braided suture is more diffi-
the body. When thinking about absorbability, ask cult to pass through tissue and more likely to cause
yourself “How long do I need the suture to keep tissue injury. For all types of suture, but especially
its strength?” Absorbable sutures are broken for multifilament suture, it is best practice when
down by one of two mechanisms and lose a “running” a suture to draw the strand through the
majority of their tensile strength within 60 days tissue as much as possible to limit en masse move-
[4, 5]. The two mechanisms by which suture ment through multiple entry and exit points.
material is absorbed are proteolysis and hydroly- Braided suture is liked for its ease of handling and
sis. Natural materials like chromic catgut are tying. Suture construction is single handedly the
degraded by proteolytic enzymes and this pro- most important property to determine the number
cess occurs quickly. Synthetic materials like of knots that should be created to secure the suture
polyglycolic acid, polyglactin, polydioxanone, (see Tables 3.1 and 3.2) and the length of suture
and poliglecaprone (just to name a few) are bro- that should be left attached to the knot when cut-
ken down by hydrolysis, which occurs ting suture. In general, a 4–5 mm tail should be left
more slowly. Absorbable suture is useful for tis- for monofilament suture and 2–3 mm should be
sue that requires wound support from a few days left for silk or braided synthetic suture.
(skin, subcutaneous tissue, muscle) to weeks or A third grouping of suture material is natural
months (fascia). Table 3.1 contains details regard- versus synthetic. It answers the question: "How
ing the tensile strength and time to absorption for much tissue reaction is this material going to
the most commonly used/available absorbable cause?" Regardless of its composition, all suture
suture materials [5]. material is a foreign body and may elicit an
Non-absorbable materials are not biodegrad- inflammatory reaction. However, synthetic mate-
able. They remain where they are placed and ulti- rials are less reactive compared to natural fibers,
mately are walled off by fibroblasts. They should which tend to produce an intense inflammatory
be used when suturing collagenous tissues that are reaction. The amount of inflammation generated
strong and heal slowly (tendon) and when long- by a suture can either promote or hinder the heal-
term stability is required (prosthetic grafts). ing process.
Table 3.2 contains details regarding the properties Suture size is another important physical
of the most commonly used/available non- property. Sizing is standardized according to
absorbable suture materials [5]. The disadvantage U.S. Pharmacopeia (U.S.P.) regulations and
of non-absorbable suture is that it can form chronic based on the diameter necessary to generate a
draining sinuses and suture granulomas. For this certain tensile strength. Table 3.3 details the
reason, avoid using it above the fascial layer. U.S.P. suture size and the corresponding
The next common subdivision of suture mate- diameters in millimeters. It varies somewhat
rials is construction. Construction refers to the with material absorbability and whether it is
number of strands that each suture is made from. natural or synthetic. The conventional nomen-
42
Table 3.1 Physical properties of absorbable suture and common uses

Absorption Natural or
Name Trade names Tensile strength time Common uses Construction Knots Synthetic
Chromic catgut Ethicon and Lost within 10–15 days 90 days Splenorrhaphy, hepatorrhaphy, Monofilament 4–6 Natural
Covidien = suture ligature of vessels, mucosal
Chromic gut layer of GI anastomosis
Polyglactin Ethicon = Vicryl 75% at 14 days, 25% at 28 56–70 Approximate soft tissue, GI Braided 4 Synthetic
days days anastomosis (mucosal layer)
Lactomer Covidien = Soft tissue approximation, ligation Braided 5–6 Synthetic
Polysorb
Polygytone Covidien = 60% at 5 days, 20 –30% at 56 days Skin closure Monofilament 5–6 Synthetic
Caprosyn 10 days
Poliglecaprone Ethicon = Monocryl 50–60% at 7 days, 30–40% 91–119 Skin closure Monofilament 4–5 Synthetic
at 14 days, complete by 21 days
days
Glycomer 631 Covidien = Biosyn 75% at 2 weeks, 40% at 90–110 Soft tissue approximation and/or Monofilament 5–6 Synthetic
3 weeks days ligation
Polyglycolic acid Syneture = Dexon 5% at 28 days 90–120 Soft tissue approximation and/or Braided 4 Synthetic
days ligation
Polydioxanone Ethicon = PDS 70% at 14 days, 58% at 28 183–238 Soft tissue approximation, fascial Monofilament 6–10 Synthetic
days, 25% at 6 weeks days closure
Glycolide Covidien = Maxon 75% at 14 days, 65% at 180–210 Soft tissue approximation and/or Monofilament 6–10 Synthetic
Polytrimethylene 3 weeks, 50% at 4 weeks, days ligation, pediatric CV tissue,
carbnoate 25% at 6 weeks peripheral vascular surgery
J. A. Latona et al.
Table 3.2 Physical properties of non-absorbable suture and common uses
Natural or
Name Trade names Tensile strength Common uses Construction Knots Synthetic
Silk Ethicon = Silk Secure surgical drains, ligation of large Braided 3 Natural
Covidien = Sofsilk blood vessels, outer layer in GI anastomosis
Stainless steel Ethicon = surgical Closure of median sternotomy, abdominal Monofilament 3 Natural
stainless steel wound closure, hernia repair
Polyester Ethicon = Ethibond Cardiovascular surgery, for vessel Braided 4–5 Synthetic
Covidien= Surgidac, anastomosis, and placement of prosthetic
TiCron materials
Nylon Ethicon = Ethilon 89% at 1 year, 72% at Interrupted skin closure, secure surgical Monofilament 6–7 Synthetic
Covidien = 2 years, 66% at 11 years drains, repair of lacerated nerves or blood
Monosof, Dermalon vessels
Nylon Ethicon= Nurolon 89% at 1 year, 72% at Soft tissue approximating and/or ligation Braided 4–5 Synthetic
Covidien = Surgilon 2 years, 66% at 11 years
Polypropylene Ethicon = Prolene 89% at 1 year, 72% at Vascular anastomosis Monofilament 6–7 Synthetic
3 Fundamentals of Sutures, Needles, Knot Tying, and Suturing Technique
Covidien = Surgipro 2 years, 66% at 11 years

Expanded Gore-Tex Creation of cardiac or vascular graft Monofilament 5–8 Synthetic
polytetra- anastomosis, securing Gore-Tex patch
fluoroethylene
Polybutester Covidien = Novafil, Lacerations from blunt trauma Monofilament 4–7 Synthetic
Vascufil
43
Table 3.3 U.S.P. suture sizes 3.1.2.3 Needles

Suture U.S.P. size Diameter (mm) Needles are necessary for carrying suture mate-
8-0 0.040–0.049 rial through tissue. The goal is to achieve this
7-0 0.050–0.069 with as little trauma to the tissue as possible.
6-0 0.070–0.099 Needles must be sharp to avoid resistance within
5-0 0.100–0.149
the tissue, rigid enough to resist bending, and
4-0 0.150–0.199
ductile to allow for bending before breakage. To
3-0 0.200–0.249
2-0 0.300–0.339
expand on these points, grasping the tip of a nee-
1-0 or 0 0.350–0.399 dle with forceps or a needle holder should be
1 0.400–0.499 avoided as this dulls the point and increases the
resistance on your next pass through the tissue. A
needle that is too weak will bend easily resulting
clature is number—zero and pronounced in decreased control of the needle once it is
“number, Oh.” Size ranges from 1 to 12-0 inserted into tissue and possibly damage the sur-
where more zeroes indicate a smaller size. rounding tissue. If a needle is bending, it means
The smaller the suture size, the less tensile too much force is being applied or that the size of
strength it has. Tensile strength refers to the the needle driver is too large relative to the
maximal stress that a strand can withstand needle.
before breaking. While breaking suture is The basic anatomy of all surgical needles
undesirable, it is better to break the suture (depicted in Fig. 3.2) is the same; they each have
when it is in your direct focus so that you can a point, a body, and a swage (the end which is
replace it rather than have it break later and attached to suture material). The types of needle
having it go unnoticed. points are tapered, cutting, reverse cutting, taper-
The loss of tensile strength over time should cut, and blunt. Tapered needles (Fig. 3.3a) are
not be confused with the rate of absorption. Loss
of tensile strength occurs upon implantation of
suture, with tying (knotted sutures have two- Chord Length
thirds the strength of unknotted sutures), and (Bite Width)
with exposure to tissue environment (4–13% Point Swage
reduction after being soaked in sodium chloride Radius
solution for 24 hours). Tables 3.1 and 3.2 list loss
of tensile strength for commonly used suture
[6–11].
Arc Length
The final elements found on the suture pack-
age that describe the suture material are length Body
and color. Length is important when you are
th
working in a deep space because you want the eng h)
h o rd L i dt
strands to be long enough to be manipulated C eW
(Bit Chord Diameter
outside the cavity or when running along the (Bite Depth)
length of an incision because you don’t want to
run out of suture before you reach the end. A
good rule to guide the length needed for a "run- Fig. 3.2 Anatomy of a surgical needle. The three main
ning" closure is to have a suture that is 4 times parts of a surgical needle are the swage, body, and point.
the length of the incision that you are clos- The swage is attached to the suture and the body is the
portion grasped by the needle driver. The chord length is
ing. Sutures come in various colors, but other the distance between the swage and the point and deter-
than knowing you should not use dyed suture at mines the bite width. The chord diameter determines the
the skin level, it is not of much consequence. bite depths and varies with the curvature of the needle
Fig. 3.3 Types of

needle points. Each
needle point is designed Tapered
for a specific function. a
Namely, tapered needles
(a) are appropriate for
suturing bowel, blood
vessels, and fascia,
whereas cutting needles
(b–d) are suited for skin,
and blunt needles (e) are b Conventional
used on highly cutting
vascularized organs
c Reverse
cutting
Tapercut
d
e Blunt
cone shaped and suitable for sewing soft tissues weakest part of the needle and holding it here
(fat, muscle, blood vessels, gastrointestinal vis- often results in distortion of the needle. It also
cera, and fascia). Cutting needles (Fig. 3.3b) have causes more tissue trauma because the swage is
a triangular body with a sharpened cutting edge wider than the suture material itself. The other
on the inside curve. A reverse cutting needle type of needle end is an eye where the suture
(Fig. 3.3c) has a sharp edge on the outside of the must be manually secured to the needle. Unlike a
needle curve. Generally, cutting needles are suit- swaged needle, an eyed needle causes minimal
able for inserting sutures in the skin. They create trauma to the tissue. Swaged sutures can be per-
holes in the tissue that are larger in diameter than manent or controlled released. Compared to a
the suture itself which precludes their use in tis- permanent suture, which must be cut from the
sue where leakage can occur. Reverse cutting needle, controlled released sutures can be
needles are stronger than a conventional cutting detached with a quick, straight tug on the needle
needle and are preferentially used when minimal while holding the suture strand taut. In this way,
tissue trauma is desired. Blunt needles (Fig. 3.3e) the needle “pops-off” the strand. This feature
are dull and are reserved for suturing highly vas- allows for efficient interrupted suturing.
cularized solid organs (i.e. liver). The needle body is the portion designed for
Most modern surgical needles are affixed to grasping the needle with a needle holder. Several
suture via a swage. The swage is the thickest but important properties of the needle body are
gauge, curvature, and chord length. The size of because a more curved needle requires less rota-
the needle is a function of gauge and chord tion to exit tissue [6–11].
length. The gauge is the diameter or thickness of The specific needle types that are available
the needle and varies from thousandths of an inch through the major manufacturers are pictured in
to hundredths of an inch. The chord length Fig. 3.4 to illustrate various curves and relative
(Fig. 3.2) is the arc distance between swage and sizes [12]. To gain familiarity with the character-
point and determines the bite width. Needle cur- istics of various needle sizes, arrange two col-
vature is measured by what proportion of a circle umns of dots at varying widths on a cloth. The
is completed and ranges from 0 (straight) to dot in the right column serves as the entry point
5/8 (Table 3.4). A more curved needle requires and the dot in the left column serves as the exit
less lateral movement for advancement. This fea- point. The goal is to improve the accuracy with
ture can be taken advantage of when suturing two which the needle exits as one improves their
edges as the exposure of a wound decreases “needle tip consciousness.”
General Surgery Cuticular
Taper Point Reverse Cutting

Ethicon Covidien B.Braun Ethicon Covidien B.Braun
1/2 Circle 3/8 Circle
22 mm
16 mm
CT-3 GS-23 HR22S M-2 DS16
26 mm 19mm
CT-2 GS-22 HR26S FS-2 C-13 DS19
37 mm
24 mm
CT-1 GS-21 HR37S FS-1 C-14 DS24
40 mm 24 mm
CT GS-24 HR40S FS C-15 DS24
48 mm 30 mm
CTX GS-251 HR48 FSL C-16 DS30
65 mm 39 mm
TP-1 GS-26 HR65 FSLX C-17 DS39
76 mm 45 mm
XLH GS-27 HR76 LS-1 DS45
LR GS-18 DS76 76 mm
5/8 Circle 1/2 Circle

26 mm
15 mm
UR-6 GU-46 FR26 M-1 C-21 HS15
36 mm
UR-5 GU-45 18 mm
FR36 J-1 C-22 HS18
23 mm
UR-4 GU-44 FR40 X-1 C-23 HS23
40 mm
1/2 Circle Heavy Body Straight Cutting

13 mm
51 mm
UCL HR13SS TS SC-1 GS51
22 mm
M0-7 HGS-23 HR22SS KS SC-2 GS60 60 mm
26 mm
M0-6 HGS-22 HR26SS SKS GS65V 65 mm
30 mm
M0-5 HGS-20 HR30SS
37 mm
M0-4 HGS-21 HR37SS Endoscopic
M0-2 HGS-24 40 mm
HR40SS
Taper Point
Ethicon Covidien B.Braun
Straight
Blunt Point ST-4 GR19
19 mm
35 mm
CTB-1 BGS-21 HRN35 40 mm
ST-1 GR40
50 mm
CTX-B BGS-25 HRN50
65 mm
BP-1 HRN65
85 mm
BP BGS-28 HRN85 1/2 Circle
22 mm
SH-1 CV-25 HR22
26 mm
SH V-20 HR26
CT-2 GS-22 HR26S 26 mm
Fig. 3.4 Needle comparison chart. The specific needle for comparison. Modified from https://www.aesculapusa.
types that are available through the major manufacturers com/assets/base/doc/DOC571RevC-
are grouped according to point type and arranged by size AesculapNeedleComparisonChart-3-foldBrochure.pdf
Table 3.4 Various needle curves and their uses small, the tension of the anastomosis may cause
Curvature Common uses your sutures to tear through the tissue. Your nee-
Straight Skin, laparoscopy dle selection matters here as well. Cutting and
Half-curved/ski Laparoscopy reverse cutting needles leave triangular cross sec-
¼ circle Eye tional holes in tissue, but your suture has a circu-
3/8 circle Skin closure, small blood vessels
lar cross section. This additional space also may
½ circle Closure below the skin
lead to increased needle hole bleeding and inad-
5/8 circle Trocar site fascia, bladder
vertently can weaken the tissue and your sutures
may saw through the vessel wall. Tapered needles
3.1.3 Technical/Practical have a circular cross section which better approx-
Considerations/Safety imate the cross section of your suture, and should
Precautions be used in these situations.
Scenario C: You have been rotating on a
There is no ultimate suture that will work under colorectal service and just finished an open col-
any circumstance, but guiding principles will ectomy where you closed fascia with heavy
allow you to choose the best option. Suture selec- suture such a PDS™ or Maxon™. Your very next
tion should be based on knowledge of the physi- case is a hemorrhoidectomy. After resecting the
cal and biologic characteristics of the material hemorrhoid, you notice bleeding at the apex of
(which you are now an expert on), the rate of tis- your incision and want to suture ligate this point.
sue healing, and patient factors (infection, frailty, You ask for chromic suture. This is an example
obesity, etc.). Ultimately, suture selection where you cannot just use the same suture you
depends on surgeon training and preference, as used in your last case to close fascia. Different
well as institutional factors. tissues vary greatly in healing time. Fascia takes
Let us talk about specific situations in which weeks to reach its full strength, and thus requires
suture and needle selection comes into play. a very slow absorbing or even permanent suture
Scenario A: You are the surgical intern and are to close. Mucosa, whether it is oral, rectal, or oth-
paged to the trauma bay to see a patient who erwise, is a very rapidly healing tissue and makes
tripped and fell through a glass door. He/she has a highly absorbable suture desirable for
multiple lacerations on his/her extremities. These approximation.
wounds are contaminated, as are most traumatic Scenario D: You perform a melanoma exci-
wounds. In addition to thoroughly irrigating the sion right along the edge of one of your patient’s
lacerations, your goal is to reapproximate the tis- shoulder blades. The skin is thick here, and of
sues. Inert (monofilament) suture should be used course you realize that every time your patient
when tissue is contaminated as they cause less moves their arm that the wound closure will be
tissue inflammation and reaction. tested. Here tensile strength of the suture you
Scenario B: You are about to begin the proxi- choose will matter. Bigger (thicker) suture has
mal anastomosis of a femoral to popliteal bypass higher tensile strength than finer suture, as well
when the surgical attending is paged to an emer- as braided suture typically has a higher tensile
gency. On their way out of the operating room the strength that of a similar monofilament. For ten-
surgeon tells you to start the anastomosis as the don repairs, which are highly mobile and tough
vascular clamps have already been applied and tissues, large braided sutures are often used due
the leg is now ischemic. In this situation, the size to their extremely high tensile strength.
of the suture you choose has great implications. Scenario E: You have just finished a pannicu-
If the suture size is too large, it will traumatize lectomy and have two drains underneath the
the vessels and you will have difficulty control- abdominal flap. You are asked by the circulating
ling needle hole bleeding. If the suture size is too nurse which suture you would prefer to secure
the drains to the skin. Suture has memory mean- will have difficulty maneuvering your needle in
ing that different suture materials have variable and out of the lumen that you are trying to sew.
ability to resist changes in configuration. You can Scenario G: You decided to use an open Hasson
think of this as how stubborn the suture is to technique to enter the abdomen on a laparoscopic
remaining in the position where you place it. Silk case. The case is done and you now turn your
and other braided sutures typically have less attention to closure of the fascia at this port. Your
memory and are easily manipulated. Some syn- patient’s anterior fascia is 5 cm below the surface
thetic monofilaments and even nylons are stiffer, of a 1 cm long incision. This scenario requires
and have greater memory. You must be aware that taking advantage of highly curved needles (5/8th
these sutures do not as easily give up their shape. Curvature, or 5/8th of the way around a circle).
It is easier to tie around a drain with a suture with First your chord length must be small enough
less memory. You choose your suture and begin such that the needle will fit inside this incision.
tying knots, knowing that these drains may Needles that are not as highly curved (3/8th or ½
remain in place for weeks and your knots must curvature) can be used when sewing tissues that
not slip. Braided suture, due to the higher contact are more accessible and shallower in the operative
surface area on itself allows for fewer knots to field as they require a larger arc of motion to
hold securely than monofilaments. You can tie smoothly pass them through the tissue. A 5/8th
down the drain using only three or four throws of curvature needle can almost be completely rotated
a silk knot, but you may need to place six or more through tissue from a fixed fulcrum, allowing you
knots in a nylon suture as this knot has a higher to get an adequate bite of tissue while deep in a
tendency to unravel since it is a monofilament hole, all by rotating your wrist.
suture. Scenario H: It is Sunday morning and a patient
Scenario F: It’s the middle of the night and who was walking to their grandmother’s house
you have just performed an emergent perforated sustained a gunshot wound to their abdomen. You
colectomy on a morbidly obese patient who had take the patient to the operating room and notice
five prior laparotomies. The attending hurriedly a large laceration in the liver as well as a colot-
leaves the room as soon as you finish irrigating omy. You begin frantically asking for suture to
the abdomen, leaving you to close the incision. repair these injuries. The liver and the colon have
You confidently, but inattentively take the needle quite different consistencies and the purpose of
driver from the scrub tech and turn your attention your suturing on each organ will be different.
to the wound edge. You are met with a thick wall Suturing a highly vascularized, soft, and friable
of tissue resembling ground beef and lacking dis- organ requires a special needle, one with a blunt
cernable layers. In this scenario, it may be appro- tip. This will allow the needle to pass through the
priate to perform a “mass closure” of the tissue without causing further lacerations, and the
abdominal wall, taking a bite that goes through tip pushes small blood vessels out of the path of
all layers of the abdominal wall, regardless of the needle, without puncturing them or causing
your ability to distinctly identify them. This can- bleeding. Needles that are used to sew tendon,
not be accomplished with a small needle. The skin, or other soft tissues often have sharp or
chord length (distance of the straight line between “cutting” tips to allow the needle to enter and
the tip and the tail of the needle) will need to pass through the tissue smoothly. Blunt needles
slightly over-approximate the thickness of all the can be used on organs such as the lung, liver, or
layers of tissue you are trying to close. If the spleen.
chord length in inadequate, you will not be able Now you turn your attention to the colotomy.
to push the needle through the thick mass of tis- You believe the hole is small enough to repair pri-
sue, and instead lose the needle within the tissue. marily. You are given a needle and look carefully
Likewise, when you are sewing through thinner at the tip when you notice that the cross section of
tissue, such as bowel or blood vessels, make sure the tip is a triangle with sharp points. This is
that the chord length is not too long or else you called a cutting needle and this leaves a triangular
hole in the tissue that you are sewing. The ining closure in colorectal procedures only [13,
17]. In a meta-analysis, the overall risk of surgi-
cross-sectional shape of suture is circular, so you
can imagine that a circular suture sitting inside acal site infection in the antibiotic-coated group
triangular hole will not be as watertight as a cir-was 10.4% compared to 13.0% in the control
cular suture passing through a circular hole. You group [18]. Two meta-analyses have been incon-
clusive, in large part because of variability in
will need to use a “taper” point needle in this sce-
nario, where the body of the needle gradually patient demographics, the type of suture material
tapers to a circular point, without any sharp used, and closing technique [19, 20]. Future stud-
edges. Tapered needles are used on blood vessels, ies are necessary to determine the utility and
bowel, bladder, or in any situation where a water- define a clinical application for this innovation.
tight closure is important. Taper points have less Barbed suture is another innovation in suture
of a tendency for suture to tear through the tissuematerial that is gaining popularity. Its design has
because the hole in the tissue is round, as opposedlinear nicks along its length which allows the
to triangular where the apices act as a lead point suture only to be pulled in one direction. As a
for suture to tear through. concept, barbed suture can be traced back to 1956
when Dr. John H. Alcamo patented his idea.
Clinically, barbed suture was first used in 1967
3.1.4 Current Controversies/Future by Dr. A.R. McKenzie for tendon repair in human
Directions cadavers and in vivo in dogs. Physical character-
istics of the early suture design limited the appli-
Antibiotic-coated material was recently intro- cation of barbed suture. From 1967 to 1999, a
duced as a novel method for fascial closure with variety of techniques were presented. Dr. Harry
a specific application to decrease surgical site J. Buncke (a microsurgeon) is credited for patent-
infections (SSIs). Triclosan is a bacteriostatic ing the modern design of one-way sutures with
agent that interferes with microbial lipid synthe- exterior barbs and either a uni- or bi-directional
sis. Triclosan-impregnated suture types ranging needle. This design was ultimately acquired by
from absorbable monofilament to braided are Quill Medical in 2002, commercialized as
commercially available. Data from animal and in Quill™ Knotless Tissue-Closure Device and
vivo studies support that when triclosan-coated FDA approved in 2004 [21].
suture is used to close wounds there is inhibition Currently, there are three types of barbed
of bacterial colonization. A number of non- suture commercially available [18, 21]:
randomized studies and randomized controlled
trials have been performed to assess the effective-
1. Quill SRS™ (Quill Self-Retaining System;
ness of decreasing SSIs when midline fascial clo- Angiotech Pharmaceuticals, Vancouver,
sure is performed with triclosan-coated suture British Columbia, Canada)—this is a bidirec-
[13–17]. One single-center randomized trial tional barbed suture
examining outcomes after closure of general and 2. V-Loc™ Absorbable Wound Closure device
abdominal vascular procedures showed a signifi- (Covidien, Mansfield, MA, USA)—this is a
cant reduction in SSIs from 11.3% to 6.4% with unidirectional barbed suture that has only one
the introduction of PDS Plus (antibiotic-coated needle and a loop at the opposite end for
suture) compared to non-coated PDS suture [14]. anchoring the suture in tissue
The PROUD trial studied midline closure of all 3. Stratafix™ (STRATAFIX Knotless Tissue
midline laparotomies in well matched control Control Devices, Ethicon Inc., Somerville,
and study groups and found that the rate of SSIs NJ, USA)—this suture has a unique spiral dis-
did not differ between the PDS Plus group tribution of the barbs and anchors
(14.8%) and the non-coated PDS II group
(16.1%) [16]. Similarly, no differences were Barbed suture is used frequently by plastic
found in surgical site infection rates when exam- surgeons and is gaining attractiveness in robotic
surgery (see Fundamentals of Knot Tying, wrote about tying 16 knots and nooses used to
Ligatures, and Suturing). apply traction when reducing dislocations and
setting broken bones or to hold patients in posi-
Take-Home Points tion when performing surgery. Interestingly, the
“Hercules” knot which he described but did not
• Precise knowledge of suture materials and provide any particular use resembles the current
needles is required to be a competent surgeon’s knot which is extensively used by all
surgeon. sorts of surgical disciplines today [1, 2].
• The process of suture selection may also
depend on surgeon training and preference as 3.2.1.2 Ligatures
well as the type of suture material that is avail- Ligating refers to tying a ductal structure with a
able at a particular location. suture thread. Ambroise Paré is credited for intro-
• No one suture will have all desirable charac- ducing the concept of ligatures as a method to
teristics, but selection can be guided by patient control hemorrhage in modern surgery. He
factors, the type of tissue, and suture designed an instrument called the bec de corbin
properties. (which can be likened to a hemostat) to control
• Needle selection depends on the type, loca- the bleeding while the vessel was handled.
tion, and accessibility of the tissue to be Although Paré’s suggested technique was not ini-
sutured, as well as the size of the suture. tially readily accepted, this practice became a
• Select your needle such that you minimize turning point in the evolution of surgery [3].
trauma to the tissue you are sewing.
Remember: the tissue you are sewing should 3.2.1.3 Suturing
not realize what is happening to it. Like knot tying, the technique of sewing is thou-
sands of years old and evolved from a civilian
skill that was necessary for survival. In the Stone
3.2 Knot Tying, Ligatures, Age, needles made from bone, antler, horn, or
and Suturing ivory were used to punch holes in animal hides
and then thread was drawn through the holes. As
3.2.1 Historical Background/ a method for closing cutaneous wounds, an
Introduction Indian physician Sushruta wrote in the first
detailed description of surgical suturing in 500
3.2.1.1 Knots and Knot Tying B.C. Ancient Egyptians also wrote about the use
The practice of using knots to secure ropes or of medical sutures to join separated wound edges,
cables is as old as human history. There are many incisions, and mummies [1, 2].
types of knots that have been employed as part of Suturing remains the fundamental technique
daily life and were necessary for survival in for closing spaces, reducing infection, speeding
ancient times. Before knots were adopted for use healing, and minimizing scarring. Modern sutur-
in surgery, intricate knots were developed and ing is no longer limited to simple techniques for
utilized by other trades such as sailors and tackle cutaneous closure. Methods have been developed
makers. Proprietary knots are not unique to sur- for application in every type of tissue and all
gery and some are still in use in surgical special- organ systems. Perhaps the most diverse methods
ties today. For example, the miller’s knot which are those that have been described for use in the
is used to secure the opening of a sac (usually gastrointestinal tract.
containing grains) has been adopted for use in Knot tying and suturing form the foundation
ligating vascular pedicles particularly in veteri- for more advanced surgical techniques. Mastery
nary medicine. of these basic skills is imperative. Unlike many
The earliest accounts of surgical knots are other surgical skills which are difficult or require
from the first century. A Greek physician Herakles sophisticated simulation, these techniques can be
easily practiced with little equipment required more critical is the direction in which each strand
other than your own two hands. Our aim in this is pulled when tightening the knot as this deter-
section is to provide explanations on the proper mines whether the knot “lies flat” and the direc-
application of various knots and types of stitches tion of the second-hitch which determines
with a focus on describing the subtleties of sutur- whether the knot will “be square.” This will be
ing and knot tying that are often not found in text- discussed in more detail in the next section
books and typically transferred verbally from “Types of knots.”
mentor to mentee. Knots can be tied two-handed or one-handed.
The two-handed tie is the easiest and most reliable
method for tying even the most stubborn suture
3.2.2 General Concepts materials like surgical steel. In a two-handed tie,
both hands are actively involved in forming the
3.2.2.1 Knot Tying crossing of strands and tightening the knot. For
this reason, it provides a better sense of the tension
Knot Security on both suture ends and makes for tying a much
Knots serve to secure two ends of suture as a liga- safer knot. If you want to be a surgeon, master this
ture or to anchor suture in tissue. Knot strength is technique. The one- handed tying technique is
defined as the force necessary to cause slippage. advantageous because it is more efficient; it can be
Knot slippage can have postoperative conse- performed with the left hand while still holding an
quences from thicker scar formation to more seri- instrument in the right hand. The main challenge is
ous complications including hemorrhage or in creating square knots. When in doubt about
leaks. Knot strength depends on the area of con- which to use, the two-handed tie should be used by
tact, suture construction (braided versus mono- default and most certainly should be used when
filament), knot tightness, and length of suture tying important structures.
projecting from the knot. Certain principles apply
to all types of suture materials: Tips for Practicing Knot Tying
Whether employing a one- or two-handed tech-
• Knots should be tied quickly, but speed should nique, the suture ends should always be under
not substitute for accuracy (i.e., creating a complete control. This requires practice to gain
square knot). familiarity with the optimal suture length for
• Friction between the strands should be each strand based on your hand size. In general,
avoided. the working strand (the one being passed through
• Choose the simplest knot for the suture mate- the loop) should be at a length that prevents
rial and make the knots as small as possible. redundancy of the strands within the loop, avoids
Extra knots do not add strength, but rather interference with other instruments in the envi-
weaken the suture material and just add bulk. ronment, and reduces the incidence of the knot
• The completed knot should be firm so that it being prematurely pulled up and thus loosening.
holds securely, but not too tight that the suture A resident even at the most junior level should
breaks, cuts through tissue, or decreases feel comfortable crossing the strands and passing
circulation. suture through the loop with either hand. This is
a mandatory skill because you will be asked to tie
Square Knot by One-Hand and Two-Hand when you are standing on different sides of the
Techniques operating room table in relation to the structure to
The basic maneuver for knot tying involves be tied and handed ties that are already crossed in
crossing the strands to create a loop and passing a particular arrangement. A good target for prac-
one end through the loop to emerge on the oppo- tice is being able to tie 50 knots per minute both
site side. It does not matter if initial strand cross- two- and one-handed with each hand taking the
ing is right over left or left over right. What is dominant role.
Instrument Tie a
Knots can also be created with the aid of an Simple
knot
instrument. An instrument tie is most commonly
used when suture is too short to be hand tied,
tying in a deep cavity, or to secure cutaneous
stitches with greater efficiency. To perform an b
instrument tie, the suture should be pulled
through the tissue so that there are two ends (one Granny
short about 2–3 mm and a longer end attached to knot
needle). Holding the needle driver over the center
of the wound, the long end of the suture is
wrapped clockwise around the needle holder tip
twice. The short end of the suture can then be
grasped with the needle driver and pulled through c
the looped suture. The knot is tightened by cross-
ing hands. For subsequent knots, the needle Square or
driver should again maintain a central position Reef knot
relative to the wound. The suture should be
wrapped counterclockwise once around the nee-
dle driver and tightened by grasping the short
end, pulling it through the loop, and pulling the
ends in opposite directions from the first knot to d
create a square knot. This can be repeated until an
adequate number of knots are placed and the Surgeon’s
suture should be cut no longer than distance knot
between interrupted stitches to prevent the suture

tails from being caught in the subsequent knot.
Fig. 3.5 Types of surgical knots. (a) A simple knot is one

3.2.2.2 Types of Knots
half-hitch. (b) A slip or Granny knot is made with two
There are several different types of surgical knots: half-hitches of the same throw. This allows for slippage of
simple knot, slip knot (also known as a Granny the strands and adjustment of tension on the knot. (c) A
knot), square knot, and surgeon’s knot (Fig. 3.5). square or reef knot is made with two-half hitches of oppo-
site throws. It does not allow for slippage and locks the
A simple knot is also referred to as a half-hitch. It
strands in place at the knot. (d) To make a Surgeon’s knot,
involves only one revolution of one strand around one end of the suture makes two passes through the loop
the other. All surgical knots require two half- on the first hitch prior to locking the first throw with an
hitches. The orientation of the second half-hitch opposite half-hitch
dictates the type of knot. More specifically, if two
identical half-hitches are tied in a row as occurs The most common surgical knot is the square
when the suture strands are inadvertently pulled or reef knot (Fig. 3.5c). Compared to a granny
in the same direction, a slip or Granny knot is cre- knot, the second half-hitch is made by crossing
ated. Looking down on the knot, the ends are at the strands in the direction opposite to that of the
right angles to the standing part (Fig. 3.5b) which first one. In this knot, the first hitch sets the ten-
allows for slippage of the strands. This feature sion on the tissue and the second secures the
which allows for tightening of the knot has advan- knot. As alluded to previously, the square knot is
tages and disadvantages. It can be used initially to the most secure and it is best to develop a habit of
generate the desired tightness of a knot, but should throwing square knots whenever possible. To
not be the only type of knot used because it has a facilitate creation of a square knot when using the
tendency to slip and can open up spontaneously. two-handed technique, alternate between using
your thumb and index finger on the same hand to are chosen and the type of tissue that is being
create the loop. For the one-handed technique, brought together. In this section, we will describe
alternate between a forehand (leading with the these techniques and concentrate on specific
index-finger) and a backhand (leading with a points that are troublesome.
middle-finger) throw.
The proper placement of a knot requires the Basics of Needle Holding
left hand grasping one end of the suture, the The two main components of needle holder are
structure being ligated, and the right hand grasp- the jaw and the handle. The jaws of the needle
ing the opposite end all positioned in a straight holder should match the needle size. The needle
line to avoid traction on the tissue when the knot should be stable within the jaws when the needle
is being tightened. The hands controlling the driver is tightened with just one catch of the
ends of suture must cross to guarantee that a knot ratchet. The handle of the needle driver must be
lies flat. It is preferable to cross in the sagittal appropriate for the depth needed for the suture
plane to prevent obscuring view of the knot. This placement. If you are stitching in a deep space, a
often requires adjustment of posture. A surgeon long-handled needle driver is necessary to pre-
once told me that tying square knots is like a vent your hand from blocking your view of the
dance and that he could tell from outside of the operative site. You should always ask for the nee-
operating room if knots were square based on dle on a proper needle holder in order to maxi-
whether or not the tying surgeon’s shoulders mize your efficiency.
were moving back and forth. Figure 3.6 depicts how to hold the needle
Another strategy that works to limit the holder and properly “load” or position a needle
amount of hand-crossing is to exchange the end within the jaws of a needle holder. When holding
of suture at the beginning of knot formation. the needle holder, distal tips of the thumb and
Alternatively, you can change which hand forms ring fingers should be positioned in the rings with
crossing of strands based on the orientation of the index and middle finger on shaft to provide sta-
two suture strands. If the passing end of the suture bility (Fig. 3.6a). To load the needle, it should be
is closer to you than the other end, use the index situated at the tips of the instrument and oriented
finger hitch first (for a two-handed tie) or the at a 45° angle from the line of the instrument
middle finger hitch first (for a one-handed tie) to (Fig. 3.6b), pointing away from the surgeon as
create the first half-hitch. If the tying end of the shown in Fig. 3.6a. Whether one loads the needle
suture is far from you, use the thumb hitch first midway along its curve, close to the tip, or closer
(for a two-handed tie) or the index finger hitch to the swage depends on the distance of tissue
first (for a one-handed tie) to create the first that surgeon would like the needle to travel.
half-hitch. Placing a needle too far back on the needle holder
When tightening or securing a knot, the index or failure to follow a needle’s curve as it passes
finger should be used to push or slide the knot through tissue can result in distortion of the nee-
down. The key here is that the finger aims into dle. For most common uses, the needle should be
empty space, slightly off to the side of the knot loaded 1/3 to 2/3 of the distance from the swage
rather than down into the tissue you are tying. (Fig. 3.6c).
This technique is demonstrated in Fig. 3.9c, d.
The surgeon’s knot (Fig. 3.5d) will be dis- Proper Use of Needle Driver
cussed in a later section in the context of tying “Driving” a needle through tissue requires knowl-
under tension. edge and respect for the fact that needles are
curved and will only pass through tissue in a
3.2.2.3 Suturing Technique circular motion. This requires the acquisition of a
With few exceptions, the basic techniques of nee- steady rotational wrist movement from a pro-
dle holding and needle driving are the same nated to supinated position. Lateral movement of
regardless of the specific suture and needle that a needle caused by pushing a needle straight for-
b
c
45º
Fig. 3.6 Holding and loading a needle driver. The proper between the needle’s tip and swage at the very ends of the
way to hold the needle driver with the thumb and ring fin- jaws (a), at a 45° angle from the line of the instrument (b)
ger is demonstrated in panel a. When positioning the nee- and perpendicular to the short axis of the driver (c)
dle within the jaws, the needle should be loaded halfway
(Fig. 3.7). This should be particularly empha-

sized if one desires to complete a bite through
Lateral movement of both ends of tissue in one pass. In this case, the
needle may cause
tissue trauma surgeon must pick up the opposing segment and
bring it toward the needle rather than torquing the
needle and dragging it to the opposing segment
of tissue.
With this in mind, proper technique for tissue
entry involves entrance into the tissue perpen-
dicularly (Fig. 3.8a) with the wrist pronated and
supinating the wrist until the needle exits the
Fig. 3.7 Needle “driving.” The correct technique of wound or the needle holder makes contact with
advancing a needle requires rotating the needle through tis- tissue (Fig. 3.8b). For the needle to completely
sue. Pushing the needle through tissue in a straight line
exit the tissue, one can use a forceps to rotate
(rather than rotating along the axis of the curvature of the
needle) causes trauma to the tissue at the needle entry point the needle through the tissue or re-engage the
needle driver in a pronated position on the por-
tion of the needle exiting the tissue (Fig. 3.8c).
ward while it is inserted in tissue can result in At times, the needle tip will not emerge from the
trauma to the tissue at the entrance wound tissue enough to completely exit. This can hap-
a b c
90°
Fig. 3.8 Needle entry and exit. The needle enters the tis- with the tissue (b). Reengage the needle in a pronated posi-
sue perpendicular to the tissue (a) and rotates through the tion near the needle tip’s exit site of the tissue and continue
tissue along the axis of the curvature of the needle until the along the needles natural rotation (c) to ensure the needle
needle exits the wound or the needle holder makes contact completely exits without causing undue trauma
pen for several reasons—the bite can be too big hand should be situated so that the palm is facing
for the needle, the needle was loaded too close down such that rotating the needle does not result
to the tip, etc. If this occurs, rather than remov- in an uncomfortable and awkward over-twisting
ing the needle and creating a new entrance of the wrist and forearm.
wound, forceps can be used to apply counter An extension of this practice is an advanced
pressure on the tissue near the anticipated point maneuver of adjusting the needle orientation
of emergence to expose more of the needle and without the use of a second hand. It can be
avoid grasping the needle tip. accomplished by resting the needle tip on a sta-
tionary object (surgical drapes or nearby soft tis-
Tips for Practicing Handling a Needle sue), opening the ratchet on the needle driver
Driver slightly while maintaining grasp of the needle
When possible, residents should strive to remove body, and using the tip of the needle driver as a
the needle from tissue in the proper orientation fulcrum to turn the needle slightly in the desired
for the next bite as this allows for efficient, one- direction.
handed continuous suturing. One can practice the
movements necessary for properly advancing and Maximize Utilization of Body Positioning
loading a needle by using a “push, push, pull” Your attending surgeons will never miss a chance
method. For this exercise, a piece of cloth (OR to point out whenever you appear awkward dur-
towels work well), needle holder, suture, and for- ing an operation. For the right-handed surgeon,
ceps are needed. The resident should begin by an easy way to avoid this criticism is to sew (with
“pushing” or passing the needle through the cloth the needle tip pointing) toward yourself when-
until the tip is exposed and the needle holder is in ever possible. Occasionally, certain stitches
contact with the towel. The needle holder should require you to point the needle away from your
then be repositioned toward the swage of the nee- body or “sew away from yourself,” but normally
dle and “pushed” to advance the needle tip even it is not necessary. In general, your dominant
farther out of the cloth. The needle can then be hand should be moving toward your non-
removed from the cloth by positioning the needle dominant hand, but exactly how this looks will
in the proper orientation for the next bite within vary depending on your body position as well as
the jaws and then “pulling” or drawing the needle the orientation of the wound. As with knot tying,
outward. Of note, when positioning the needle get used to adjusting your body positioning to
holder for the final movement, the operator’s give yourself the best leverage. Some specific
examples to illustrate this concept include turn- removing unnecessary instruments, and cover-
ing your body perpendicular to the OR table and ing projections with towels. It also helps to limit
taking your first bite on the opposite side when the tail to the least length necessary for tying a
closing a longitudinal fascial incision. When you knot.
are unsure of which end to start with a running
stitch, it can be helpful to image that you are sew-
ing towards your left foot. 3.2.3 Technical/Practical
Considerations/Safety
Suture Bite Size Precautions
The size of the bite depends on the needle size,
the distance of the needle insertion site from the 3.2.3.1 Knotting Under circumstances
wound edge, and depth of the bite taken. It is yet Just when you think you’ve mastered tying knots,
another spatial skill that must be learned, but you will find yourself in a situation that makes
once it is understood it can be leveraged for you think again. This section will describe tech-
various applications. Generally, bites should be niques for approaching the following circum-
symmetric on each side to allow for an equal dis- stances: tying under tension, tying into a body
tribution of tension. If a wound is asymmetrical, cavity, passing ties around a hemostat, and pass-
different sized bites can be used to correct the ing ties into a deep cavity.
appearance of the defect. Smaller bites are
employed when a more precise closure is desired Tying Under Tension
(i.e., ends of incision that is not uniform in length Tying knots under tension should be avoided
to prevent dog-earing). Larger bites are used because they have a tendency to slip. However,
when less wound tension is desirable. certain circumstances (i.e., fascial closure,
drawing together two structures that are at a
Tips for Practicing Proper Bite Size distance) require it. Using specialized knots
The spatial awareness skill can be honed through such as a surgeon’s or a fisherman’s knot is one
an exercise nicknamed “needle tip conscious- way to help avoid slippage of the first knot. To
ness.” This exercise can be performed using an create a surgeon’s knot, one end of the suture
OR towel marked with two columns of dots of makes two passes through the loop on the first
various widths. The purpose is to enter at one dot hitch prior to squaring the knot (Fig. 3.5d).
and emerge at the other with accuracy. It requires While this type of knot decreases the likelihood
knowledge of the needle and attention to way the of wound separation as the second hitch is
needle is loaded and the depth of entry. being formed, it should be note that it offers no
additional strength and generates a bulkier knot
Suture Tail Control which can be difficult to tie and more prone to
As a final point, the concept of suture tail con- breakage. It is primarily used for heavy mono-
trol is an important one that is often forgotten filament suture.
until it becomes a problem. Suture material has Other techniques for tying under tension
a tendency to get caught around the handles of require the participation of an assistant. First, the
surgical instruments or any other projection assistant can compress tissue together to relieve
along its path. This can be extremely detrimen- the tension. If the tissue is not compressible, the
tal when needle movement is hindered or exag- strands must be kept taut after the first half-hitch
gerated by any subsequent manipulation of the is formed and tightened. To keep hold of the first
strands. Techniques to combat this occurrence hitch, the strands can be rotated 90°. Then, the
are the intentional setting of the tail opposite the assistant can place a finger to compress the first
direction of sewing which can be done by drag- half-hitch which the second hitch is formed. The
ging the tail across the wound and flicking the assistant’s finger can be released as the knot is
instrument so that the tail is cast away from you, tightened.
Surgeon passes suture

behind hemostat
a
Two instruments should
b meet at tips to ensure
complete ligation
Assistant grasps
blood vessel
with hemostat
Tighten knot by pulling

strands with equal force
in opposite directions
c
Fig. 3.9 Ligation around hemostatic clamp. Panel a dem- to-tip” (b). As the knot is being tightened, the clamp is
onstrates how to properly pass a suture ligature around a slowly released to allow for the tie to compress the tissue
clamp. The suture within the passer should be brought within the clamp (c). Tying in a hole may require pulling
around the tissue to be tied by passing the tip of the pass- up on one strand of suture while simultaneously pushing
ing clamp directly facing the tip of the tissue clamp tips down the other strand of suture with your index finger
(a). The clamp and passing instrument should meet “tip- with equal tension in both directions (d)
Tying in a Body Cavity forming a square knot becomes dependent on

Tying a good knot in a deep space is difficult. It pulling both strands with equal force in opposite
presents a challenge for a number of reasons. directions. Unless one is acutely aware, the natu-
First, the resident must manipulate the strands ral tendency is to pull one of the sutures with
gently to avoid undue upward tension because unopposed force. This converts a square knot into
even minor movements can be amplified over the a slip knot which can loosen spontaneously or
distance and result in tearing or avulsion of the give way to internal pressure.
tissue. Second, due to limited space, pulling the Essential habits to develop proficiency with
ends of strands in opposite directions in the hori- this skill include ensuring an adequate length of
zontal plane is not always possible. The key to suture material, using a two-handed technique,
and forming half-hitches outside of the cavity. An (Fig. 3.9a). The suture can be held with a forceps
adequate length of suture material is long enough or on a hemostat in the right hand of the surgeon.
to be manipulated outside of the cavity. Using a The loose end of the suture is passed behind the
two-handed technique prevents generating exces- assistant’s instrument (Fig. 3.9a). The two instru-
sive torque on the structure being tied. A helpful ments should meet at the tips to ensure that the
exercise for recognizing the degree of tension ligature is entirely around the tissue contained in
that is exerted on tissue is tying knots on the tab the clamp and positioned just below the jaws of
of an empty can. This exercise teaches residents the clamp (Fig. 3.9b). As the first throw is tight-
through tactile feedback. With the goal of mini- ened, the assistant should be given a cue to begin
mal to no movement of the can during the form- opening the clamp just as the knot is being
ing or setting of the knot, residents can develop cinched.
the “soft hands” necessary for tying delicate
structures. 3.2.3.2 Methods of Suturing
It is important to advance the knot into the The primary goals of suturing are to close dead
cavity before securing it. Pulling the two ends of space, support and strengthen wounds until heal-
the suture outside of the body often advances the ing increases their tensile strength, approximate
crossing of the strands to the point that there will skin edges for cosmesis and functional result,
be appropriate length to secure the knot. If it does and/or minimize bleeding and infection.
not, you may have to manually push the pre- Stitching can be classified broadly according
formed knot into the deep space prior to setting to the number or layers (one or multiple), number
yourself up to tighten the knot. of rows (typically only one), or technique (inter-
To tighten the knot, the movement is a pushing rupted versus continuous). Interrupted suturing is
down on one end with a simultaneous matched safer because the tension on each suture can be
pulling on the other end from within the body adjusted individually and if one suture comes
cavity with the same force (Fig. 3.9d). Sometimes undone, the integrity of the entire closures is not
it is necessary to use forceps to position and affected. For continuous suturing, the integrity
manipulate a knot into a very deep space. Under depends on just one knot, but for the same reason,
these circumstances, the forceps act as an exten- it can be carried out rapidly because less knot
sion of your fingers, but this comes with a loss of tying is required.
tactile feedback on the degree of tension being
applied and the potential to damage or break the Approximating Skin and Soft Tissues
suture. Tightening a knot in a cavity is another The goal of subcutaneous closure is to re-
skill that is easily practiced outside of the operat- approximate and evert the skin edges. The subcu-
ing room. There are pre-fabricated practice taneous tissues themselves are not typically
boards with cylinders of various sizes, but empty sutured closed, but instead brought together by
canisters that are found commonly around the closing the deeper layers of tissue as well as the
hospital or house also do quite well to simulate a dermal and subcuticular layers above. The most
deep, narrow working space. commonly used stitches to accomplish this are:
simple, vertical mattress, continuous subcuticu-
Ligation Around Hemostatic Clamp lar, and inverted-U stitch. The principal differ-
Ligating a blood vessel or tissue that is grasped ences in these suturing methods is whether the
by a hemostatic clamp (hemostat, Kelly clamp, or sutures are placed in an interrupted fashion or use
right angle) is a common technique for achieving one continuous suture and the orientation of the
hemostasis. Sufficient tissue around the vessel knot (above or below the skin).
should be cleared away. The assistant should
position the clamp with its tips turned upward Simple Interrupted
and with the tissue near the end of the clamp, but A simple interrupted is the workhorse stitch.
ensure that the very tip of the clamp is free You can never go wrong using this stitch to
close any wound. One disadvantage of the stitch Continuous Subcuticular Stitch
is that is leaves marks at the entry and exit One of the most popular, but misunderstood cos-
points. Another is that for longer incisions it can metic stitches is the continuous subcuticular stitch
be time consuming and it can be uncomfortable (Fig. 3.10). The purpose of the stitch is to invisibly
for patients to have these stitches removed. For align two skin edges. Most likely you have seen this
stellate lacerations, it is useful for aligning stitch incorrectly result in a serpentine appearing
angulated skin flaps. In cases where you are wound. If done properly, this stitch should make
concerned about contamination, it is preferable your incision disappear. The key principals to this
because the entire wound will not come apart if stitch are shown in Fig. 3.10. First, ensure that the
one stitch is removed in order to allow for drain- suture runs continuously and precisely within the
age or packing. A vertical mattress is a variation same horizontal plane. Second, there must be direct
of the simple interrupted that can be used when opposition of the suture exit point on one side and
the tissue is fragile. The placement of the suture entry point on the other side. Any deviation from
takes tension off the suture line. When placing this plane results in scalloping of the wound. Third,
this stitch, load your needle as far back on the the bites should maintain the same depth from the
needle holder as possible without positioning on surface throughout the length of the wound.
the needle swage to allow for a large bite. For The proper technique to ensure a good closure
the reverse bite, load the needle in a back- is called “sewing straight with a curved needle.”
handed position. Be careful when setting the Ninety percent of this technique relies on
knot to avoid excessive tension; this results in utilization of the retracting (left-hand) forceps.
puckering of wound edges and makes for diffi- The wound edge should be grasped sufficiently
culty removing. far away from the predicted exit point of the nee-
Buried
knot
Fig. 3.10 Continuous
subcuticular stitch. This
stitch is most commonly
used to close skin.
Ensure the plane the
needle travels is
completely parallel with
the surface of the skin
(inset). When you cross
the suture to the
opposite side of the
wound, it is essential
that you enter the tissue
directly opposite of the
last stitch making sure
that you do not travel
forward at all and that
you maintain the same
depth from the surface
throughout the length of
the wound Continuous Subcuticular Stitch
dle and pulled to tension in line with the wound Suture Ligature
(Fig. 3.10 inset). Imagine laying your needle on Suture ligatures and figure-of-eight can be used
the skin along the wound; this is the desired ori- for achieving hemostasis. The suture ligature,
entation that your needle should be in as it passes colloquially known as a stick tie, should be used
through the tissue. When you enter the tissue, when a vessel can be identified and clamped or
pronating your wrist will cause your needle to prior to division. On the other hand, when a ves-
advance farther laterally from the wound edge sel is not clearly identifiable, has retracted into
than necessary, warping the closure. The proper tissue, or the surrounding tissue is friable and dis-
motion is a simple pushing of the needle through section is prohibitive, the figure of eight stitch is
the tissue without any supination of the wrist. the preferred technique. In performing this tech-
nique, after the first bite on one side of the sus-
Inverted U-Stitch pected bleeding point, pull up on both ends of the
An inverted u-stitch is often employed to close suture to ensure that the bleeding has stopped.
laparoscopic port sites. All too often, when one is This simultaneously helps to maneuver the tissue
done placing this stitch, it appears as though the for the second bite.
wound is still open. The primary reason for this
failure is that the curve of the U is not superficial Continuous Running Locking Stitch
enough. The superficial entry and exit point A continuous running locking stitch (Fig. 3.11)
should be at the exact cell layer that the knife cuts resists unraveling when you are sewing a long
the skin. The forehand portion of the stitch is wound. This technique is most efficiently per-
generally not problematic, but one should take
the time to ensure that the needle exits as close to
the surface of the wound as possible. When start-
ing the superficial bite, it is often difficult to find
the correct depth. Use your forceps to reach
inside the wound and pull the dermis into the
middle of the wound. While using your needle tip
to push back the epidermis, you can then drive
the needle straight through the dermis.
Stitches for Fascial Closure and Hemostasis
Continuous Running
The continuous over and over stitch is sometimes
called a baseball stitch or a running whipstitch. It
is used to quickly close long incisions. There are
two techniques that you can practice for effi-
ciency. First, practice releasing and reloading the
needle while it is in the tissue. You will find that
after reloading the needle, it is in a back-handed
configuration and you will need to turn the needle
holder 180° in your hand prior to taking the next
bite. An alternative technique can be liked to a
“pitch and catch” motion. This involves passing
the needle through the tissue with rotational wrist Fig. 3.11 Continuous running locking stitch. This fast
suturing technique will help close longer wounds and
movement and releasing the needle to be grasped maintain tension on the incision by mechanism of the
and rotated through the remaining tissue using “locking” loop, which is formed by passing the needle and
the forceps. suture through the last placed loop
formed with an active assistant who will present mucosal surface is inverted and the fibromuscu-
the loop of suture after each bite for the surgeon lar layer is incorporated. It can be used in an
to pass the needle under. Otherwise, this stitch interrupted fashion where the tension can be set
can be cumbersome and time consuming for a on each individual suture or in a continuous
solo surgeon. fashion.
Stitches for Gastrointestinal Anastomosis Purse-String Suture

The next series of stitches are for sewing on A purse-string suture is essentially a continuous
bowel. They hinge on the concept of a seromus- Lembert suture around a circular opening. The
cular bite which effectively inverts and approxi- size of the opening dictates the number of sutures
mates two ends of bowel [22]. to complete the circle. If the opening is large, it
may require reversal of the needle for a back-
Lembert Suture handed stitch. One way to quickly switch between
The Lembert suture is the quintessential stitch a forehand and backhand is by loosely grabbing
that includes a bite of serosa and submucosa just proximal to the point of the needle with
about 2.5 mm from cut edge and exits just proxi- Debakey forceps and either tapping the tail of the
mal to cut edge of bowel (Fig. 3.12). It should be needle toward or away from you to change the
stressed that more so than for any other stitch, orientation of the needle.
the needle must enter perpendicularly to the tis-
sue. A helpful way of thinking about this is that Connell Stitch
the needle tip should be pointed straight down to The Connell stitch is typically used for the ante-
the floor and rotated sharply just after the needle rior mucosal layer of two-layer anastomosis
is felt popping through the serosa. If done cor- because it is more fluid tight and slightly hemo-
rectly and the bite is of an appropriate thickness, static. The suture should be placed loose enough
the suture should not be visible through the to avoid ischemia of the bowel wall. Depicted in
bowel wall. It is the safest and most useful stitch Fig. 3.13, the stitch is often remembered as “the
in constructing a GI anastomosis because the bar crawl.” First, take a full thickness bite from
Continuous Lembert Interrupted Lembert
Fig. 3.12 Lembert stitch. These seromuscular bites pre- depth of the submucosal plane, and thus not visible
dominate when creating a gastrointestinal anastomosis. through the bowel wall. Always take these stitches in two
The needle must enter the serosa perpendicularly about bites to ensure that you are truly entering the tissue at a
2.5 mm from the cut edge. The suture must be at the 90° angle
1
4 3
6
2
5
Connell Stitch
Fig. 3.13 Connell stitch. This stitch is used to invert the cut edge is always done within the lumen of the bowel.
mucosa so that the serosa is opposed. Each bite must be Traveling to the other side is done directly in line with the
full thickness through serosa and mucosa. Traveling along exit point of your last stitch
serosa to lumen about 4–5 mm from the cut edge 3.2.4 Current Controversies/Future
of the bowel or “enter the bar” (#1). After travel- Directions
ing a short distance (about 3 mm) parallel to the
cut surface (#2), exit the lumen to serosa or “leave 3.2.4.1 Knotless Suturing
the bar” (#3). Then, cross to the opposite edge of Knots have several inherent and acquired limita-
the enterotomy or “go across the street” (#4) and tions. They reduce a suture’s tensile strength, dis-
repeat the same out to in (#5) and then in to out tribute tension unequally along a wound, can
(#6) sequence. extrude from a wound, serve as a potential nidus
for infection, and can come undone as a result of
Modified Gambee Stitch human error. Barbed suture was developed and
The Gambee stitch allows for apposition of two allows for knotless suturing where knot tying
layers (mucosa and serosa) with a single stitch. would affect cosmetic outcome because of
This allows you to use a single suture to mimic unequal tension or extrusion.
a two-layer anastomosis. It can be useful in cre- Barbed suture has linear nicks along its length
ating an anastomosis when two cut edges are which allows the suture only to be pulled in one
mismatched in size. When performing a modi- direction. It was first introduced as a concept in
fied Gambee stitch (Fig. 3.14), enter serosa 1956. It was first used clinically in 1967. From
6–8 mm from cut edge (#1) and penetrate the 1967 to 1999, a variety of designs were trialed.
mucosa into the lumen but immediately exit by The modern design of one-way sutures with exte-
taking a bite through the mucosa and submu- rior barbs has been employed since 2004 and
cosa 2–3 mm from edge (#2). The second part of there are currently three types available commer-
the stitch follows a mirror image: enter the sub- cially (see Sect. 3.1).
mucosa 2–3 mm from the edge (#3), penetrate Barbed suture allows for knotless suturing
the mucosa and immediately return through the and as a result is appealing to surgeon’s who
mucosa to exit the serosa 6–8 mm from the cut encounter circumstances where tying knots is
edge (#4). quite frankly difficult. For example, laparo-
3 mm
4 1
3 2
Modified Gambee Stitch
Fig. 3.14 Modified Gambee stitch. This stitch allows you to perform a “two layer” closure that inverts the mucosa and
apposed the serosa using one stitch
scopic knot tying is considered to be one of the • It is not sufficient to learn simply how to form
most technically challenging surgical skills. The knots. Just as important is how to tighten and
ability to properly and efficiently tie surgical place knots.
knots requires extensive rehearsal. This chal- • You must become proficient tying one and
lenge remains for robotic suturing. As mini- two-handed knots, using both your left and
mally invasive techniques predominant and right hands. Furthermore these skills must be
robotic techniques gain momentum in general practiced to the point where you automatically
surgery practice, the use of barbed suture is use the most efficient technique to tie each
becoming more commonplace. knot presented to you.
To date, there have been 17 RCTs in various • Needle tip consciousness (the knowledge of the
surgical disciplines (cosmetic surgery, bariatric position of the tip of the needle as it passes
surgery, urology, gynecology, and orthopedic through tissue) is an ability that needs to be
surgery) to evaluate outcomes with barbed suture acquired in order to safely and efficiently suture.
versus conventional suture. Outcomes that have • Mastery of suturing is essential to all aspects of
been studied include suture time, operative time, surgery, from achieving hemostasis to restor-
and post-operative complications. And, although ing proper function of various organ systems.
there are theoretical advantages of this technique • Knowing various methods of suturing can
(i.e., stronger closure), no studies have compre- help you choose the most appropriate for each
hensively examined the benefits and clinical tri- situation.
als have only consistently shown a reduction in • Practice knot tying every single day.
suture or operative time [23].
Take-Home Points
Suggested Readings
• Basic techniques of needle holding, needle
driving, and knot placement are the same Dunn DL. Wound closure manual. Somerville: Ethicon;
2005.
regardless of the specific suture and needle Boros M, editor. Surgical techniques: textbook for medi-
that are chosen. cal students. Szeged: Innovariant; 2006.
Knot Tying Videos http://www.bumc.bu.edu/surgery/ 13. Baracs J, Huszár O, Sajjadi SG, Horváth OP. Surgical
training/technical-training/basic-knots-sutures/. site infections after abdominal closure in colorec-
ACS/APDS Surgery Resident Skills Curriculum. tal surgery using triclosan-coated absorbable suture
(PDS Plus) vs. uncoated sutures (PDS II): a random-
ized multicenter study. Surg Infect. 2011;12:483–9.
14. Justinger C, Slotta JE, Ningel S, Gräber S, Kollmar O,
References Schilling MK. Surgical-site infection after abdominal
wall closure with triclosan-impregnated polydioxa-
1. Kirkup J. The history and evolution of surgical instru- none sutures: results of a randomized clinical pathway
ments. V Needles and their penetrating derivatives. facilitated trial. Surgery. 2013;154:589–95.
Ann R Coll Surg Engl. 1986;68:29–33. 15. Nakamura T, Kashimura N, Noji T. Triclosan-coated
2. Barr J. Lister’s ligatures. J Vasc Surg. 2014;60:1383–5. sutures reduce the incidence of wound infections and
3. Rutkow I. The rise of modern surgery: an overview. the costs after colorectal surgery: a randomized con-
In: Townsend CM, Beauchamp RD, Evers BM, trolled trial. Surgery. 2013;153:576–83.
Mattox KL, editors. Sabiston textbook of surgery: the 16. Diener MK, Knebel P, Kieser M. Effectiveness of
biological basis of modern surgical practice. 20th ed. triclosan-coated PDS Plus versus uncoated PDS II
Philadelphia: Elsevier; 2017. p. 2–19. sutures for prevention of surgical site infection after
4. Knot Tying Manual. Ethicon http://surgsoc.org.au/ abdominal wall closure: the randomised controlled
wp-content/uploads/2014/03/Ethicon-Knot-Tying- proud trial. Lancet. 2014;384:142–52.
Manual.pdf. 17. Mattavelli I, Rebora P, Doglietto G. Multi-center

5. Surgical Knot Tying Manual, 3rd ed. Covidien http:// randomized controlled trial on the effect of triclosan-
www.covidien.com/imageServer.aspx?contentID=11 coated sutures on surgical site infection after colorec-
850&contenttype=application/pdf. tal surgery. Surg Infect. 2015;16:226–35.
6. Boros M, editor. Surgical techniques: textbook for 18. “STRATFIX™ Knotless Tissue Control Devices.”

medical students. Szeged: Innovariant; 2006. http://www.ethicon.com/healthcare-professionals/
7. “Basic Knots” http://www.ruralareavet.org/PDF/ products/wound-closure/stratafix-knotless-tissue-
Surgery-Knot_Tying.pdf. Accessed 26 Aug 2017. control-devices. Accessed 12 Sep 2017.
8. Cooper P. Observations on surgical training and tech- 19. Wang ZX, Jiang CP, Cao Y, et al. Systematic review
nique. In: unknown editors. The craft of surgery. 1st and meta-analysis of triclosan sutures for prevention
ed.: Boston; year unknown. p. 3–18. of surgical-site infection. Br J Surg. 2013;100:465–73.
9. Deitch E, editor. Tools of the trade and rules of the 20. Elsolh B, Xhang L, Patel SV. The Effect of antibiotic-
road: a surgical guide. Philadelphia: Lippincott coated sutures on the incidence of surgical site
-Raven; 1997. infections in abdominal closures: a meta-analysis. J
10. Kirk RM. Handling instruments and handling threads. Gastrointest Surg. 2017;21:896–903.
In: Kirk RM, editor. Basic surgical technique. 6th 21. Matarasso A, Ruff GL. The history of barbed sutures.
ed. Amsterdam: Elsevier Health Sciences; 2010. Anesthet Surg. 2013;33:12S–6S.
p. 21–46. 22.
Zuidema GD, Shackelford RT. Gastrointestinal
11. Unknown. Dissecting and suturing. In: Scott-Conner Suturing. In: Zuidema GD and Shackelford RT,
C, editor. Chassin’s operative strategy in general sur- editors. Surgery of the Alimentary Tract, 2nd ed.
gery: an expositive atlas. 3rd ed. New York: Springer; Saunders (W.B.) Co Ltd; 1986. p. 556–78.
2002. p. 26–37. 23. Lin Y, Lai S, Huang J, et al. The efficacy and safety
12.
“Needle Comparison Chart.” https://www.aes- of knotless barbed sutures in the surgical field: a
culapusa.com/assets/base/doc/DOC571RevC- systematic review and meta-analysis of randomized
AesculapNeedleComparisonChart-3-foldBrochure. controlled trials. Sci Rep. 2016;6:23425. https://doi.
pdf. Accessed 12 Sep 2017. org/10.1038/srep23425.
Fundamentals of Patient
Positioning and Skin Prep 4
Giulio Giambartolomei, Samuel Szomstein,
Raul Rosenthal, and Emanuele Lo Menzo
4.1 Introduction 4.2 General Concepts
The evolution of surgery from being performed 4.2.1 OR Environment

only through an open incision to being completed
with minimally invasive techniques has required Modern operative room’s design results from
several changes to the traditional operating room an evolution of technology and evidence-based
setup but also mandated new and—at times— studies on potential patient’s injuries due to
extreme positions to be kept during the procedure improper surgical positioning. However,
at hand. These have required the surgeons to despite newly engineered materials built to
become even more attuned to paying special protect pressure vulnerable areas, careful
attention to the positioning of patients prior to patient positioning by the surgical team is par-
any surgical procedure since a mistake at this amount in order to safely and successfully
stage may result in poor or inadequate exposure complete an operation. While surgeons have
and possibly in injury. Also the increased utiliza- traditionally focused on proper positioning to
tion of surgical implants on one hand, and the ensure appropriate exposure of a target organ,
growing prevalence of multidrug-resistant bacte- at times, safety considerations have been
ria on the other, demanded the manufacturing and overlooked.
utilization of new and more potent skin prepping
compounds. The surgical resident is an integral
part of the team and has to be familiar with the 4.2.2 Postsurgical Injuries
most up-to-date strategies for safe conduct in the and Epidemiology
operating room, including the utilization of team
huddles, preoperative checklists, and time-out. Although not extensively discussed in surgical
programs, a thorough knowledge of the patho-
physiology and etiology of potential position-
G. Giambartolomei · S. Szomstein · R. Rosenthal related injuries should be part of a well-rounded
E. Lo Menzo (*)
surgeon.
Department of Surgery, The Bariatric and Metabolic
Institute, Cleveland Clinic Florida, Weston, FL, USA The possible complications of patient posi-
e-mail: lomenze@ccf.org tioning in the operating room can be summarized

66 G. Giambartolomei et al.
as follows: falls, ocular injuries, peripheral neu- Ulnar neuropathy is the most common
ropathies, pressure ulcers, and general peripheral neuropathy and is more frequent in
anesthesia-related. males [4]. It was previously thought to be a con-
sequence of stretch and compression of the nerve
4.2.2.1 Falls due to its superficial course around the medial
Unfortunately, hospital falls remain a current epicondyle of the elbow. Observed symptoms
problem, and it is extensively reported in the lit- usually are hypoesthesia of the fourth and fifth
erature. No accurate data have been published fingers, hypothenar eminence’s muscle atrophy,
about the perioperative frequency of falls, except and claw hand. Warner et al. retrospectively ana-
for anecdotal episodes resulted in patient’s death. lyzed 414 patients with a diagnosis of periopera-
Thus an assessment of fall risk is advisable when tive ulnar neuropathy and found that factors
admitting the patient to the operating room. other than patient incorrect positioning are
involved in developing this condition, such as
4.2.2.2 Ocular Injuries male gender, BMI less than 24 or higher than 38,
The frequency of ocular injuries is usually low and length of hospitalization higher than 14
(<0.1%), but the range of severity could vary days. Their conclusions were supported by a
from mild discomfort to corneal abrasions and to delayed onset of neuropathy, usually 24 h after
permanent loss of vision. Simply taping the eye- the procedure, suggesting mechanisms other
lids more than ointment application during gen- than simple compression or stretch. However,
eral anesthesia can prevent minor damages they found that 53% of the patients regained
secondary to anesthesia-related reduction of motor function and sensation within 1 year and
tears. Instead retinal ischemia and consequent those patients who did not regain full function
unilateral or bilateral loss of vision could be a presented only minor disability from pain and
result of low optic artery inflow and venous out- weakness (Fig. 4.1).
flow secondary to high ocular pressure in the Brachial plexus injuries are extensively
prone position [1]. reported as a complication due to malpositioning
of the patient and can potentially be irreversible
4.2.2.3 Peripheral Neuropathies depending on the mechanism of nerve injury.
Peripheral neuropathies are the second most In general, they are associated with median
common complication in the American Society sternotomy, in which the brachial plexus can be
of Anesthesiologist’s closed claim database, damaged during sternal separation, and with
occurring in 16% of the cases [2]. The severity of head-down position when the arm is hyperex-
the symptoms and expected recovery vary tended over the trunk due to arm-board incorrect
depending on the mechanism and extent of the placement or shoulder brace compression [5]. A
injury [3]. Neuropraxia is the most common situ- lower incidence of brachial plexus injury is found
ation when the injury involves the endoneurial in the prone position. Also, an exaggerated rota-
capillaries, resulting in perineural edema and tion of the neck or hyperextension of the arm may
conduction block. The main symptom of neuro- favor a brachial plexus injury (Fig. 4.2).
praxia is paresthesia. A complete resolution of Related symptoms will vary from decreased
symptoms is usually achieved within 1 week sensation around the shoulder area to motor
since there is no axonal damage. Whenever the impairment in arm abduction and usually resolve
insult is intense enough to generate segmental within 6–8 months depending on the severity.
demyelinization, the functional recovery will Lower limb nerve injuries are usually second-
take a few months. More severe damages are axo- ary to a compression of the common peroneal
notmesis and neurotmesis that involve complete nerve at the head of the fibula and in 80% of the
axonal rupture within an intact nerve sheath and cases are encountered when the patient is placed
complete nerve disruption, respectively, which in lithotomy position [6]. Thin patients who
are unlikely to resolve spontaneously. smoke are more susceptible to this kind of injury
4 Fundamentals of Patient Positioning and Skin Prep 67
a b
Fig. 4.1 Ulnar nerve injury. (a) Potentially nerve threatening position. (b) Correct positioning (taken from web)
that may result in foot drop and loss of sensation nerve. Clinical symptoms of femoral nerve injury
over the lateral aspect of the leg and dorsum of are sensory loss along the area covered by the
the foot [3] (Fig. 4.3). anterior and lateral femoral cutaneous nerves and
Up to 15% of lower limb peripheral nerve will resolve spontaneously in 94% of the cases.
injuries are related to the sciatic nerve, especially
with hyperflexion of the hip and extension of the 4.2.2.4 Pressure Ulcers
knee in exaggerated lithotomy position. This will According to the Agency for Healthcare Research
result in loss of extension and flexion of the foot and Quality, 2.5 million patients are affected by
and decreased sensation along the anterior and pressure ulcers every year, of which 60,000 die
posterior aspects of the leg and foot. from direct consequences.
Femoral neuropathy comprises 4% of the The surgical patient is more vulnerable to
cases and is usually caused by continuous com- pressure effect because the anesthesia itself
pression from intraabdominal retractors on ilio- induces vasodilation that leads to a decrease in
psoas muscle and external iliac artery, resulting blood pressure and perfusion. In addition, the
in ischemic or mechanical damage to the femoral typically cooler operating room environment,
Fig. 4.2 Brachial plexus injuries. (a)

Incorrect extension of the arm board more
than 90°. (b) Correct position of the arm
board. (c) Inadequate arm padding
resulting in a sagging arm board. The
dorsal extension of the arm stretches the
brachial plexus. (d) Correct leveling and
padding of the arm board to minimize More than
90 degrees
brachial plexus stretch and ulnar nerve
compression at the wrist (taken from web).
From Winfree CJ, Kline a
DG. Intraoperative positioning nerve
injuries. Surg Neurol. 2005
Jan;63(1):5-18; discussion 18. Review.
Figs. 1 and 2 page 8. Permission not
requested
b 90 degrees
a b
and the use of vasopressors and diuretics, may will result in occlusion of blood flow and tissue
result in additional decrease in tissue perfusion. ischemia. Skin and underlying tissues can toler-
It has been shown that a pressure greater than ate high pressure for short amount of time and
32 mmHg, which is the capillary filling pressure, low pressures for prolonged time, so that the sur-
gical patient is predisposed to develop ischemic
injuries anyway. The duration of pressure over
2 h is associated with an increased risk of devel-
opment of pressure ulcers [7]. These occur more
likely over bony prominences covered by skin
and small amounts of muscles and subcutaneous
tissue (Fig. 4.4).
Identified risk factors associated with the
development of perioperative pressure ulcers can
Common be divided into intrinsic or patient-related, extrin-
peroneal sic, and operating room related.
nerve injury Tibia Patient-related risk factors comprise of the
ability to maintain an adequate tissue perfusion.
Fibula These factors include malnutrition (serum albu-
min ≤3 g/dl), older age, ASA score ≥3, decreased
mental status, immobility, infection, inconti-
nence, impaired sensory perceptions, and comor-
bidities such as diabetes, peripheral vascular
disease, pulmonary disease, BMI, and altered
hemodynamic status.
Extrinsic and operating room-related factors
include the type of anesthesia, use of vasopres-
sors, length of surgery, room temperature, type of
table and pads, positioning and warming devices,
retractors, intraoperative blood pressure fluctua-
tions, and all the factors that affect shear forces,
moisture, and friction. The most meaningful risk
Fig. 4.3 Common peroneal nerve injury (taken from web)
Pressure
Epidermis
Skin
Dermis
Subcutaneous
fat
Deep fascia
Muscle
Periosteum
Bone
Fig. 4.4 Pressure
exerted over bony
prominences
factor is the duration of the procedure, with 4.3.2 Basic Positions

increased risk of developing pressure ulcers after
2.5–3 h. Every surgical subspecialty requires a different
Rhabdomyolysis is a syndrome caused by position in order to provide ideal exposure of the
crush injury to the skeletal muscles that might surgical site. Also, every surgeon might adjust the
occur intraoperatively. The mechanism is related basic position according to his/her technical needs.
to an ischemia-reperfusion syndrome that com-
promises sarcolemmal membrane integrity.
Skeletal muscle is able to tolerate up to 2 h of 4.3.3 Supine
ischemia with a complete recovery, but the
inflammatory response that follows the reperfu- This position is widely applied in surgical proce-
sion may be more detrimental for the evolution of dures, including abdominal surgery, urology,
the syndrome, due to its increase in capillary per- orthopedic surgery, otorhinolaryngology, and
meability, delivery of oxygen-derived free radi- plastic surgery or whenever the surgical site is
cals leading to sarcolemmal disruption, and located on the anterior aspect of the body.
spreading into circulation of intracellular compo- The operative table is horizontally flat; the
nents like myoglobin and potassium ions [8]. The patient lies on his/her back, hips and knees
resulting syndrome is characterized by hyperka- extended and arms positioned along the trunk or
lemia, hypocalcemia, and high serum creatine abducted on arm boards. If the arms are posi-
kinase (CK), which might lead to acute renal fail- tioned along the patient’s sides, the palm should
ure, severe arrhythmias, and disseminated intra- be facing the thigh; if placed on arm board,
vascular coagulation. Clinical presentation could proper padding should be provided together with
vary from numbness to pain and motor deficit of supination and slight flexion in order to minimize
the interested area and dark urine. The extended ulnar nerve compression injuries (Fig. 4.5).
lithotomy position is mostly involved in this type The pressure points more susceptible to poten-
of complication, followed by lateral decubitus tial injury are the occiput, the spinous processes
position. Obese patients are at particularly high of the thoracic vertebrae, the sacrum and coccyx,
risk for developing this syndrome. the scapulae, the olecranon, and the calcaneae. It
is a standard practice to use pink foam and pads
to protect these pressure points. The routine use
4.3 Technical/Practical of such adjuncts should be included in the surgi-
Considerations/Safety cal checklist.
Precautions Abduction of an arm could make an access to
IVs and peripheral veins for the administration of
4.3.1 Patient Positioning drugs and blood draws easier for the anesthesiol-
ogist. However, this position could result in less
The goals of a correct patient positioning can be work-space for the surgeon, especially if there is
summarized as follows: ensuring optimal surgi- reduced range of motion of the patient’s shoulder.
cal exposure while protecting anatomical struc- Moreover, extra care must be taken not to hyper-
tures and ensuring patient comfort and dignity. extend the upper limbs more than 90° from the
This must be accomplished while still guaran- trunk (Fig. 4.2). Also, the arm boards should be
teeing adequate access for the anesthesia team at the same height of the table, in order to avoid
to the airway and to intravenous medication brachial plexus injuries. Brachial plexus injuries
administration. are extensively reported as a complication due to
It is therefore preferable to ensure a comfort- malpositioning of the patient and can potentially
able position to the patient when he/she is still be irreversible depending on the mechanism of
conscious. nerve injury, as previously described.
Fig. 4.5 Supine position (taken from web)
The patient must be thoroughly secured to the and away from the neck. Finally, in head-up tilt
table with restraining straps or belts, surrounding positions, a footboard can be used, after provid-
the thighs, the arms, and sometimes the chest. ing optimal padding to the heels.
These precautions are necessary to ensure stabil-
ity of the patient even in steep positions (such as
the head-down tilt (Trendelenburg), and the head- 4.3.4 Lateral
up tilt (reverse Trendelenburg) without exerting
excessive pressure on the limbs that might impair This position is usually used in neurosurgery,
blood flow or stretching injuries to the brachial thoracotomies, and total hip replacement, as well
plexus. Securing the patient at the wrist level is as in urology and vascular surgery when retro-
then contraindicated (Fig. 4.6). This is particu- peritoneal structures are approached directly. In
larly important for obese patients, as the weight general surgery this position is utilized for the
shifts can cause compression injuries, limbs to laparoscopic approach to the spleen and adrenal
falls from table and arm board, and even torso to gland.
fall from the operating table. For steep reverse The patient is usually transferred from a
Trendelenburg position, foot plates can be uti- supine to a lateral position when secure endotra-
lized to prevent patients from sliding (Fig. 4.7). cheal anesthesia has been already established.
However, careful foot padding and knee align- During the rolling maneuver, a correct spinal
ment are paramount to prevent compression alignment should be maintained, and shearing
injuries. and friction injuries should be avoided. A pillow
These principles are particularly important in or headring should be placed to support the head
laparoscopic surgery. In fact, because of the and maintain correct alignment with the neck and
reduced ability of retraction, the exposure of the the rest of the body.
operative field is often achieved by the use of The patient lies on one side, usually at 90°
gravity of steep table tilts. Vacuum beanbags can angle between the patient’s back and the table.
be utilized as an adjunct to improve patient sta- The lower limb resting on the table should be
bility on the operating room table. It is important flexed with an angle of 90° between the thigh and
to avoid direct contact of the beanbag to the the leg, while the other lower limb should be
patient’s skin, in order to avoid skin burns and extended. A pillow should be placed between the
lacerations. The use of shoulder braces during legs to prevent damage to peroneal and saphe-
steep head-down tilt positions could result in nous nerves.
potential compression of the brachial plexus. To protect the axillary nerve bundle and artery
Hence, when used they should be well padded of the arm resting on the table, an axillary roll
Fig. 4.6 A Trendelenburg position with the patient The prevention of injuries of the brachial plexus second-
secured at the wrists determines a downward pull of the ary to malposition of the patient during surgery. Clin
humerus head and stretching injury of the brachial plexus. Orthop Relat Res. 1988 Mar;(228):33-41. Fig. 5-A page
From Cooper DE, Jenkins RS, Bready L, Rockwood CA Jr. 37. Permission not requested
Fig. 4.7 Adjustable foot

plate for reverse
Trendelenburg positions.
From the web
Fig. 4.8 Lateral decubitus position (taken from web)
should be positioned just under the axilla to In the lithotomy position, the patient lies on
relieve direct lateral pressure on the shoulder and the back; inferior limbs are positioned on leg
avoid perfusion impairment. However, there are holders, unforcedly abducted about 30–45° from
few old reports of complications of axillary rolls the midline; and thighs are flexed over the hips
secondary also to compression of the axillary with an angle of about 80–100° on the trunk, with
vessels, nerves, and even bronchus (“axillary” the knees being flexed until the legs are parallel to
compression syndrome) [9]. For this reason, the frontal plane of the torso (Figs. 4.9 and 4.10).
some authors suggest to use a rubber foam under In order to prevent traction of the obturator nerve,
the upper chest just inferior to the tip of the scap- the leg should be abducted and aligned with the
ula, instead of an axillary roll. It is also advisable contralateral shoulder (Fig. 4.11).
to check the radial pulse of the dependent arm to The patient’s buttock should be positioned at
confirm a proper perfusion. the edge of the lower table break, to reduce lordo-
The upper arm should be kept horizontal by sis, and the external rotation of the hips should be
the use of a pillow or by an arm board. The hori- minimal (Figs. 4.10 and 4.11). The legs and feet
zontal position of the arm will also allow for a should be positioned on stirrups with a popliteal
more reliable and precise blood pressure mea- support and a calf rest, avoiding unnecessary
surements. The palm of the inferior hand is posi- pressure points and minimizing movements
tioned upward, and the palm of the superior hand within the stirrups (Fig. 4.12). For this reason
is positioned downward. stirrups with a foot and ankle support are pre-
Proper padding should be provided to pressure ferred to decrease pressure on the calf (Fig. 4.13).
points such as the downside ear, the acromion Also appropriate padding should be provided to
process, the olecranon, the rib cage, the iliac the head of the fibula to avoid common peroneal
crest, the greater trochanter, the medial and lat- injuries, excessive hip flexion can stretch sciatic
eral condyles of the knee, and the medial and lat- and obturator nerves, and the femoral nerve can
eral malleoli (Fig. 4.8). be compressed under the inguinal ligament
(Fig. 4.14). Legs should be raised simultaneously
and slowly to avoid a progressively increasing
4.3.5 Lithotomy venous return impairing cardiovascular function,
especially in poor heart-compliant patients. Also
This position is widely used in gynecological, when raising legs above heart level, peripheral
urological, and colorectal/proctologic surgery, as pulses should be checked because local ischemia
it provides direct access to the perineal area [10]. to neuromuscular structures can occur, resulting
Fig. 4.9 Lithotomy position (taken from web)
in a compartment syndrome [9]. Similarly, at the

end of the procedure, legs should be simultane-
ously and slowly lowered to avoid spine torsion
and to allow the vessels to progressively refill
minimizing the risk of hypotension due to rela-
tive hypovolemia.
The upper limbs should be positioned on pad-
ded arm boards, abducted no more than 90°, or
over the abdomen. Placing the arms to the
patient’s side could result in finger injury when
the lower table section is elevated.
Critical pressure points in the lithotomy position
are the occiput, the spinous processes of the tho-
racic vertebrae, the sacrum, the medial and lateral
epicondyles, the olecranon, the scapulae, the femo-
ral condyles, and the medial and lateral malleoli and
calcaneae, so proper padding should be provided.
Fig. 4.10 Correct position of the sacrum (from the
Prevention of Positioning Injuries during Gynecologic
Operations. Guideline of DGGG. M. C. Fleisch, D. 4.3.6 Prone
Bremerich, W. Schulte-Mattler, A. Tannen, A. T. Teichmann,
W. Bader, K. Balzer, S. P. Renner, T. Römer, S. Roth, F. The prone position is frequently used for surgi-
Schütz, M. Thill, H. Tinneberg, and K. ZarrasGeburtshilfe
Frauenheilkd. 2015 Aug; 75(8): 792–807. doi: cal access to the posterior spine and thorax and
10.1055/s-0035-1557776). Permission not requested the posterior cranial fossa. Since the patient lies
on the ventral aspect of the torso, unfavorable using chest and pelvis support or using a special-
cardiorespiratory mechanics occurs. In fact, ized prone operating table (Jackson table).
abdominal compression causes an increase in Arms can be either raised beside the head on
intraabdominal pressure that might lead to a padded arm boards or retained along the sides of
compression of the vena cava and ultimately in a the body; when raised bedside the head, forearms
decrease in venous return and cardiac output. should be lower than the head to avoid brachial
Also epidural veins could be engorged and result plexus stretching (Fig. 4.15).
in increased surgical bleeding. It is therefore
mandatory to allow diaphragmatic excursion
Fig. 4.12 Avoid pressure to the popliteal fossa with the

ankle suspended (from the Prevention of Positioning
Injuries during Gynecologic Operations. Guideline of
DGGG. M. C. Fleisch, D. Bremerich, W. Schulte-Mattler,
A. Tannen, A. T. Teichmann, W. Bader, K. Balzer, S. P.
Renner, T. Römer, S. Roth, F. Schütz, M. Thill,
H. Tinneberg, and K. ZarrasGeburtshilfe Frauenheilkd.
2015 Aug; 75(8): 792–807. doi: 10.1055/s-0035-1557776).
Permission not requested
Fig. 4.11 Correct angulation and abduction of the lower

extremities to prevent traction of the obturator nerve
(from the Prevention of Positioning Injuries during
Gynecologic Operations. Guideline of DGGG. M.
C. Fleisch, D. Bremerich, W. Schulte-Mattler, A. Tannen,
A. T. Teichmann, W. Bader, K. Balzer, S. P. Renner,
T. Römer, S. Roth, F. Schütz, M. Thill, H. Tinneberg, and
K. ZarrasGeburtshilfe Frauenheilkd. 2015 Aug; 75(8): Fig. 4.13 Stirrups with foot and ankle support to avoid
792–807. doi: 10.1055/s-0035-1557776). Permission not pressure on the calf. From the web. Permission not
requested requested
Extra caution should be taken when moving iliac crests, patellae, and toes, which should be
the patient from supine to prone, especially to adequately padded.
endotracheal tube, vascular access, and shearing Common complications occurring after
of the skin that could result in injuries. prone interventions are facial swelling, chemo-
The head should be placed on a supporting sis, and temporary blurred vision. Other rare
device and gently turned laterally to provide complications are corneal abrasions, ischemic

airway access. In females with large breasts,
optic neuropathy, and central retinal artery
these should be positioned laterally; in males, thrombosis which could result in permanent loss
genitalia should be appropriately placed to avoid of vision, as already discussed.
compression or torsion.
Ankles and feet should be placed in the neu-
tral position with the aid of a padded footboard; 4.4 Skin Prep
hips and knees should be slightly flexed.
Important pressure points in the prone posi- Since 1867, the year of Lister’s “Antiseptic
tion are ears, eyes, cheeks, acromion processes, principle of the practice of Surgery” publica-
tion, great efforts have been employed in
ensuring an increasing rate of sterility of the
surgical field.
The introduction of sterile gloves and hand
scrubbing certainly reduced the incidence of
Saphenous nerve healthcare-associated surgical site infections
(SSIs). However, according to WHO, the burden
Peroneal nerve
Femoral nerve of this preventable complication is of 20,196 SSIs
obturator nerve
out of 2,417,933 surgical procedures performed in
the USA in 2014, accounting for about an extra
900 billion US$ [11]. There is no clear-cut level of
bacterial skin load that should be removed before
surgery; however 80% of bacteria in surgical site
infections derive from the skin of the patient. In
order for a product to be approved to use as disin-
fectants, the Food and Drug Administration
requires a reduction of colony- forming units
Fig. 4.14 Nerves potentially affected by incorrect lithot- (CFU) by more than two log10 at dry sites (e.g.,
omy position. From the web. Permission not requested
Fig. 4.15 Prone position (taken from web)

abdominal skin) and by three log10 at moist sites 4.4.2 Hair Trimming
(e.g., groin), when tested at both 10 min and 6 h.
Besides hand hygiene and sterile gloves and According to WHO, hair should not be removed
instruments, proper patient’s skin preparation from the patient’s surgical field. If necessary, they
contributes to reduce the risk of surgical wound should be trimmed with a clipper preoperatively
contamination. The first antiseptic agent used or in the operative room, as shaving is strongly
from Lister was phenol, promptly replaced by discouraged at all times. In fact, in a review from
cresol which was ten times more active and less 2011, the authors identified three trials that com-
corrosive on living tissues. pared shaving with clipping and showed that the
Respectively, in 1950 and 1955, chlorhexidine incidence of SSIs was significantly higher in the
gluconate and povidone-iodine solutions were shaving groups (RR 2.09). Probably this evidence
introduced into commercial use, and they are still could be elucidated by less skin trauma caused by
widely used as antiseptic agents in the surgical the clipper compared to the razor [15]. However,
field. the same review showed no statistically signifi-
cant difference in SSI rates between hair removal
and no hair removal [14].
4.4.1 Preoperative Home
Shower/Bath
4.4.3 Surgical Site Preparation
Preoperative home showering with antiseptic
agents is considered a well-accepted procedure for The purpose of the presurgical treatment of intact
reducing skin microflora, but its efficacy in ulti- skin in the OR is to reduce as much as possible
mately reducing surgical site infection is debated. the load of skin bacteria before incision of the
The most used antiseptic for this purpose is by skin barrier. The three important variables con-
far chlorhexidine gluconate. tributing to a surgical site infection are the dose
Chlebicki et al. selected 16 prospective random- of bacterial contamination, the virulence of the
ized or quasi-randomized trials comparing preoper- bacteria, and the resistance of the host. Surgical
ative chlorhexidine baths versus non-antiseptic soap skin preparation can affect only the first of such
baths or no baths, focusing on surgical site infection variables [16]. It has been shown how the risk for
outcomes [12]. They found the incidence of devel- surgical site infection increases significantly if
oping a surgical site infection to be statistically non- the wound is contaminated with more than 105
significant between the two groups, as 6.8% of the microorganisms per gram of tissue. Whenever a
patients developed SSIs in the chlorhexidine group foreign body is present at the surgical site, how-
versus 7.2% in the control group. ever, this amount is much lower however (100
The authors also concluded that these results staphylococci per gram of tissue on braded
could be biased by different antibiotic prophylaxis suture).
and/or by patients’ lack of bathing instructions. The skin is not a sterile surface; bacteria
In fact, Paulson et al. showed that a daily 4% tend to colonize the deeper layers of the stratum
chlorhexidine gluconate for 5 days progressively corneum and therefore cannot be shed by sim-
reduced the microbial load of abdominal and ple desquamation. Antiseptics bind to the stra-
inguinal region [13]. tum corneum to prolong their chemical action,
Chlorhexidine is found to have a cumulative together with a mechanical action, in order to
antibacterial effect that lasts longer than other kill and inhibit contaminating and colonizing
antiseptic agents. flora. Commensal flora comprises Staphylococci,
Despite this findings, WHO’s global guide- Pseudomonas, Propionibacteria, and diphtheroid
lines for the prevention of surgical site infections organisms which can lead to harmful infection if
still advise to bathe or shower with either plain or they are allowed to grow and overcome host’s
antimicrobial soap before surgery [14]. defenses.
4.4.4 Antiseptic Solutions
The ideal antiseptic agent should have the follow-

ing properties:
• Kill all bacteria, fungi, protozoa, viruses,

tubercle bacilli, and spores.
• Nontoxic.
• Hypoallergenic.
• Safe to use in all body regions.
• Not be absorbed.
Fig. 4.16 Surgical site preparation (taken from web)
• Present residual activity.
• Safe for repetitive use.
A thorough preoperative skin preparation is
thus recommended routinely, and its efficacy is Lately two kinds of antiseptics have been uti-
thought to be dependent to the antiseptic used lized for surgical skin preparation:
and the method of application. According to the
Center for Disease Control and Prevention –– Iodine-/iodophor-based solutions: effective
(CDC), the patient’s surgical site should be against a wide spectrum of Gram-positive and
prepped as follows [17]: Gram-negative bacteria, tubercle bacillus,
viruses, and fungi. The mechanism of action
• The skin must be primarily cleaned from gross comprises free iodine molecules bound to a
contamination (dirt, soil, etc.). polymer (povidone) that can penetrate cell
• The site of the area prepared should be suffi- walls and oxidize microbial contents. It is
cient to include any potential incision different soluble in both water and alcohol. The risk of
from the main incision site, including drains. side effects, such as staining, tissue irritation,
• The solution should be applied in concentric and iodine absorption, is lower with iodo-
circles. phors than with aqueous iodine. Increased
• A dedicated instrument should be used serum iodine levels have been found in
(sponge, swab), and the applicator should be patients, so other products should be consid-
discarded once the periphery has been ered for patients with thyroid dysfunction.
reached. The efficacy of iodophors is reduced in the
• Time should be allowed for the solution to dry, presence of organic material such as the
as alcohol-based solutions are flammable, and blood. They are, however, preferred for anti-
to achieve a complete antimicrobial effect, as sepsis of mucous membranes and open
per manufacturer. wounds.
–– Chlorhexidine gluconate-based solutions:
aqueous or alcoholic; it is effective against a
Also the Association of periOperative wide range of Gram-positive and Gram-
Registered Nurses (AORN) stated that the appli- negative bacteria, yeasts, and some viruses. It
cator used should be sterile and the solution is most commonly formulated as a 4% aque-
should be applied with friction and extend from ous solution, but the alcoholic version seems
the incision site to the periphery (Fig. 4.16) [18]. to result in having a superior antimicrobial
In fact, friction increases the antibacterial effect activity. Chlorhexidine gluconate destroys the
of an antiseptic. For instance, alcohol applied bacterial cell membrane, resulting in a bacteri-
without friction reduces bacterial counts by 1.0– cidal effect, especially for vegetative Gram-
1.2 log10 CFU, as compared with 1.9–3.0 positive and Gram-negative bacteria. In
log10 CFU when friction is used. addition, it has a durable antimicrobial action
for up to 6 h. However, chlorhexidine has little tray. This is especially helpful during ostomy
activity against bacterial and fungal spores. takedown during the dissection around the
The alcoholic compounds are not suitable for ostomy itself. Urostomies can be gently cannu-
use at or in close proximity to mucous mem- lated with red rubber catheters secured with ster-
branes or the eyes. ile adhesive drapes. Prepare the ostomy gently in
order to avoid mucosal injuries.
A recent Cochrane review (2015) highlighted Open wounds, especially if traumatic, should be
how 0.5% chlorhexidine in methylated spirit was mechanically debrided using normal saline with a
superior to povidone-iodine paint only in one drip sheet under the wound. The surrounding area
study [15] out of 13 clinical trials where it should be prepped first, while the open wound is
achieved a statistically significant result in terms packed with sterile gauze. The gauze should then
of SSI rate [15]. They recruited 542 patients be discarded, and the open wound prepped last.
undergoing clean surgery classified as “hernia,
genitalia, veins and other clean operations” and
showed a 13% of SSI rate in the povidone-iodine 4.4.5 Antiseptic-Related Fires
versus 6.3% in the chlorhexidine group. It is
important to note, though, that they did not report A general concern regarding alcohol-based solu-
the concentration of povidone-iodine paint. tions has always been their potential flammabil-
All other trials reported in the review were ity, which is highly increased in the presence of
based on comparison either of two different anti- other two components such as oxygen and heat
septics or different concentrations of the same that are largely present in the operative room
antiseptic, and no statistical significance in term [19]. These concepts will be further expanded
of SSI rate was found. upon in Chap. 25.
However, the WHO global guidelines for the As clearly illustrated in the surgical triangle of
prevention of SSI strongly recommend the utiliza- fire showed below (Fig. 4.17), there are many
tion of alcohol-based antiseptic solutions with factors that contribute to initiate a fire in the oper-
chlorhexidine gluconate for surgical site skin prep- ating room, and all must be taken into consider-
aration in patients undergoing surgical procedures, ations. Alcohol preparations account for the fuel
in spite of low to moderate level of evidence. aspect, especially when they are pooled or are not
Ostomies and open wounds require special allowed to dry correctly or are spilled largely
consideration. First of all, no chlorhexidine prod- over drapes and gowns.
ucts can be used. Sponges used to prep open Vo et al. reported their own case of a third-
wounds, and intestinal stomas, should be used degree burn occurred in a urologic procedure,
once and then discarded. The intact skin should be which required the intervention of a plastic sur-
prepped first, before open wounds and ostomies. geon afterward [20]. The solution used was 2%
For intestinal ostomies that are not part of the chlorhexidine in 70% isopropyl alcohol. They
surgical field, seal off the ostomy with a sterile also reported other six cases of accidental fires
adhesive drape, prior to the surgical site prepara- occurred during surgery, and they finally pro-
tion. If the ostomy is in the surgical field, place a posed best practice recommendations:
soaked sponge over the stoma before the intact
skin is prepped, and then discard at the end of the 1. Before the application of chlorhexidine, the
prep. The mucin and organic matter can inhibit surgeon should ensure that no absorptive
the effectiveness of antiseptic agents, and it materials are present or should remove them
should be mechanically removed along with the after the patient has been prepped.
residual of the adhesive material of the ostomy 2. A sufficient amount of visibly dyed chlorhexi-
bag. Some surgeons elect to close the skin of the dine should only be used to prevent pooling.
mucocutaneous junction with running sutures to Application of chlorhexidine-soaked sponges
avoid spillage, using a separate prep and surgical should be avoided.
Common Fuels in the OR: OR Heat Sources:

• Alcohol skin preps also called Ignition Source
• Drapes • Electrosurgical units
• Gowns e.g., the “Bovie”
• Gauze • Lasers
• Hair • Fiberoptic light source
Oxidizers in the OR:

• Oxygen
• Nitrous Oxide
Fig. 4.17 Surgical triangle of fire (taken from web)
3. Ensure complete evaporation of chlorhexidine ability to form spores, and the sensitivity to
by allowing a longer drying time than what is heat, chemicals, and disinfectants. Since the
recommended by the manufacturer (2 min to bacterial spores are among the most difficult to
3 min); 5 min is preferred. eliminate, the p rocess capable of eliminating
4. Residual chlorhexidine should be dried with a such spores is considered sufficient to eliminate
surgical towel. other infectious agents. If bacterial spores are
5. Surgical drapes should only be applied once not eliminated, the process cannot be named
chlorhexidine has completely evaporated. sterilization but “high-level disinfection.”
Adhesive drapes should be used and arranged The process of sterilization is composed of
so that residual chlorhexidine vapor is directed several phases.
away from the surgical field. Initially the instruments have to be cleaned by
6. The electrocautery unit should be used with mechanically removing the gross contamination
the lowest possible setting and should be of organic and inorganic matter. This process is
placed in its quiver when it is not being used. called decontamination. In fact, the presence of
mechanical matter can decrease the efficacy of
microbicidal agents.
4.4.6 Preoperative Sterilization The next step is the inspection to assure that
the gross matter has been effectively removed.
Sterilization is a process aimed to eliminate all The instruments are then assembled in trays
microorganisms and spores from an instrument and packed specifically to allow the sterilizing
or device. There are different levels of steriliza- agents to be effective. The packaging system
tion based on the different degrees of resistance should be permeable to the sterilizing agent but
of the microorganisms. The capacity of the resistant to traction and manipulation.
microorganism to resist sterilization depends, Table 4.1 summarizes the different types of
in terms, on the presence, composition, and sterilizing agents with their advantages and
thickness of the cell wall or viral envelope, the limitations.
Table 4.1 Summary of the different sterilizing agents with their advantages and limitation
Method Advantages Limitations
Heat (steam • Short exposure • Not compatible with thermolabile items
sterilization) • Effective for prions • Does not eliminate pyrogens
• Not toxic for humans or the environment • Cannot be used for oils or powders
• Easy certification
• Low cost
• Widely available
• Easy to operate
Heat (dry air) • Not corrosive • Long exposure
• Deep penetration • Not compatible with thermolabile items
• Not toxic for humans or the environment • Hard to certify
• Easy to operate • High cost
• Widely available • Efficacy against prions not known
Ethylene oxide • Compatible with thermolabile items • Long exposure
• Penetrates certain plastics • Not effective for prions
• Easy to operate • Toxic for humans and
• the environment
Hydrogen • Compatible with thermolabile items • Not all materials are compatible
peroxide • Short exposure • Not effective for prions
plasma • Not toxic for humans or the environment • Does not reach the center of long lumens
effectively
• Easy to operate
Liquid • Short exposure • Useful only for materials that can be immersed
peracetic acid • Easy to operate • In existing equipment, few containers can be
in automatic processed
equipment • Not toxic for the environment • Not effective for prions
• Processed items must be used immediately
Formaldehyde • Compatible with thermolabile items • Not all materials are compatible
• Short exposure • Not effective for prions
• Easy certification
From WHO Library Cataloguing-in-Publication Data WHO guidelines for safe surgery: 2009: safe surgery saves lives.
ISBN 978 92 4 159855 2 (NLM classification: WO 178) © World Health Organization 2009. Requests for permission
to reproduce should be addressed to WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27,
Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4806; e-mail: permissions@who.int). Permission not requested
Take-Home Points • Ulnar neuropathy is the most common periph-

eral neuropathy.
• The patients’ safety in the OR is guaranteed • Besides hand hygiene and sterile gloves and
via a systematic approach by the entire opera- instruments, proper patient’s skin preparation
tive team. contributes to reduce the risk of surgical
• The utilization of team huddles and preopera- wound contamination.
tive checklists and time-out has become the • Antiseptics bind to the stratum corneum to
standard approach currently followed in oper- prolong their chemical action, together with a
ating rooms. mechanical action, in order to kill and inhibit
• A thorough knowledge of the pathophysiol- contaminating and colonizing flora.
ogy and etiology of potential position-related
injuries should be part of a well-rounded
surgeon. Editors’ Comments
• Simply taping the eyelids during general anes-
thesia can prevent minor damages secondary • Appropriate patient positioning is a critical
to anesthesia-related reduction of tears. part of any operation. Residents should be
knowledgeable about the benefit and risks 5. O’Connell MP. Positioning impact on the surgical
patient. Nurs Clin North Am. 2006;41(2):173–92.
associated with having any patient rest on the 6. King CA, Bridges E. Comparison of pressure relief
operating room table in a specific position for properties of operating room surfaces. Perioper Nurs
any given time. A surgical trainee should Clin. 2006;1(3):261–5.
study the specific position required for a pro- 7. Primiano M, Friend M, McClure C, et al. Pressure
ulcer prevalence and risk factors during pro-
cedure with the same focus they use with any longed surgical procedures. AORN J. 2011;94(6):
other step of the operation. 555–66.
• The operating room table—with its several 8. Slater MS, Mullins RJ. Rhabdomyolysis and myoglo-
additional components—is a part of the oper- binuric renal failure in trauma and surgical patients: a
review. J Am Coll Surg. 1998;186(6):693–716.
ating room the surgical trainee needs to be 9. Furnas H, Canales F, Buncke GM, Rosen
familiar with it to allow for maximum benefit JM. Complications with the use of an axillary roll.
to be derived from its use. Ann Plast Surg. 1990;25(3):208–9.
10. Graling PR, Colvin DB. The lithotomy position in
colon surgery. AORN J. 1992;55(4):1029–39.
11. Global guidelines for the prevention of surgical site
Suggested Readings infection. Geneva: World Health Organization; 2016.
Available from: https://www.ncbi.nlm.nih.gov/books/
NBK401132/.
Warner MA. Perioperative neuropathies. Mayo Clin Proc.
12.
Chlebicki MP, Safdar N, O’Horo JC, Maki
1998;73(6):567–74.
DG. Preoperative chlorhexidine shower or bath for
O’Connell MP. Positioning impact on the surgical patient.
prevention of surgical site infection: a meta-analysis.
Nurs Clin North Am. 2006;41(2):173–92, v
Am J Infect Control. 2013;41(2):167–73.
Dumville JC, McFarlane E, Edwards P, Lipp A,
13. Paulson DS. Efficacy evaluation of a 4% chlorhexi-
Holmes A, Liu Z. Preoperative skin antiseptics
dine gluconate as a full-body shower wash. Am J
for preventing surgical wound infections after
Infect Control. 1993;21(4):205–9.
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2015;4:CD003949.
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Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis
183–7.
WR. Guideline for prevention of surgical site infec-
15. Tanner J, Norrie P, Melen K. Preoperative hair

tion, 1999. Hospital Infection Control Practices
removal to reduce surgical site infection. Cochrane
Advisory Committee. Infection control and hospital
Database Syst Rev. 2011; (11):Cd004122.
epidemiology. 1999;20(4):250–78; quiz 79–80.
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(4):CD003949.
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Proc. 1998;73(6):567–74. tion: WO 178) © World Health Organization. 2009.
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Fundamentals of Incisions
and Skin Closures 5
Folasade O. Imeokparia, Michael E. Villarreal,
and Lawrence A. Shirley
5.1 Introduction with describing the more optimal placement of

incisions along tissue folds. This orientation
Every operation is punctuated by what may allowed for an individual’s natural folds to act as
appear to be the most basic of surgical actions, the a guideline for incisions given that the perpen-
creation and closure of the incision. Basic as these dicular muscle contractions in relation to the skin
may seem, a sound understanding of anatomy and would create folds unique to an individual
physiology for the creation and re-approximation (Fig. 5.1b). The use of skin folds minimizes the
of wounds is required to successfully complete less appealing scarring from following “Langer
the operation planned, allow the patient the best lines” in live tissue. Consequently, the modern-
opportunity for wound closure, and avoid costly, day verbiage “Langer lines” is often conflated
physically, and/or mentally burdening postopera- with the more optimal orientation described by
tive morbidities. Kraissl.
The general concepts of modern-day incision While the tenets of successful incisions and
and closure were first described in the mid- to closure have evolved since the days of Langer
late nineteenth century. The Austrian anatomist, and Kraissl, a strong understanding of anatomy,
Karl Langer, is credited with the description of wound behavior, and healing still applies. This
scar orientation based on local collagen configu- chapter will address the principles of incision and
rations. Known as “Langer lines,” these orienta- closure of routine general surgery procedures.
tion patterns served as unofficial guidelines for
surgical incisions (Fig. 5.1a). However, Langer’s
descriptions were largely applicable to the cadav- 5.2 General Concepts
eric tissue he studied. In practice, in vivo wounds
and scars varied from the anticipated results pre- The anatomic considerations of incisions and
dicted with “Langer lines.” Austrian-born plastic closures begin with an understanding of the skin
surgeon, Cornelius Kraissl, was later attributed structure and properties. The largest organ of the
body, the skin, oversees several functions: pro-
tection of the internal organs from the environ-
F. O. Imeokparia · M. E. Villarreal • L. A. Shirley (*)
ment (e.g., trauma and pathogens), temperature
Department of Surgery, The Ohio State University
Wexner Medical Center, Columbus, OH, USA regulation, as well as neurosensory interface
e-mail: Lawrence.Shirley@osumc.edu (pain, temperature, pressure).

84 F. O. Imeokparia et al.
Fig. 5.1 (a) Langer lines (via Basic Techniques in lines (via Borges AF, Alexander JE. Relaxed skin tension
Pediatric Surgery. Carachi R, Agarwala S, Bradnock TJ lines, Z-plasties on scars, and fusiform excision of lesions.
(Eds). Springer-Verlag Berlin Heidelberg 2013. Chapter Br J Plast Surg. 1962;15:242-254)
A7: Skin Lines and Wound Healing; pg 34-35). (b) Kraissl
The skin is divided into three main layers: the follicles. This layer is known for its protective
(a) epidermis, (b) dermis, and (c) subcutaneous function. The dermis contains abundant fibro-
tissue (Fig. 5.2). blast cells that produce collagen. Collagen cre-
The epidermis consists of four layers (from ates the strong tensile strength of the skin. The
deepest to superficial): stratum basale, stratum spi- subcutaneous tissue has two components, a
nosum, stratum granulosum, and stratum corneum. superficial fatty layer (Camper’s fascia) and a
Some regions of the skin contain an additional layer membranous deep layer (Scarpa’s fascia).
known as the stratum lucidum that lies between the The physiologic considerations pertaining to
stratum granulosum and corneum. This is most incisions and closures center around wound heal-
commonly found in areas of the body with dense ing. This process involves three phases: inflam-
thickness, such as the bottom of the feet and the matory, proliferative, and remodeling. The
palms of the hands. The stratum basale houses the inflammatory period is characterized by epitheli-
melanocytes that give the skin its pigmentation. alization. The proliferative period is notable for
Within the epidermis, there are no blood vessels. collagen deposition, granulation deposition, and
The dermis hosts blood vessels, nerve recep- neovascularization. Lastly, the remodeling period
tors, sweat and sebaceous glands, as well as hair consists of collagen cross-link formation.
5 Fundamentals of Incisions and Skin Closures 85
Fig. 5.2 Layers of the

skin (via Plastic and
Reconstructive Surgery.
Siemionow, M,
Eisenmann-Klein, M
(Eds.). Springer-Verlag Epidermis
London Limited 2010.
Chapter 7: Grafts,
Local and Regional
Flap; pg 69)
Dermis
Subcutaneous tissue
Muscle
Factors that inhibit wound healing include is an essential piece to selecting the right incision;
desiccated environments, hypoxemia or frank for example, a pathology’s lateral position within
ischemia, and the presence of devitalized or a cavity may alter the benefit of certain incisions;
necrotic tissue. With these concepts in mind, cre- similarly planned or potential stomas should be
ation and closure of an incision require attention considered for preoperative marking. Given the
to confirming hemostasis, preserving surround- breadth of general surgery, there is a wide range
ing structural integrity, and maintaining sterility. of possible operative sites and incisions.
The process of wound healing begins in the first Careful handling of tissue is also important
24 h after a wound is created and lasts for up to during incision. The use of tools that result in
1 year. During this time, the tensile strength of a crushing of the skin should be avoided as this may
wound will increase as collagen is formed. At lead to unsightly scarring from damage to the epi-
approximately 3 weeks after an incision or wound dermis. The least damaging method for handling
is created, the tissue has about 20% of the original or retraction of the skin should be employed such
strength of the tissue. Between 6 and 8 weeks, the as that achieved with fine skin hooks or Adson
tissue will have about 70% of the original strength forceps. If pursuing exploration or a planned pro-
of the tissue. Through the remainder of the healing cedure on a prior surgical site, it is recommended
process, the wound will only increase to a maxi- to follow the scar of the previous incision. Parallel
mum of 80% of the original strength of the tissue. or adjacent incisions should be avoided because
the intervening tissue between the previous scar
and the new incision is susceptible to ischemia
5.3 Technical/Practical and/or necrosis from interrupted blood supply.
Considerations/Safety Moreover, it is ideal to avoid creating multiple
Precautions defects, knowing that each defect only achieves
80% of the original tissue strength.
5.3.1 Incisions: General
Considerations
5.3.2 Incisions: Technical
The major goal in choosing the optimal surgical and Practical Considerations
incision is assuring adequate exposure. Simply
identifying the most advantageous access point When making an incision, one should stretch and
for the specific target organ while keeping in mind apply tension to the skin at the starting point with
potential additional components to the procedure the non-dominant hand and, with the belly of the
blade (if using sharp dissection), draw the scalpel injury to structures in the abdominal cavity. If
perpendicular along the line of the planned inci- possible, extending the incision a short distance
sion with the dominant hand. If possible, this superiorly or inferiorly will allow for entrance
should be accomplished with a single sweep of into the intra-abdominal space through an area
the scalpel. Multiple sweeps will result in where adhesions are less likely to be encoun-
detached or ragged edges of the skin and subcu- tered. Many incisions can be used to access the
taneous tissue at different levels within the inci- peritoneal and retroperitoneal spaces of the abdo-
sion that may result in delayed wound healing or men (Fig. 5.3).
necrosis. The pressure utilized should be enough
to incise through the epidermal and dermal lay- 5.3.3.1 Vertical Midline
ers. Once through the dermal layer, the additional Abdominal pathologies of the upper and lower
tissue may be further dissected sharply with the intraperitoneal cavity are generally suitable for a
scalpel or with electrosurgical energy. vertical midline incision. This incision should
Whether sharp dissection with a scalpel or follow the linea alba through its length. The linea
electrosurgical energy is used for the creation of alba is the band of connective tissue separating
a skin incision has been a question posed and the bilateral muscle pairings of the rectus abdom-
investigated over many years. A meta-analysis of inis in the anterior abdominal wall. A true mid-
these randomized controlled trials by Ly showed line vertical incision will avoid entrance into
no difference in wound complication rates or muscle or damage to major vessels or nerves and
pain scores between the two modalities but did is a convenient avascular plane. Two anatomic
find electrosurgical energy to result in less blood structures to be aware of in the entry through a
loss and shorter incision time [1]. midline incision include the falciform ligament
The following content will highlight common superiorly and the bladder inferiorly. Superiorly,
incisions of the abdomen, retroperitoneum, neck, the falciform ligament may require ligation to
and breast. accommodate visualization in the upper abdomi-
nal structures, while incisions extending to the
suprapubic region should include careful visual-
5.3.3 Incisions: Abdomen ization or palpation of the bladder to avoid inad-
vertent injury in the suprapubic space. As a
After incising through the skin and subcutaneous midline incision extends caudally, the umbilicus
fat, the abdominal fascia is encountered: a small can be followed with a slight curvilinear devia-
incision created sharply with knife, scissors, or tion to either the left or the right and brought back
electrosurgical energy should be used to begin to midline. When pathologies are anticipated in
opening of this layer. Once the fibers of the fascia the upper abdominal cavity such as with the dis-
are divided, the opposing sides can then be gently tal esophagus, stomach, proximal duodenum,
grasped with clamps and then lifted upward while liver, and pancreas, the incision can be limited to
concurrently being pulled slightly apart by an superior to the umbilicus. Similarly, when the tar-
assistant. This maneuver will bring the perito- get organ is in the lower abdominal cavity such as
neum into view so that it may be sharply incised with the sigmoid, rectum, or bladder, the incision
exposing a small window into the peritoneal cav- can be kept inferior to the umbilicus. Although
ity. This window should be spread or further midline incisions are the mainstay for abdominal
incised so it is wide enough to fit two fingers operations, several other incisions hold specific
inside the intra-abdominal space. Using electro- benefits (Table 5.1).
surgical energy or sharply with scissors, the
length of the remainder of fascia can be opened 5.3.3.2 Paramedian
using an assistant’s hands or the surgeon’s oppo- The less often-used paramedian abdominal inci-
site hand to guide and gently lift the abdominal sion is created 2 to 5 centimeters lateral from the
tissue upward for direct visualization and avoid midline. The incision remains vertical through its
a b c
d e f g
h i j
Fig. 5.3 Abdominal incision types. (a) Midline vertical. racoabdominal) (via JE Skandalakis, SW Gray, and JR
(b) Paramedian (muscle retraction). (c, d) Oblique. (e) Rowe. Anatomical Complications in General Surgery.
Transverse. (f, g) Thoracoabdominal. (h) Paramedian New York: McGraw-Hill, 1983)
(muscle splitting). (i) Pararectus. (j) “Hockey stick” (tho-
length. If one’s interest lies in lateral structures length and placement of the incision based on the
such as the spleen, this can provide useful inci- structures or disc spaces of interest. Planning for
sion. More so, when interest lies in retroperitoneal this incision begins with proper patient position-
structures such as the kidneys, adrenal, inferior ing. While this incision can be utilized with the
vena cava, or aorta (as is needed for anterior spine patient in the supine position, occasionally a gen-
exposure), the paramedian incision provides tle rotation of 30–40 of the torso may be benefi-
ample exposure. Care should be taken to plan the cial. Depending on the laterality of the site of
Table 5.1 Abdominal incision advantages/disadvantages

Incision Advantage Disadvantage
Vertical midline • Avascular • Highest risk of herniation
• Expeditious opening, closure • Cosmetically unappealing
• Easily extended
• Wide visualization
Paramedian • Access to lateral structures • W
ell-vascularized—risk of structural damage
• Buttressed closure on entrance
• Highest risk of infection
• Cosmetically unappealing
Transverse • Ideal for infants, small children, • Well-vascularized
hepatobiliary surgery • Limited exposure
Oblique • Cosmetically appealing—may lie with • Multiple-layered closure
skin folds • Limited exposure
Thoracoabdominal • Exposure of more than one cavity • Well-vascularized—risk of structural damage
on entrance
• Painful incision
interest, the patient can be positioned with the lat- with vertical incisions, transverse incisions divide
eral side of interest up. The free arm is placed at the tissue through a well-vascularized plane
90° from the long axis of the body in flexion and including muscle fibers; thus, care must be taken
abduction. The contralateral leg and hip are placed through dissection into the peritoneal cavity. It
in slight flexion. Pressure points should be appro- has been widely debated whether transverse inci-
priately padded. sions or vertical incisions are superior to the
The incision can either be carried down other. Mostly replete with non-randomized, non-
through the muscle fibers of the rectus abdominis blinded trials, there is not sufficient data to advo-
or lateral to the fibers of the rectus abdominis and cate consensus on the optimal choice between the
thus through the linea semilunaris. When the two [2, 3]. Limited exposure of the extreme upper
incision is carried down through the fibers of the and lower abdomen reduces the more widespread
rectus abdominis, the dissection does not proceed value of the transverse incision.
through an avascular plane. Namely, the superfi-
cial or deep epigastric vessels may be encoun- 5.3.3.4 Oblique
tered in this dissection. Thus, care must be taken Oblique abdominal incisions, much like trans-
when incising through the abdominal wall to pre- verse, may be advantageous in instances of very
serve and avoid injury to these structures. If inad- specific areas of pathology or interest. For exam-
vertently transected, one should be prepared to ple, the McBurney incision is an oblique incision
isolate and ligate these vessels. As such, the latter in the right lower quadrant that runs parallel to
technique is the more commonly employed of the the external oblique muscle at a point about one-
two. Many practitioners find the paramedian inci- third the distance from the anterior superior iliac
sion advantageous when the rectus is retracted spine to the umbilicus. The incision is readily
medially because the re-approximation of the employed for open appendectomies. A variation
rectus over the posterior sheath at closure is to the McBurney incision is the Rockey-Davis
thought to buffer or strengthen the closure. incision that is also positioned in the right lower
quadrant but employs a less severe oblique angle,
5.3.3.3 Transverse orienting with a patient’s skin folds for a theoreti-
The transverse incision, although largely sup- cally improved aesthetic result. Furthermore, the
planted in modern general surgery with the verti- Kocher incision is an oblique subcostal right
cal midline incision, is useful in specific upper quadrant incision utilized for upper abdom-
instances, such as in infants, small children, inal procedures, such as open cholecystectomy or
obese patients, or hepatobiliary diseases. Unlike adrenalectomy.
A pre-peritoneal oblique incision is per- 5.3.4 Incisions: Retroperitoneal

formed for renal transplantation. These inci-
sions are oriented much like an oblique incision Closely related to the abdominal incisions
for an open inguinal hernia repair—medial to described are retroperitoneal incisions. These
the anterior superior iliac spine extending incisions are typically undertaken for manage-
toward the pubic symphysis. Unlike the inguinal ment of retroperitoneal structures. This approach
hernia repair incision, this incision is often was largely described in the paramedian incision
superior to the inguinal ligament and extends section. Additionally, the thoracoabdominal
closer to the midline, as the bladder will need to approach, just described, can be kept extraperito-
be identified for the ureteral anastomosis. neal if needed.
During the dissection for this incision, the peri-
toneum is not entered but can be closed with
absorbable suture if done so accidentally. The 5.3.5 Incisions: Neck
external oblique and internal oblique aponeuro-
ses are encountered and incised. The epigastric Neck incisions need to achieve the three goals com-
vessels, spermatic cord, or round ligament mon to any incision: allow adequate exposure of
should be spared and is retracted medially. After anatomy, allow for potential extension, and allow
this retraction, the external iliac artery and vein for successful, safe, and cosmetic closure. Just as
are exposed for the planned anastomoses. with the abdominal cavity, many incisions can be
used to access the structures of the head and neck,
5.3.3.5 Thoracoabdominal and knowledge of the surgery being performed and
Thoracoabdominal incisions are generally the complications that may arise can help one plan
employed to simultaneously address a pathology a safe and cosmetic incision. The most common
spanning both the thoracic and abdominal cavi- general surgery operations of the neck include tra-
ties. For example, the various types of thoracoab- cheostomies, thyroidectomies and parathyroidecto-
dominal aneurysms, distal esophageal and mies, and excisional lymph node biopsies.
stomach lesions, as well as unique liver or splenic A tracheostomy incision is often performed
processes can be adequately dealt with via a tho- using a midline vertical incision extending from
racoabdominal incision. With the patient posi- the cricoid cartilage down to the level of the
tioned in a lateral position with the hip flexed, a fourth or fifth tracheal ring. This exposure does
curvilinear, subcostal paramedian incision can be not follow the circumferential skin fold of the
extended continuously from the abdomen onto neck, but such a vertical incision allows for better
the thorax. The incision should be traced up to access and can be extended if needed for added
the level of the most appropriate intercostal space visualization and used in the emergent setting.
for the identified pathology of interest. Incising Thyroid and parathyroid incisions should fol-
the thoracic structures will usually include some low the natural folds of a patient’s skin (Fig. 5.4).
muscle splitting and division of the latissimus Thus, this incision is typically curvilinear and
dorsi, serratus anterior, and the external oblique. made approximately two fingerbreadths above
At the intercostal rib space, the intercostal mus- the sternal notch. At the time of skin marking, the
cle is divided traversing as flush to the superior surgeon should evaluate the natural skin creases
edge of the rib as possible. This maneuver will of the patient by gently flexing and extending the
help to avoid injury to the intercostal vessel bun- patient’s neck, opting to use a natural crease to
dle. The costal cartilage can be excised if neces- allow the scar to be hidden when fully healed.
sary during this incision. It is also possible to These incisions can extend laterally for addi-
incise the diaphragm sharply or with electrocau- tional exposure. About 4–5 cm is the most com-
tery but care must be taken to avoid injuring the mon length of incision; however larger lesions
phrenic nerve. may require extension.
Fig. 5.4 Operative planning for midline cervical incision prior to thyroidectomy
A general surgeon may be referred to patient axillary lymph node management are beyond the
diagnosed with persistent cervical lymphade- scope of this chapter and will not be addressed.
nopathy, and an incisional or excisional lymph However, incision choice for these techniques
node biopsy may be needed. The incisions for will be discussed below. The principles behind
excisional biopsies tend to be more free form, the ideal breast incision can be applied to the
but in general, a few rules can be followed. management of breast abscesses and will be
First, the site must be identified. This is typi- touched on briefly.
cally done on physical exam with palpation, When percutaneous, ultrasound-guided, or
using preoperative imaging or even intraopera- stereotactic biopsy results are discordant with
tive ultrasound guidance. Once identified, the concerning imaging findings, it is often prudent
anatomy of that region of the neck should be to pursue excisional biopsy for a more adequate
deeply considered. For example, cervical zones sample of tissue for thorough pathological
2, 3, and 4 are positioned in proximity to the review. The first principle in choosing the inci-
carotid sheath and zone 5 to the accessory spi- sion for an excisional biopsy is to identify the
nal nerve. Finally, once identified and potential site of the pathology. Lesions are most com-
hazards or underlying structures accounted for, monly identified with radiologic-assisted wire
the incision can be marked in relation to skin localization or on physical exam with palpable
folds or other landmarks such as the sternoclei- lesions. In the operating room, after on-table
domastoid muscle. For cosmetic reasons, pain exam and review of preoperative imaging, the
control, and recovery purposes, the incision next step is to assure that the site is in a location
can be planned small enough to accommodate where healthy, uninvolved breast tissue margins
excision of the lymph node and extended, if will be obtained. The final principle to consider
necessary. in the choice of incision on the breast is
cosmesis.
Considering the quadrants of the breast,
5.3.6 Incisions: Breast the most ideal incision in any quadrant is a
curvilinear peri-areolar incision if the pathol-
A general surgeon is expected to have a level of ogy is amenable. In the medial and lateral
comfort in surgical management of benign and central quadrants, radial incisions are ideal
malignant breast diseases. Central to this man- choices. At the 5–7 o’clock position, many
agement are excisional biopsies, lumpectomies, consider a radial incision to also be a good
and mastectomies. Details to the approach of choice. And lastly, in the superior and inferior
aspects of the outer and inner quadrants, cur- 5.4 Closures

vilinear incisions following skin folds are
ideal [4]. The principles of wound closure can be summa-
Simple mastectomies should include the nip- rized into three major components: achieving pri-
ple areolar complex (NAC). With a marking pen, mary skin closure, minimizing wound-healing
an ellipse encompassing the NAC should be complications, and optimizing cosmesis. This
drawn with the patient supine after induction of chapter will not cover the methods to securely and
anesthesia. The extent of the elliptical incision is safely approximate abdominal fascia, as this topic
made as follows: two points should be marked in is covered in a different section in this textbook.
line with the NAC. The first point is medial at the Primary closure of the skin requires healthy,
border of the sternum. The second point is well-vascularized tissue. To this end, if there is
marked lateral at the anterior axillary line. With any concern that the vascular supply to the skin
the non-dominant hand, the breast tissue is edges is compromised or that there is contamina-
manipulated downward, and a straight line is tion from the procedure performed, debridement
drawn from the medial point to the lateral point. when able is recommended. Delayed closure,
Once the line is drawn, the breast tissue is after an initial period of granulation, may also be
released, and a curvilinear line will result. A sec- employed.
ond line is drawn delineating the inferior aspect The wound class can aid in determining the
of the incision by manipulating the breast tissue risk to developing a surgical site infection (SSI)
upward. These two lines will result in an ellipse. with primary closure. Contributors to SSI include
Adjustments to the lines may be required in order wound class of the site, seroma or hematoma for-
to assure that when brought together, the remain- mation, and patient-based factors. SSI can pro-
ing skin can be brought together without undue long healing times and burden patients with
tension. further costs of care that may include dressing
The medial perforating vessels are the critical supplies, durable medical equipment, and skilled
perfusion to the skin which should be carefully nursing care. The risk to develop a SSI is linked
considered when planning the incision and dur- to the wound class. There are four wound class
ing dissection. types: clean wounds carry a risk of SSI at 2%,
A few final pearls on breast incisions are to clean contaminated at 3–5%, contaminated at
keep in mind that a patient may require reopera- 5–10%, and gross contaminated wounds have the
tion for additional excision of tissue or a mastec- highest risk of SSI at 30%. The Joint Commission
tomy after lumpectomy, so placement of incisions on Accreditation of Healthcare Organizations
should always bear this caution in mind. created national patient safety guidelines that
Additionally, one should forgo upper/inner quad- include recommendations to limit SSI. Major
rant incisions as they tend to be the most cosmeti- perioperative recommendations include the use
cally unappealing [5]. Lastly, as mentioned, the of prophylactic antibiotics that are administered
complete discussion of the management of within 1 h of surgical incision, the use of
malignant breast disease is not covered here, but chlorhexidine surgical bath preoperatively, and
the NCCN Guidelines for breast cancer are easily the clipping of hair when appropriate [7].
accessible [6]. Closure of dead space is a simple but essential
Modified radical mastectomy (MRM) inci- concept that can help reduce infection risk.
sions are similar to those of simple mastectomies. Closure of dead space begins with careful inspec-
An important variation compared to simple mas- tion and evacuation of tissue space fluid collec-
tectomies is that MRM incisions will encompass tions. Retained hematomas and seromas can serve
axillary lymph node levels 1 and 2 and so should as energy-rich reservoirs for bacteria and accumu-
be extended or angled further toward the axillary lation of oxygen free radicals that weaken the
tail for sufficient dissection. strength of a closure. Thus, closure of dead space
begins with identification and control of fluid Wounds can be closed with glues or adhesives,
sources, including meticulous hemostasis of the staples, or sutures. When closing the skin with
wound bed. Using an absorbable suture, the suture, one may decide between absorbable ver-
Scarpa’s fascia and reticular dermis are the ideal sus nonabsorbable forms (Table 5.2). Absorbable
layers to re-approximate to markedly reduce dead sutures degrade and lose their tensile strength
space. Generally speaking, the subcutaneous fat within 60 days. When choosing the optimal
should not be re-approximated given the tendency suture for closure, important aspects include the
that re-approximation strangulates blood supply inherent behavior of the suture material, pre-
which results in fat necrosis, another nidus for dicted course of wound healing, and how the
bacteria. Notably, closed suction drainage may be suture will interact with the tissue. Ideally, when
used per surgeon preference. a wound achieves maximal strength, suture is no
A final principle of closure is cosmesis. longer needed for reinforcement. Therefore,
Whatever technique of closure is utilized, all slowly healing tissue, including skin, fascia, and
attempts should be made to recreate the patient’s tendon, is often closed with nonabsorbable suture
natural contour and symmetry. Furthermore, fol- or absorbable suture with extended wound sup-
lowing skin folds, in accordance with the concept port, whereas rapidly healing tissue, gastrointes-
of Kraissl lines, should help minimize tension to tinal tract and bladder, may be closed with
avoid inadvertent skin separation and unsightly absorbable suture. The details of primary suture
scars. Some closures may be beset by abnormal closure material and techniques are numerous
scar formation including keloid and hypertrophic and referenced in Chap. 3.
scarring. Keloids are the result of granulation tis- Occasionally, a secondary line of sutures,
sue overgrowth at the site of skin injury that may retention sutures, is needed to reinforce the pri-
extend beyond the borders of the original skin mary suture line. This is typically done when
insult. Although considered a benign disorder, it there is a concern for wound healing with only a
can often lessen the quality of life for the patient primary suture line being intact or a concern for
in regards to poor cosmesis, pain, and pruritus. sudden increases in intra-abdominal pressure on
Hypertrophic scars are similar to keloids, as they abdominal incisions. Retention sutures are meant
are also raised lesions, but they do not extend to increase/contribute to the tensile strength of
beyond the boundaries of the original wound. The the primary suture line and are placed laterally to
best treatment for keloid scarring is prevention, the primary suture. Retention sutures are pre-
but if unable to do so, other treatment options are dominantly created with thicker nonabsorbable
available, such as pressure therapy or triple ther- suture and are kept in place with a bolster, to pre-
apy with corticosteroids, 5- fluorouracil, and vent cutting into the skin when the incision is
pulsed dye laser. Prior unappealing scars, either under stress, until the concern for improper
hypertrophic or atrophic, can be considered for wound healing has decreased, approximately
complete excision at the time of closure. 2–6 weeks postoperatively.
Suture Options
Absorbable Non-absorbable
Braided Monofilament Braided Monofilament
Vicryl Vicryl Fast Ethilon

Chromic
rapide Absorbing Monocryl Ethibond Silk
Table 5.2 Suture Gut
Gut
options for skin closure
5.5 Current Controversies/ • Three major goals of skin closure include

Future Directions minimizing wound-healing complications,
achieving primary skin closure, and optimiz-
Secure skin closure is an integral part of every suring cosmesis.
gical procedure and has routinely been performed • Take all necessary steps to prevent wound-
with sutures, staples, and dermal adhesives. In healing complications.
recent years, dermal adhesive technology compa- • Primary closure of the skin requires healthy,
nies have made advances in their closure devices. well-vascularized tissue.
One such device is a two-part skin closure system • Suture types can be broadly classified as
designed to approximate skin edges of an incision absorbable versus nonabsorbable based on
in place of or in addition to a traditional subcuticu- degradation properties. Choice depends on
lar stitch. Its components are a flexible, self-adhe- needs of the tissue in wound healing.
sive polyester mesh and a topical skin adhesive
that is painted over the mesh. It keeps the tradi- Editors’ Corner
tional skin adhesive property of providing protec-
tion from organisms commonly responsible for • Imaging studies should be routinely used to
surgical site infections (S. aureus, S. epidermidis, best plan the operative approach and decide on
and E. coli). This new system also allows for a the most useful location and orientation of the
theoretical superior distribution of tension along incision.
the incision by creating individual points of ten- • When planning a vertical midline incision, the
sion and stress that are unavoidable with sutures surgical trainee should remember the basic
and staples. There have yet to be any randomized anatomic characteristic of the linea alba: it is
controlled trials comparing this newer technology typically V shaped with its widest part in the
with traditional skin closure techniques. epigastric area. Access at this location is typi-
Barbed suture wound closure devices eliminate cally safer.
the need to tie knots at skin closure without com- • When planning a re-laparotomy, access should
promising the strength and security that traditional be sought a few centimeters proximal or distal
suture and traditional knot tying provide. The to the previous incision to try and minimize
suture is designed to have multiple, unidirectional, the risk of bowel injury.
circumferential barbs located along the entire • Several of the incisions described in this chap-
length of the suture to grasp the tissue and distrib- ter can be used as extraction sites after
ute the tension across the wound. The main benefit advanced laparoscopic procedures. While
that has been demonstrated between barbed many surgeons favor low transverse incisions
sutures when compared to traditional suture has for such role (i.e., lap colon-rectal proce-
been the decreased OR time with barbed suture dures), no final consensus has been reached on
along with decreased suture utilization [8]. No the ideal location for such incisions.
cosmetic benefit was identified at 12 weeks
between barbed suture and traditional suture.
Suggested Readings
Take-Home Points
Roses RE, Morris JB. Incisions, closures, and manage-
• Tenets of incision and closure revolve around ment of the abdominal wound. In: Zinner MJ, Ashley
SW, editors. Maingot’s abdominal operations. 12th ed.
an understanding of anatomy, wound behav-
Columbus: McGraw-Hill.
ior, and healing. Skandalakis LJ, Skandalakis JE, Skandalakis PN. Surgical
• The major goal in choosing the optimal surgi- anatomy and technique: a pocket manual. 3rd ed.
cal incision is assuring adequate visualization. New York: Springer.
Fischer JF, Jones DB, Pomposelli FB, et al. Fischer’s gery: a randomized, double-blind equivalence trial
mastery of surgery. 6th ed. Philadelphia: Lippincott (POVATI: ISRCTN60734227). Ann Surg. 2009;
Williams & Wilkins. 249(6):913–20.
Zollinger RM, Ellison EC. Zollinger’s atlas of surgical 4. Bland KI, Klimberg VS. Master techniques in sur-
operations. 10th ed. Columbus: McGraw-Hill. gery: breast surgery. 1st ed. Philadelphia: Lippincott
Bland KI, Klimberg VS. Master techniques in sur- Williams & Wilkins; 2011.
gery: breast surgery. 1st ed. Philadelphia: Lippincott 5. Zollinger RM, Ellison EC. Breast anatomy and
Williams & Wilkins. incisions. In: Zollinger RM, Ellison EC, editors.
Oertli D, Udelsman R. Surgery of the thyroid and parathy- Zollinger’s atlas of surgical operations. 10th ed.
roid glands. 2nd ed. Berlin: Springer. Columbus: McGraw-Hill; 2016. http://accesssurgery.
mhmedical.com.proxy.lib.ohio-state.edu/content.asp
x?bookid=1755&sectionid=119131008. Accessed 12
Aug 2017.
References 6. NCCN clinical practice guidelines in oncology
(NCCN guidelines): breast cancer. Version 2.2017.
1. Ly J, Mittal A, Windsor J. Systematic review and https://www.nccn.org/.
meta-analysis of cutting diathermy versus scalpel for 7. Joint Commission. The joint commission. 2017.
skin incision. Br J Surg. 2012;99(5):613–20. https:// https://www.jointcommission.org/.
doi.org/10.1002/bjs.8708. 8. Rubin JP, Capla JM, Dunn RM, Gusenoff J, Hansen J,
2. Brown SR, Tiernan J. Transverse verses midline Hunted J, Walgenbach K. A multicenter randomized
incisions for abdominal surgery. Cochrane Database controlled trial comparing absorbable barbed sutures
Syst Rev. 2005. https://doi.org/10.1002/14651858. versus conventional absorbable sutures for dermal
CD005199.pub2. closure in open surgical procedures. Aesthet Surg J.
3. Seiler CM, Deckert A, Diener MK, et al. Midline 2014;34(2):272–83.
versus transverse incision in major abdominal sur-
Fundamentals of Retractors
and Exposure 6
Michael B. Ujiki and H. Mason Hedberg
6.1 Introduction tors appear to be miniature versions of their open

counterparts, while in some circumstances
Proper exposure is critical to maximizing safety entirely new instrumentation has been developed
and efficiency in the operating room. An opera- to meet previously nonexistent needs.
tive field should be large enough to allow the The following chapter reviews technical con-
operating surgeon and assistants to visualize crit- siderations of surgical exposure, from patient
ical anatomy and manipulate instruments com- positioning to economy of motion. A useful sca-
fortably and also no larger than necessary in lar paradigm for retraction is introduced: large-
order to minimize unnecessary trauma. There are scale field exposure, effective recruitment of the
many varieties of surgical retractors, and the abil- operative assistant, and moment-by-moment use
ity to choose the right tool for the job can help of the surgeon’s nondominant hand. Additionally,
meet the goal of keeping the view clear and the types of surgical retractors available for open and
wound small. laparoscopic surgery are described and catego-
Traditional stainless steel open surgical retrac- rized for convenient reference.
tors were designed alongside the procedure they
were intended to assist, with shapes that were
carefully considered to meet a specific need. 6.2 Exposure
Effective, versatile designs have persisted to
become common surgical instruments found in 6.2.1 Positioning and Gravity
operating rooms worldwide. The evolution of
material science, laparoscopic, and robotic pro- Setting up the ideal operative field begins with
cedures brought with them new instrumentation patient positioning. Positioning must take into
for retraction. Some minimally invasive retrac- account the location of the surgeon and assistant
with respect to the operative field, as well as the
fixed and universal surgical retractor—gravity.
M. B. Ujiki (*) Gravity can be especially useful for abdominal
Department of Surgery, Grainger Center for
Innovation and Simulation, NorthShore University procedures given the mobility of some intra-
HealthSystem, Evanston, IL, USA abdominal organs. In general, once abdominal
e-mail: mujiki@northshore.org access has been obtained and initial exploration
H. Mason Hedberg completed in a neutral position, the operating
Department of Surgery, University of Chicago table should be adjusted for gravity retraction
Medicine, Chicago, IL, USA away from the operative field. This is
e-mail: herbert.hedberg@uchospitals.edu

96 M. B. Ujiki and H. Mason Hedberg
accomplished by elevating the operative field vantages. For example, while direct optical entry
with respect to the abdomen: appendectomy poses a risk to intra-abdominal structures adhered
should be performed with the head down and to the abdominal wall, it has been shown to
right side up, cholecystectomy with the head and reduce iatrogenic injuries from initial trocar
right side up [Editors’ Note: Move the target placement compared to Hasson technique in
organ toward the surgeon]. obese patients [2].
The utility of gravity differs between open and Once initial port placement is accomplished,
laparoscopic surgery. During open surgery, visu- additional ports can easily and safely be passed
alization is physically limited to an angle depen- through the abdominal wall under visualization
dent upon the size of the incision and distance with the laparoscope and a cushion of pneumo-
between the incision and the target organ. This peritoneum. A useful rule of thumb for laparo-
restricts maneuverability of the table, and in scopic port placement is triangulation, illustrated
some cases where gravity could be of assistance, in Fig. 6.1. Working ports should be positioned
packing and external retraction are utilized. such that when the instruments’ tips are brought
Laparoscopic surgery brings the view to the oper- together at the operative target, there is a 45–75°
ative field, so extreme table angles that would be angle between the instruments. This angular
inappropriate for open surgery can be advanta- range allows the necessary ergonomics for most
geous. For example, steep reverse Trendelenburg laparoscopic maneuvers. Usability of laparo-
is extremely useful for laparoscopic procedures scopic instruments is maximized when about
in the upper abdomen. half the length of the shaft is inside the abdomen.
Regular adult instruments are 36 cm long, so
working ports should be about 10–15 cm away
6.2.2 Incision and Port Placement from the location of the operative target as esti-
mated on the skin (Fig. 6.2). Generally the best
Location of incision or laparoscopic ports is the position for the camera to aid hand-eye coordi-
second consideration when setting up the ideal nation is behind and in between the working
operative field. The advantages of midline inci- ports, although for some procedures ergonomics
sions for open surgery have been well described: may be improved to have the camera to the out-
blood supply to the abdominal wall is maintained, side of the two working ports. Additional assis-
musculature is left intact for flaps such as TRAM, tant or retraction ports can be added laterally as
and access and closure can be performed rela- needed [3].
tively quickly [1]. A long midline laparotomy can
access the entire abdomen, so incisions made ini-
tially small for local exploration can easily be
extended when necessary. There are cases where
incisions off the midline are appropriate, such as
McBurney incision for appendectomy or right
subcostal for cholecystectomy—patients may
recover more quickly from a small incision
directly overlying these structures than a larger
midline laparotomy.
Up to half the operative complications that
occur during laparoscopic surgery happen during
initial port placement. The initial port may be
placed after insufflation with a Veress needle,
open with Hasson technique, or with an optical Fig. 6.1 Triangulation of working ports and assist port
trocar. Each technique has advantages and disad- placement (top view)
6 Fundamentals of Retractors and Exposure 97
to demonstrate appropriate positioning and

tension. Over time, a good assistant will
achieve synergy with the surgeon, anticipating
the order of maneuvers and providing the cor-
rect exposure for each when needed.
3. Moment-by-moment use of the surgeon’s

nondominant hand
The third level of retraction is the moment-by-
moment adjustments made by the operating
surgeon’s nondominant hand. The only thing
moving more than the surgeon’s nondominant
hand in the operative field is the surgeon’s
dominant hand. Motion-tracking studies of
surgeons’ instruments have demonstrated
working-space volume, and path length of
Fig. 6.2 Determining distance between working port and instrument tips can differentiate novice from
operative field expert surgeons [4]. The nondominant hand of
novices tends to move more than the dominant
hand, while the opposite is true of expert sur-
6.3 Retraction geons. Expert surgeons also operate in a volu-
metrically smaller space than novices. The
It can be useful to consider three spaciotemporal shift in the use of the nondominant hand
levels of retraction during a surgical case in order reflects improved economy of motion—mak-
to maintain ideal exposure at all times: ing the appropriate exposure adjustments only
when they are needed to improve performance
1. Large-scale field exposure of the dominant hand.
On the largest scale is retraction that sets the
stage for the entire operative field. This
includes factors that are set and may remain 6.3.1 Retractors
unchanged for the duration of a case: patient
positioning, gravity retraction, and self- Many types of surgical retractors have been devel-
retaining retractors. While these elements of oped over time. Many of the traditional retractors
exposure can be easy to “set and forget,” it is still in use today were developed alongside the
important to consider adjusting them when procedures they are intended to assist, with spe-
visualization or ergonomics are compromised. cific shapes designed to provide exposure for a
It may be the case that various steps of a long particular surgical maneuver. Both new materials
operation benefit from subtle adjustments to and new procedures have continued the pursuit of
gravity and self-retaining retractors. These designing the ideal tools to assist surgical expo-
adjustments can be worth the time when econ- sure. This section will place various retractors
omy of motion subsequently improves. into general categories and describe their distin-
2. Effective recruitment of the operative assistant guishing characteristics. See Tables 6.1, 6.2, and
The second level of retraction is that offered 6.4 for lists and brief descriptions of handheld,
by the assistant; the assistant’s hand is provid- self-retaining, and laparoscopic retractors, respec-
ing retraction at a smaller and more mobile tively. Associated photographs are provided for
scale than gravity or self-retaining retractors. specific examples. Tables 6.3 and 6.5 provide
It is the job of the surgeon to offer the correct some retraction pearls for common open and lapa-
instrument for the particular circumstance and roscopic procedures (Tables 6.4 and 6.5).
Table 6.1 Handheld retractors

Handheld
Name Description Figure
Richardson retractor Broad slightly saddled blade for body wall retraction 6.3a
Green retractor An open-ended Richardson for visualization of retracted tissue
Kocher retractor Broad flat blade with inward bent tip
Richardson-Eastman retractor Double-ended Richardson 6.3b
Goelet retractor Similar to but smaller than Richardson-Eastman
US Army retractor “Army-Navy” medium double ended with flat, narrow blades 6.3c
Mayo-Collins retractor Like US Army with forked blades
Mathieu retractor One end like US Army, one end like Mayo-Collins
Farabeuf retractor Similar to but smaller than US Army with flat, solid handle
Roux retractor Farabeuf with saddle blades
Parker retractor Farabeuf with curved blades
Parker-Mott retractor Parker with one curved and one straight flat blade
Little retractor Small, curved blade for fine, superficial retraction
Cushing vein retractor Small, saddle blade for gentle retraction of vein or nerve 6.4a
Love nerve retractor Thin, long handle with small curved blade
Blair (Rollet) retractor Small, fine rake for superficial retraction of wound edge
Volkman retractor Larger Blair—rake with blunt or sharp teeth
Freeman facelift retractor A rake with sharp, widely spaced prongs in a curvilinear pattern
Ragnell retractor Small, double ended with narrow, perpendicular spatulas
Linde-Ragnell retractor Ragnell with rough surface for increased friction
Senn retractor Small, one end like Ragnell, one end like Blair 6.4b
Davis retractor Larger Ragnell
Crile retractor Similar to Davis or Ragnell with proportionally wider blades
Jackson tracheal hook Provides vertical elevation of the trachea for emergent airway
Meyerding finger retractor One end like a Ragnell or Blair, other end with a finger-loop
Lahey retractor Single-ended US Army or Ragnell with solid handle
Langenbeck retractor Similar to a Lahey with a thinner, deeper blade
Skin hook Small, pair of hooks for superficial retraction, raising skin flaps 6.4c
Deaver retractor Broad, flat, and deep retractor with flat handle 6.5
Kelly retractor Deaver-like blade with a formed handle
Harrington retractor “Sweetheart” heart-shaped end for deep, gentle retraction 6.6b
Davidson retractor Broad, bent shape for scapula retraction 6.6a
Doyen retractor Large, saddle blade for pelvic exposure
Ribbon retractor “Malleable” bendable strip for customizable use 6.7
Table 6.2 Self-retaining retractors

Self-retaining
Weitlaner retractor Opposing rakes with finger rings and ratchet-locking mechanism 6.8a
Gelpi retractor Opposing spikes with finger rings and ratchet-locking mechanism 6.8b
Beckman retractor A long Weitlaner with hinged ends 6.8c
Beckman-Weitlaner retractor A Weitlaner with hinged ends
Adson retractor A long Weitlaner with ends at a fixed angle
Beckman-Eaton retractor A Beckman with broader rakes
Bookwalter retractor system Ring mounted to bed suspended over incision. Various retractors can be
positioned to provide sustained, opposing tension
Omni retractor system Adjustable arms mounted to bed positioned around incision. Various
retractors mount to arms to provide sustained tension
Table 6.2 (continued)
Self-retaining
Rultract Skyhook retractor Positions an adjustable arm vertically over the operative field to provide
system tension with retractors of various types and sizes
Lone star retractor Hooks with elastic tethers that can be stretched from a firm, circular
scaffold to produce circumferential retraction
Balfour retractor A pair of deep, opposing retractors on rails to open a laparotomy, with a 6.9
third retractor in between to apply perpendicular tension
Finochietto retractor “Rib spreader” opposing blades with rack-and-pinion mechanism
Wound protector Set of plastic rings separated by a thin, flexible plastic cylinder 6.10
Table 6.3 Retraction pearls for common open procedures

Open procedures Wrong Right
Inguinal hernia Using a metal retractor to Using a soft retractor like a Penrose to prevent injuries
retract cord structures
Cholecystectomy Inadequate initial exposure A self-retaining retractor system can be helpful to achieve
leads to difficulty as the ideal exposure: right ribs elevated, Deaver or sweetheart to
dissection proceeds deeper retract the liver, colon inferior, and stomach medial. Packs can
into the abdomen be used to elevate segment IV and expose the porta hepatis
Laparotomy “Set and forget” self-retaining Self-retaining retractor systems should be adjusted as the
retractor technique operation proceeds to provide ideal exposure in the operative
area and relieve pressure on tissues when possible
Table 6.4 Laparoscopic retractors

Laparoscopic
Hasson “S” retractor Thin curved blades to aid open entry initial trocar placement
Keith needle and suture Can be passed across the abdominal wall to elevate structures
Laparoscopic peanut Simple shaft with cotton fabric tip
Laparoscopic Deaver Retractable curved blade for blunt dissection and retraction
Fan retractor End of shaft has spreadable blades to form broad surface 6.11
Nathanson retractor Curved, rigid rod passed through abdominal wall, mounted to bed
Articulating retractors Rod with one to four joints that flex and lock. Can be inserted
through port and mounted to bed for self-retained retraction
Table 6.5 Retraction pearls for common laparoscopic procedures

Laparoscopic
procedures Wrong Right
Inguinal hernia Neglecting a full urinary Bladder should be emptied prior to surgery to avoid trocar
bladder injury and improve exposure
Cholecystectomy Inadequate manipulation of Infundibulum should be retracted toward the camera and
gallbladder infundibulum laterally for best exposure of biliary anatomy
Exploration Leaving the patient supine Take advantage of gravity retraction to minimize unnecessary
tissue manipulation
Fig. 6.3 Common
handheld retractors. (a) a
Richardson, (b)
Richardson-Eastman, (c)
US Army
Fig. 6.4 Fine handheld

retractors. (a) Cushing a
vein retractor, (b) Senn
retractor, (c) skin hook
Fig. 6.5 Various Deaver

retractors
Fig. 6.6 (a) Davidson scapula retractor, (b) Harrington

“sweetheart” retractor a b
Fig. 6.7 Various
malleable ribbon
retractors
a b
Fig. 6.8 (a) Weitlaner

retractor, (b) Gelpi
retractor, (c) Beckman
retractor
Fig. 6.9 Self-retaining Balfour retractor
a b
Fig. 6.10 Wound protector: This self-retaining retractor the other is used to wrap and shorten the cylinder, which
is a set of plastic rings separated by a thin, flexible plastic opens the incision and isolates wound edges (b)
cylinder (a). One ring is placed through the incision, and
Fig. 6.11 Laparoscopic
fan-style retractor
6.3.2 Handheld Retractors Retractor blades are rectangular, positioned at

a right angle to the handle. The intended use of
Handheld retractors are meant to be mobile and bladed retractors determines the shape and
easily repositionable. They are generally in the height/width proportion of the blade. Blades
hands of the surgical assistant, who should come in three shapes: flat, curved, or saddled.
change position in between maneuvers as appro- Retractors with flat blades often come in two
priate to the procedure. All handheld retractors varieties, with or without a slightly inwardly bent
have two basic commonalities: the working end distal tip that forms a lip to prevent retractor slip-
to manipulate tissue and the handle. They may be page. The US Army retractor (Fig. 6.3c) is a very
double ended, with two working ends and a han- common instrument that is manufactured both
dle in the middle, to allow rapid exchange with and without a distal lip. Curved retractors
between two types of working ends. Working conform to cylindrical structures for secure
ends come in two major varieties: blades or rakes. retraction. Saddle-shaped blades are similar to
curved but have a second curve opposite and per- to secure elastic bands that tether small hooks for
pendicular to the first, like a hyperbolic parabo- tissue retraction. Opposing hooks are placed cir-
loid. This shape helps reduce tissue damage at the cumferentially, resulting in widening of the ori-
edges of the retractor. The Richardson (Fig. 6.3a) fice and access to the rectum. Another notable
is a familiar retractor utilizing this shape. The flat self-contained retractor is commonly known as a
portion of the Richardson’s blade reflects its wound protector (Fig. 6.10). This is a set of plas-
intended use against the abdominal wall, whereas tic rings connected by a cylindrical plastic sheet.
the Cushing vein retractor (Fig. 6.4a) has no flat One ring is passed through the wound, and the
surface and is intended for gentle retraction of a extracorporeal ring is turned around its circum-
cylindrical structure. ference order to wrap and shorten the cylindrical
The second type of retractor working end is sheet. As the sheet shortens, it applies pressure
the rake. The individual prongs of rakes vary both against the wound edges and forces them apart.
in number and sharpness. For example, Fig. 6.4c This retractor isolates wound edges from the
is of a skin hook, which is a small retractor with operative field, and has been shown to reduce risk
two sharp prongs, intended to raise a thin, super- of wound infection [5, 6].
ficial layer to develop skin flaps. The hooks allow Retraction systems are mounted to the operat-
penetration and stable retraction of thin tissue ing table and can support multiple different retrac-
without distorting or concealing the wound edge. tors at once. Common examples are the
The Senn retractor (Fig. 6.4b) features one end Bookwalter and Omni systems. The Bookwalter
with multiple, thicker prongs, which results in involves mounting to the table a steel ring that
less tissue penetration than the two hooks on the surrounds the incision. Individual retractors are
skin hook. The number, distribution, and sharp- then secured to the ring. Similar to self-constrained
ness of the rake determine the application it is retractors, the Bookwalter relies on opposing
best suited to. forces to keep the ring in centered; too much ten-
sion on one side or the other can skew the original
fixation to the table. There are several different
6.3.3 Self-Retaining Retractors sizes of supporting rings to accommodate differ-
ent sized surgical incisions. In contrast, the Omni
Self-retaining retractors are appropriate for expo- system utilizes steel arms that can be positioned
sure that is expected to remain unchanged for around the incision to support various retractors.
long periods of time or when the hands available This eliminates the need for different size compo-
at the operating table are needed for more active nents as with the Bookwalter rings. While both of
tasks than retraction. They fall into two major these systems can be considered critical to long,
categories: relatively small, self-contained instru- open surgical cases, they also are bulky and can
ments and large, table-mounted retraction restrict access around the operating table.
systems. Sustained pressure against tissues can result in
In order to provide retraction without fixation ischemia and injury. Risk of injury is proportional
to the operating table, self-contained instruments to the quantity and duration of force applied and
utilize opposing forces. One of the most familiar as such is more often associated with self-retain-
examples is the Weitlaner (Fig. 6.8a), which uses ing retractors used during long cases. Clinically
finger loops and a ratchet mechanism to direct relevant retractor injury is rare when proper pre-
two rakes away from each other. Two of these caution is taken. Steel retractor blades of mounted
instruments placed perpendicularly to each other retractor systems should be separated from tissue
can provide excellent exposure through a small with moist laparotomy pads to provide padding
wound, such as with open inguinal hernia repair. and prevent tissue desiccation. Self- retaining
Another example is the Lone Star, often used to retractors utilized in laparoscopic surgery carry
retract the anus for transanal rectal surgery. The the same risks, and ischemic injury due to laparo-
Lone Star is a circular plastic scaffold with slots scopic liver retraction has been reported [7].
6.3.4 Laparoscopic Retraction keep the falciform suspended out of the way of
the operative field.
As with open surgery, various techniques and
instrumentation for retraction have accompanied Take-Home Points
the development of laparoscopic procedures.
Take-home points, to include a summary of the
Laparoscopic retractors can also be considered
most important points (5–10 bullets):
self-retaining or handheld. The simplest of the
handheld laparoscopic retractors is the peanut,
• Perfecting exposure improves efficiency and
simply a shaft with a cotton tip. Some designs,
safety.
such as one with spreading fanlike projections
• Spaciotemporal levels of retraction during a
(Fig. 6.11), can increase surface area after passing
case:
through the trocar for more broad retraction. In the
–– Field exposure (positioning, gravity
case of robotic surgery, a robotic assist arm can act
retraction)
as both a handheld and self-retaining retractor. The
–– Assistant retraction (appropriate instru-
assist arm can be toggled and adjusted easily to
mentation and guidance)
change exposure and then left in place for as long
–– Surgeon’s nondominant hand
as needed, providing an extremely versatile and
• Know the correct retractor for the job at hand.
easily adjustable retraction.
• Be mindful to avoid retractor injury during
Anterior retraction of the left lobe of the liver
long cases.
is necessary for most laparoscopic procedures in
the upper abdomen, and several approaches have
Editors’ Comments
been developed to serve this purpose. The
• Learning to arrange the retractors for a spe-
Nathanson retractor is a curved steel rod that can
cific procedure is a critical skill that any surgi-
be percutaneously introduced subxiphoid and
cal trainee needs to concentrate on.
rotated to retract the liver. A support mounted to
• While the surgeon should consider whether or
the table holds the retractor in place. An alternate
not adequate exposure has been achieved, one
approach utilizes a trocar just inferior to the right
should beware of how inefficient it is to
lateral edge of the liver to introduce an articulat-
frequently interrupt the procedure to adjust
ing retractor, a rod that can be tightened into a
the retractors.
polygonal shape. Articulating retractors may be
• “An accomplished surgeon practices economy
exchanged through trocars as needed like any
of movements and economy of words,”
laparoscopic instrument or secured to the table
F.E. Rosato Sr., MD FACS.
for self-retaining retraction. A recent approach
for liver retraction involves grasping the liver
edge with a locking grasper, the end of which can Suggested Readings
be dropped from the device, leaving behind a
magnet attached to the liver edge. This magnet Chassin’s chapter on Incision, Exposure, Closure in
open abdominal surgery: Scott-Conner CEH, edi-
can be directed to a larger magnet placed on the
tors. Chassin’s operative strategy in general surgery.
patient’s skin to achieve incisionless, percutane- New York: Springer. p. 19–25.
ous liver retraction. Another simple but useful Review and rationale for ergonomic laparoscopic
retraction technique in the upper abdomen is port placement: Supe AN, Kulkarni GV, Supe
PA. Ergonomics in laparoscopic surgery. J
passing a Keith needle through the abdominal
Minim Access Surg. 2010;6(2):31–6. https://doi.
wall around the falciform. A gentle knot will org/10.4103/0972-9941.65161.
References 4. D’Angelo A-LD, Rutherford DN, Ray RD, Laufer

S, Mason A, Pugh CM. Working volume: validity
evidence for a motion based metric of surgical effi-
1. Scott-Conner CEH, Chassin JL. Incision, exposure, ciency. Am J Surg. 2016;211(2):445–50. https://doi.
closure. In: Scott-Conner CEH, editor. Chassin’s org/10.1016/j.amjsurg.2015.10.005.
operative strategy in general surgery. New York: 5. Lee P, Waxman K, Taylor B, et al. Use of wound-
Springer; 2014. p. 19–25. protection system and postoperative wound-
2. Tinelli A, Malvasi A, Mynbaev OA, et al. infection rates in open appendectomy. Arch Surg.
Bladeless direct optical trocar insertion in lapa- 2009;144:872–5.
roscopic procedures on the obese patient. JSLS. 6. Sookhai S, Redmond HP, Deasy JM. Impervious
2013;17(4):521–8. https://doi.org/10.4293/1086808 wound-edge protector to reduce postoperative wound
13X13693422519398. infection: a randomised, controlled trial. Lancet.
3. Supe AN, Kulkarni GV, Supe PA. Ergonomics in lapa- 1999;353:1585.
roscopic surgery. J Minim Access Surg. 2010;6(2):31– 7. Nozaki T, Kato T, Komiya A, Fuse H. Retraction-
6. https://doi.org/10.4103/0972-9941.65161. related acute liver failure after urological laparoscopic
surgery. Curr Urol. 2013;7:199–203.
Fundamentals of Dissection
7
Neal S. McCall and Harish Lavu
7.1 Introduction importance of the fundamentals of surgical tech-

nique. There exists a great deal of literature about
Surgery distinguishes itself from other fields of surgical dissection within the context of specific
medicine by its emphasis on operator depen- types of surgery and their respective consider-
dence. Studies suggest that surgical outcomes ations, yet few texts provide readers with an
relate to not only what procedure is being per- appreciation of the general and broad concepts as
formed but also by the technical competency of they relate to surgical dissection. This chapter
the operating surgeon [1–4]. Over a 5-year clini- explores fundamental surgical dissection tech-
cal time period, surgical trainees are expected to niques as well as more advanced instrumental
attain the skills to perform approximately 121 techniques and their applications across many
independent operations, despite the fact that on surgical fields.
average, they will perform less than 15% of these
procedures more than ten times during their resi-
dency [5–7]. And yet, research reveals that more 7.2 General Concepts
than 60% of operative errors stem from improper
surgical technique [8]. Human error—due to 7.2.1 Positioning
inadequate judgment, understanding, education,
experience, or skill—thus remains among the Conditions in the operative room should be
most relevant factors in surgical morbidity and designed to optimize the surgeon’s visualization
mortality outcomes [8–11]. This speaks to the of the surgical field and allow for maximal expo-
sure. Gravity should be used to a surgeon’s
advantage whenever possible. For example, many
N. S. McCall gynecologic procedures are facilitated by placing
Department of Surgery, Sidney Kimmel Medical the patient in the Trendelenburg position, in
Philadelphia, PA, USA which the patient’s head is angled 15–30° toward
e-mail: neal.mccall@jefferson.edu the ground. This maneuver allows for easy mobi-
H. Lavu (*) lization of the small intestine away from the pel-
Jefferson Pancreas, Biliary and Related Cancer vis [12]. In contrast, the reverse Trendelenburg
Center and the Department of Surgery, Thomas position (Fowler), placing the patient’s feet
Jefferson University, Philadelphia, PA, USA 15–30° below the horizontal, can decrease
Sidney Kimmel Medical College, Thomas Jefferson engorgement of the jugular veins, facilitating
University, Philadelphia, PA, USA safer dissection during head and neck surgery.
e-mail: Harish.lavu@jefferson.edu

108 N. S. McCall and H. Lavu
Positioning the patient in moderate Fowler positions associated with cardiovascular surgery by
tion with the right side rotated down can also be improving the surgeon’s visualization of small
helpful in the dissection of the left upper quad- surgical anastomoses [17]. Proper adjustment of
rant, allowing for greater exposure of the splenic the headlamp is vital; many surgeons find them-
flexure of the colon, tail of the pancreas, and selves readjusting their neck rather than their
spleen during operations involving this region of headlight intraoperatively. This can be avoided
the body [13]. by focusing one’s gaze on an object while main-
In the lithotomy position, the patient’s hips are taining the neck in a neutral position and adjust-
flexed to 80–90° and abducted 30–45° with feet ing the lamp using this gaze as a reference, prior
placed in stirrups at the level of the knees. This to the commencement of the procedure.
provides the surgeon with maximal exposure of
the perineum and rectum. A variant of this is the
low lithotomy position, where the lower extremi- 7.2.3 Exposure and Planning
ties are elevated to a lesser degree than full lithot-
omy. Care should be taken to avoid injuring the Incision planning should use standardized
neuronal and vascular structures of the leg during approaches so as to facilitate operative exposure,
this type of positioning. Notably, lithotomy posi- prevent injury to underlying structures, and opti-
tion should be avoided for periods longer than 5 h mize wound healing. For example, trocar place-
to minimize the risk of fibular and femoral neu- ment in laparoscopic lower abdominal surgery
ropathy and compartment syndrome [14, 15]. As should be carefully located so as to avoid injuring
any given operation progresses, especially if it the inferior epigastric vessels. In open surgery,
necessitates work within multiple regions of the the length of the incision should be as small as
abdomen or body, it is important to reassess bed possible while maintaining the surgeon’s ability
position periodically, ensuring that maximal expo- to have reasonable dexterity with their hands.
sure is always attained. For a further discussion of
positioning and exposure, refer to Chaps. 4 and 6.
7.2.4 Imaging
7.2.2 Lighting Cross-sectional imaging has become an invalu-

able tool in preoperative planning for complex
The importance of adequate operative lighting surgery. With special emphasis on vital structures
during dissection cannot be understated. Before at risk during a given operation (vascular, neuro-
incision, luminaires should be equipped with a nal, ureters, etc.), this allows the surgeon at the
sterile handle and positioned with hinges at time of the operation to dissect through difficult
appropriate angles from one another to minimize tissue planes with a mental 3D map of the rele-
mechanical interference during manipulation. On vant anatomical relationships. This becomes even
average, the overhead lights are readjusted every more critical during laparoscopic or robotic oper-
7 to 8 min intraoperatively to ensure consistently ations, where tactile sensation is significantly
optimal visualization of the field of dissection diminished or completely absent. A careful
[16]. When possible, luminaires should be posi- review of imaging prior to surgery with a special
tioned such that the path of light is parallel to the emphasis on vital structures allows the surgeon to
surgeon’s visual field of view, to prevent the identify potentially uncommon but critical ana-
development of eye fatigue from stray light. tomic variants, such as a replaced right hepatic
While standard surgical luminaires are adequate artery from the superior mesenteric artery during
for most procedures, particularly deep or narrow pancreaticoduodenectomy. This vessel can easily
surgical fields may necessitate the use of fiber- be injured during dissection along the lateral
optic headlamps [17, 18]. The use of these aspect of the common bile duct if the surgeon is
devices has been shown to decrease complica- unaware of its presence. Likewise, preoperative
7 Fundamentals of Dissection 109
ultrasound has been shown in particularly side of the incision to apply adequate tension.
inflamed cases of cholecystitis to predict the need The incision is begun with the tip of the scalpel
for laparoscopic conversion to open surgery dur- but then should continue primarily with the belly
ing cholecystectomy [19]. Cross-sectional imag- of the blade (#10 blade) in a single sweeping
ing such as computed tomography (CT) and motion. When multiple incisions are necessary,
magnetic resonance imaging (MRI) can help to consider making the lower incision first to mini-
elucidate the relevant surgical anatomy and, in mize blood obscuring the surgical field.
particular, define appropriate tissue dissection Compression of the edges of the incision with
planes which allows for a more rapid as well as fingertips and gauze can effectively control minor
safe surgical technique [20]. The use of oral and blood loss. The lower dermis and subcutaneous
intravenous contrast agents can further help to tissues are ideally divided with electrosurgery to
achieve diagnostic and therapeutic clarity. limit bleeding (see “Instrumental Dissection”).
Sharp scissor dissection is ideal when lysing
intra-abdominal adhesions so as to avoid thermal/
7.3 Technical and Practical electric injury to surrounding structures and to
Considerations and Safety prevent tearing of the serosal layer of the bowel.
Precautions Severely inflamed tissues may also require sharp
dissection to penetrate the hard or sometimes
The type of dissection technique used during a edematous tissue planes and to precisely stay on
given operation is most often governed by the the appropriate track with the direction of the
proximity of the dissection plane to vital sur- dissection.
rounding structures. Sharp dissection during the
incision is usually accomplished with a scalpel
and is limited to incising the skin and upper der- 7.3.2 Blunt Dissection
mis. Sharp dissection with Metzenbaum scissors
is also commonly used to lyse intraabdominal Splitting, a blunt dissection technique, generally
adhesions and to carefully dissect inflamed tissue involves inserting the closed, blunt tips of the
planes. Blunt dissection, on the other hand, often scissors into tissues and then opening the scis-
involves separating delicate (sometimes neuro- sors; this repeated rapid and gentle opening
logic or vascular) structures along a more natural motion with the blunted ends facilitates the dis-
path with fingers or blunt instruments. It allows section [22]. The splitting technique should be
the surgeon to follow natural tissue planes rather performed in a direction perpendicular to the
than creating artificial ones. strongest tissue, enabling dissection of the weaker
connective fascia. Alternatively, nearly closed
scissors can be inserted into a previously defined
7.3.1 Incision and Sharp Dissection plane and then advanced along a parallel path of
weak connective tissue. Thicker, stronger fibrous
The scalpel fitted with a #11 or #15 blade [see tissue can be carefully dissected using the sharp
Chap. 2 Appendix on instrumentation] should be aspect of the scissors. Applying too much force
held in the surgeon’s dominant hand 3–4 cm from during blunt dissection can result in unwanted
the tip of the blade, in the similar configuration as injury to the tissues [23]. For example, in the case
a pen is held with the index finger placed on the of a dissection being carried out in the popliteal
superior aspect. Alternatively, the scalpel fitted region, adipose tissue may obscure the peroneal
with a #10 blade may be held like the “bow of a nerve, and the use of blunt rather than sharp dis-
violin” with the thumb on the medial aspect of section can result in inadvertent injury [23, 24].
the instrument and the four fingers supporting the Thus, understanding the local tissue architecture
lateral side [21]. The non-dominant hand (and and relevant anatomy is paramount to the choice
eventually retractors) should be used on either of dissection technique.
Cautious manual tearing, otherwise known as during a lysis of adhesion procedure. Dense,
finger fracture, is another technique to identify a fibrous adhesions, when instilled with saline
plane of weakness in tissues. This is accom- under moderate pressure from a bulb syringe,
plished by first applying force between the index become soft and easier to dissect without injuring
finger and thumb of the dominant hand on the tis- adherent viscera. Occasionally, an epinephrine
sue that one intends to separate. Care should be solution may be preferred for vasoconstrictive
taken to avoid applying too much force during hemostasis. This technique is frequently
this maneuver, as it can result in the creation of employed in many laparoscopic procedures as
false tissue planes. However, when used appro- well as stress incontinence and pelvic organ pro-
priately, the finger fracture technique can rapidly lapse procedures, where its use aids in the devel-
speed along a particular dissection. opment of a plane underneath the pubocervical
Peeling is a technique used to liberate a flexi- fascia for sling placement.
ble structure from adherent tissue by the use of Following the initial skin incision, electrosur-
friction generated by a blunt device [i.e., sponge, gery using the Bovie is often employed to dissect
peanut, suction catheter tip]. The blunt device of through subcutaneous tissues and to cauterize
choice is gently advanced in a repetitive fashion isolated small vessel bleeding. Caution should be
perpendicular to the area of adhesion to separate used especially with monopolar electrosurgery,
the tissue layers [editors’ note: gentle additional as it can cause adjacent tissue damage. When this
rotating motion is critical to successfully apply- is used to dissect through subcutaneous tissues
ing this technique]. and enter the abdominal cavity, it is crucial to
protect underlying intraperitoneal structures, as
shown in Fig. 7.1. Bipolar energy, though safer, is
7.3.3 Instrumental Dissection less effective at dissecting through larger amounts
of tissue and is usually employed for cautery of
A number of instrumental dissection techniques small, focal, and delicate regions. Multiple
are now available to the surgeon to facilitate safe Bovie® electrodessication systems, named after
surgery. For example, water-jet dissection is a the father of modern electrosurgery, are available
form of blunt dissection which uses the high- for a variety of surgical procedures. These are the
pressure flow of water to separate tissues based most commonly utilized monopolar electrosurgical
on structure and resistance and has been employed
in hepatic, renal, parotid, and orthopedic surgery.
This technique is particularly effective in hepatic
surgery, separating ductal structures and vessels
from the overlying hepatic parenchyma. In at
least one study, the implementation of water-jet
dissection led to decreased operative transfu-
sions, complications, and length of stay in hepatic
surgery [25].
Hydrodissection is a technique that, though
often confused with water-jet dissection, is
unique in itself and does not require additional
instrumentation. It involves the injection of saline
under moderate pressure into the tissue planes
using a common bulb syringe. This technique
serves to increase the tissue volume, softens
adhesions, expands the tissue plane, and can Fig. 7.1 Electrocautery dissection. In this photograph,
the assistant surgeon is elevating tissue to be transected by
allow for transillumination [11, 26]. This is an electrocautery, so as to avoid injury to underlying intra-
extremely useful, yet underutilized, technique abdominal structures
instruments. The LigaSure® system is an example surgical site. Intraoperative photographs of a

of a bipolar diathermy instrument that seals ves- Bookwalter retraction device are shown in
sels clamped between its jaws up to seven milli- Fig. 7.2a,b. An important consideration with these
meters in size, in 2–4 s of bursts of energy. It has systems, as with all forms of retraction, however,
been shown to reduce perioperative blood loss, is that the creation of very high tensile pressure on
procedure time, and length of stay in a variety of the tissues during retraction can result in damage
surgical settings [27, 28]. and poor wound healing. For this reason, some
Surgeons may opt for ultrasound cutting and newer retraction systems, such as the elastic
coagulation instruments, such as the Harmonic® LoneStar®, have replaced rigid metal with elastic,
system. These instruments convert mechanical theoretically reducing the potential for tissue
force to heat by rupturing hydrogen atoms in the damage.
tissue. The main advantage of ultrasound dissec-
tion is a lower amount of thermal spread and adja-
cent tissue destruction compared to electrosurgical 7.3.5 Traction and Counter-Traction
systems [29]. Modern versions of this system can
now ligate vessels up to 7 mm in size [30]. The principle of traction and counter-traction can
Laser dissection and coagulation systems are dramatically improve the precision of surgical
yet another older alternative to electrosurgical dissection. This technique increases the surgeon’s
systems. They can minimize adjacent tissue dam- visual field, by separating vital juxtaposed tissues
age, providing the precise and controllable appli-
cation of energy. Laser use is more common in
a
ophthalmologic and cosmetic procedures, while
its use has declined in gynecologic and general
surgery procedures, primarily as a result of the
development of electrosurgical systems [32].
These concepts are further and more in depth dis-
cussed in Chap. 9.
Despite the increasing importance of technol-
ogy in the operating room, innovations alone can-
not replace meticulous dissection and a
fundamental understanding of anatomic land-
marks [11]. In fact, when using advanced energy
devices, it can be more difficult to follow natural
tissue planes of dissection and easier to get off b
track, as these devices can create their own (poten-
tially aberrant) planes of dissection.
7.3.4 Retraction
In terms of exposure, proper visualization of the

surgical field would be impossible without ade-
quate retraction [31]. As an example, during
complex, open abdominal surgery, self-retaining
retractors are often utilized. For example, the
Fig. 7.2 Bookwalter® retraction system (a, b). A
Bookwalter® and Omni-Tract® retraction systems Bookwalter retraction system is shown before (a) and
provide a scaffolding on which multiple retractor after (b) the abdomen is retracted, demonstrating
blades can be attached to provide exposure to the improved deep and lateral abdominal exposure
and allowing for the identification of the appro- tially allowing for cancerous breast tissue to
priate tissue planes. As an example, the Kocher remain adherent to the skin flap, whereas skin
maneuver is an operative technique that allows flaps that are made too thin can result in poor
the surgeon to mobilize the duodenum and pan- wound healing after surgery.
creatic head out of the retroperitoneum. The peri- During open abdominal surgery for adhesive
toneal attachments of the duodenum are retracted disease, hand retraction is used to create tension
laterally by the assistant surgeon, while the duo- on the adhesion. This tension allows for a sharp
denum and pancreatic head are retracted medi- dissection technique to be carried out using scis-
ally by the surgeon, as shown in Fig. 7.3. This sors. In situations where adequate tension is not
allows for the dissection to be carried out in an able to be created, sharp dissection may be inap-
avascular plane. propriate or unsafe.
During laparoscopic cholecystectomy, lateral
traction is placed on the gallbladder at the level of
Hartmann’s pouch, which positions the cystic 7.3.6 Tissue Planes
duct at a 90° angle to the common bile duct, min-
imizing the risk of inadvertent injury to the Proper identification of natural surgical planes,
hepatic or common bile ducts [32] (Fig. 7.4a–d). often avascular in nature, permits the safe isola-
During mastectomy, the surgeon places traction of anatomical structures and allows sur-
tion on the underlying mammary tissue. Skin geons to avoid injury to vital structures. These
hooks are used by the assistant surgeon to create planes are often convoluted, requiring a complex
counter-traction to expose the appropriate plane visuospatial and tactile acuity. Many examples
of dissection. These hooks should be held per- abound and vary based upon a given operation.
pendicular to the plane of dissection. Failure to For example, the white lines of Toldt on the lat-
do so may cause the flaps to be too thick, poten- eral borders of the ascending and descending
colon are avascular reflections of posterior pari-
etal peritoneum that are critical to properly iden-
tify during a hemicolectomy procedure or during
exposure of the ureters. The performance of
extraperitoneal hernia repair depends upon the
ability to create a dissection plane within the pre-
peritoneal space, which lies between the poste-
rior rectus sheath and peritoneum. Another
example is the plane between the pelvic parietal
fascia and mesorectal fascia, referred to among
colorectal surgeons as “the holy plane,” which
facilitates an oncologically sound en bloc resec-
tion of the mesorectum in patients with rectal
cancer while sparing the sacral vessels and hypo-
gastric nerves [33–36]. Improvement in the
understanding of rectal anatomy led to the devel-
opment of this technique and to substantially
lower rectal cancer recurrence rates [36].
Fig. 7.3 The Kocher maneuver. A Kocher maneuver dur- Pulmonary segmentectomy, a procedure mini-
ing pancreaticoduodenectomy is shown. The surgeon cre- mizing the degree of parenchymal resection,
ates tension on the medial duodenal wall and pancreatic depends entirely upon identification of the plane
head, while the assistant creates counter-tension with the
Debakey forceps on the retroperitoneal attachments to the
between the bronchopulmonary segments [34].
duodenum. This allows for identification of the proper This plane can be accomplished by clamping the
avascular tissue plane for dissection using the right angle segmental bronchus and then gently inflating the
a b
Fig. 7.4 Visualization of the triangle of Calot can prevent Inadequate lateral traction has been applied to the gallblad-
accidental transection of the common bile duct. (a) Lateral der resulting in the common bile duct being mistaken for
and cephalad traction has been applied to the gallbladder, the cystic duct. (c) Intraoperative photograph demonstrat-
allowing for safe transection of the cystic duct. (b) ing the right angle clamp placed behind the cystic duct
lung. The intersegmental plane, defined by pul- Additionally, the presence of putrid or foul odors
monary veins and lymphatics, should lie at the may signify infection or necrosis of tissue. In the
junction of inflated and deflated tissue [33]. setting of chronically inflamed tissue, fibrotic
changes can also contribute to the distortion of
normal anatomy. These changes may require use
7.3.7 Inflamed Tissue of sharp dissection in place of intended blunt
dissection. Chronic inflammation may also pre-
Dissection of acute or chronically inflamed tis- dispose tissues to pathologic fistulous connec-
sue may require special consideration. Acutely tions. The chronic inflammation of Crohn’s
inflamed tissue will often be more edematous disease predisposes the alimentary tract to fistu-
and vascular than healthy tissue. Edema can dis- las, including anorectal, enterovesical, and
tort the appearance and location of important enterocutaneous types [37]. Encountering
anatomic landmarks, while the increased vascu- abscesses or soft tissue infection should prompt
larity of inflamed tissues can obscure visualiza- adequate drainage and debridement. Regardless
tion of the dissection plane due to bleeding. of the pathologic condition encountered,
dissection should proceed in a direction from dilation (termed “double-duct sign”). In locally
normal tissue toward inflamed tissue, identifying advanced cases, pancreatic adenocarcinoma can
all normal landmarks before engaging altered involve the portal and superior mesenteric veins
ones. In complex, multistep operations, the order or superior mesenteric artery, which may pre-
of the completed steps should be appropriately clude safe surgical resection.
adjusted by the surgeon based upon the particu- As a general rule, resection of malignant
lar challenge a given case may pose. In such a tumors should proceed in a cautious fashion with
case, the surgeon should complete the easiest, the intent to remove the intact tumor as well as an
most straightforward steps prior to moving onto appropriate margin of surrounding healthy tissue
more difficult ones. This is important for two and the relevant lymph node basins for the tumor.
reasons. It keeps the operation moving forward Removal of large benign tumors, such as fibroids
in a timely fashion, and it also improves the visu- and posterior fossa masses, may be facilitated by
alization and mobilization of the tissues so that debulking. This can be accomplished with radio-
these are optimized prior to attempting to tackle frequency, ultrasound, or electrosurgery as means
the most difficult and potentially dangerous to reduce the tumor volume [39].
steps of the procedure.
7.4 Current Controversies

7.3.8 Neoplasms and Future Directions
Surgical resection of a neoplasm requires several 7.4.1 Cognitive Bias in Surgery

unique considerations with respect to dissection.
Foremost, preoperative planning and review of Research has demonstrated that cognitive biases
imaging become paramount. Preoperative imag- play an important role in surgical errors, includ-
ing is essential to confirm a given patient’s candi- ing wrong-patient, wrong-side, and wrong-
dacy for surgery, allow for the identification of procedure surgeries [40, 41]. One type of
anatomic abnormalities or variants, and give a cognitive bias, confirmation bias, is defined as
sense of where the dissection must proceed to one’s propensity to seek information to confirm
obtain negative surgical resection margins. rather than to challenge one’s presumptions.
If the tumor is well-encapsulated and benign Way et al. [42] retrospectively analyzed opera-
in nature, wide margins may not necessarily be tive notes and videotapes of cholecystectomy
indicated, and the surgeon can dissect closer to cases complicated by common bile duct (CBD)
the margin of the capsule. However, it is impor- injury. In some cases, the cystic duct was
tant to consider that some malignant tumors may obscured by the infundibulum. Adequate cepha-
appear to be well-defined on imaging but in actu- lad and lateral traction of the gallbladder allows
ality demonstrate microscopic invasion of sur- for what has been referred to as “the critical view
rounding tissues. Some central nervous system of safety,” as illustrated in Fig. 7.1a. However,
tumors, most notably glioblastoma multiforme, inadequate lateral traction creates the illusion
may be impossible to delineate from healthy neu- that the common bile duct is the cystic duct. Way
ronal tissue. In this case, general anesthesia may et al. found that this illusion caused the inadver-
be forgone for an awake craniotomy to ensure tent transection of the common bile duct, as
that surgical dissection does not result in a func- shown in Fig. 7.1b–d. In these cases, the authors
tional neurologic deficit [38]. It is important to be reasoned, the surgeon was betrayed by their sub-
aware of the likely direction of spread of malig- conscious brain’s propensity to relate their visual
nant tumors and the possibility of invasion or field to that of the preconceived, mental image of
impingement of adjacent vital structures. For the biliary tree.
example, pancreatic adenocarcinoma frequently While there exists evidence of the impact of
obstructs the bile and pancreatic ducts, resulting nontechnical cognitive skills on surgeon perfor-
in biliary dilatation as well as pancreatic ductal mance, consensus on how to mitigate the
impact of cognitive bias and nontechnical skill Editors’ Corner

is lacking [40]. Moreover, unlike a surgeon’s
technical skills, a surgeon’s ability to assess his • Blunt dissection: its basic concept can be sum-
or her own nontechnical skills is limited [43]. marized as finding the path of least resistance
Research has suggested that simply requiring around/toward the target organ. Adequate bal-
more operating experience is unlikely to be suc- ance between force to be used and traction
cessful [42]. Way et al. assert that more liberal- applied is only learned with careful observa-
ized use of technology, such as intraoperative tion and practice with skilled mentors.
cholangiography during cholecystectomy, could • Dissection during laparoscopic procedures
minimize the negative effects of surgeons’ cog- presents special challenges for the surgeon as
nitive biases. Another alternative would be to tactile feedback is lost and “finger fracture”
implement systematic, process alterations [44]. techniques cannot be used. Splitting and peel-
During cholecystectomy, this could be the top- ing remain very useful resources for the sur-
down approach to gallbladder dissection, which geon and are commonly used by carefully
has been shown to be safer during open proce- employing advanced energy devices and dis-
dures [42]. However, alterations of operating sectors like laparoscopic peanuts and laparo-
room processes, such as those designed to con- scopic suction cannulas. The presence of CO2
firm the correct patient and laterality, are still is a major aid during laparoscopic procedures
subject to a surgeon’s cognitive biases [45]. as it will naturally tend to “open” up natural
Regardless, it remains imperative for future planes or not inflamed or fibrotic areas and
efforts to focus on both awareness of these biases guide the surgeon in identifying areas of eas-
and decreasing their associated risk. ier dissection.
Take-Home Points
Suggested Readings
–– Surgeons should position patients in a manner
to facilitate exposure and safety. Kirk R. Basic surgical techniques. Edinburgh: Elsevier;
–– Adequate lighting is imperative to accom- 2010.
Karakousis CP. Principles of surgical dissection. J Surg
plishing safe, effective dissection. Lighting in
Oncol. 1982;21:205–6.
the operating room should be adjusted fre- Way LW, et al. Causes and prevention of laparoscopic bile
quently throughout the procedure. duct injuries: analysis of 252 cases from a human fac-
–– Modern imaging techniques should be incor- tors and cognitive psychology perspective. Ann Surg.
2003;237:460–9.
porated into a surgeon’s preoperative planning
and guide the operative approach.
–– Sharp, blunt, and instrumental dissection
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Fundamentals of Surgical
Hemostasis 8
Daniel J. Deziel
8.1 Fundamentals of Surgical from a cumulative experience of 215 years of

Hemostasis operating by seasoned surgeons. They are derived
from a collective experience with an array of gen-
8.1.1 Introduction eral abdominal, thoracic, oncologic, vascular,
and transplant operations. They come from oper-
Blood comes from blood vessels. Hence, the fun- ative circumstances that are both routine and
dament of surgical hemostasis is control of blood complex; many familiar, some scarcely believ-
vessels before, and after, they begin to spew their able; and most of them successful.
vital content. This essay will focus on principles Many surgeons will have methods that are dif-
for achieving mechanical hemostasis in the oper- ferent from those discussed here. Surgeons must
ating room. We will not invoke the coagulation develop, from experience, the techniques that
cascade or recite a litany of intrinsic and acquired work best with their tools in their patients. There
bleeding dyscrasias. Nor will we describe the is no one way to assure hemostasis. However,
physics of various energy sources or the safe use there are ways that will be more effective, or less
of the devices that dispense such hemostatic effective, and ways that will be defective. We
powers. These concepts are capably discussed in present the ways that we teach at the table.
other chapters. This chapter has a few disclaimers. The focus
Surgeons accumulate a technical vocabulary will be on the methods for handling blood vessels
for mechanical hemostasis at the operating table. and for stopping blood loss during traditional
We are taught by our mentors, we observe the open operations. Moreover, the focus will be on
traits of others, and we refine our techniques with the use of traditional surgical instruments, rather
experience. Modern textbooks give little heed to than clips or staplers or energy devices. These
technical detail. The technical fundamentals pre- latter accoutrements certainly have valuable
sented in this chapter are evidence based only in applications, particularly during laparoscopic
experience. They are principles that are sculpted operations. However, every operating surgeon
must have some familiarity with the traditional
methods. These skills, for some patients, at some
Adam Strickland, MD contributed all the pictures for this time, will become the ultimate life-sustaining
chapter
measure. These necessary skills have also become
D. J. Deziel less often learned and practiced by many current
Department of Surgery, Rush University Medical surgical trainees.
Center, Chicago, IL, USA
e-mail: daniel_j_deziel@rush.edu

120 D. J. Deziel
For the most part, we intentionally avoid spec- adhesions are spread gradually with Adson-type
ification of the type of suture material used: clamps, if possible, and sharply divided in small
permanent versus absorbable and braided versus increments. When cutting with a round-tipped
monofilament. The surgeon must know the prop- scissors, the tip must go slightly past the tissue
erties of each suture to determine its attributes being divided. When there is little space, precise
and deficiencies. The surgeon must understand cutting is done with the tip of a more pointed
the function that a suture is intended to provide in scissors.
a given situation. Informed by this, a surgeon will Respect the plane of the vessel wall. Tissue
choose what works best with their own hands, in forceps with closed tips can be used to retract a
the environment at hand. vessel, gently going from side to side. DeBakey-
type forceps are less likely to cause vascular
damage compared to nonvascular forceps. Never
8.1.2 General Concepts squeeze an artery with any type of forceps. This
may cause disruption of the vasa vasorum, subad-
First, prevent bleeding. The prerequisite is to ventitial hematoma, intimal tears, and arterial
understand the anatomy; one must know what dissection. The smaller the artery, the greater is
vessels one will find where. This means knowl- the risk. While all arteries require careful dissec-
edge of “typical” anatomy as well as the natural tion, there are some that tend to be particularly
variations that occur and, importantly, recogni- fragile and demand extra care; beware the inter-
tion of how the anatomy will be altered by patho- nal iliac artery, the subclavian artery, and the pul-
logic conditions. The technical requisite is to monary artery. If a vein must be maneuvered to
establish proximal and distal control of blood facilitate dissection, it should be grasped bluntly
vessels without inflicting trauma. This requires across its near full diameter to avoid tearing.
proper exposure and gentle handling of tissues When getting around the circumference of a
during dissection. vessel, use a blunt-tipped instrument like a Mixter
Second, stop bleeding. Bleeding is to be con- clamp rather than a clamp that has jaws with
trolled with alacrity and permanency and with more pointed tips. This is particularly important
adequate precision so as not to cause irreparable when dealing with frail vessels or when getting
injury to vital vessels or to other structures. around veins that have walls that fold on
Management of active bleeding requires compo- themselves.
sure, exposure, and familiarity with techniques One needs to acquire the skill for feeling what
for handling disrupted vessels and diffusely is at the tip of the instrument. Put the tip of the
bleeding surfaces and for inflow control. instrument behind the vessel, spread, take the
instrument out, and then place the instrument in
again and spread again. Do not chew through the
8.1.3 Technical Considerations tissue by repeatedly opening and closing the
to Control Blood Vessels jaws blindly while pushing the instrument
behind the vessel. Under direct vision, see that
Respect the integrity of the vessel. Dissect slowly, the tip of the instrument comes around cleanly
with minimal manipulation of the vessel itself. from behind the vessel and that it is not pushing
The idea is to move surrounding tissue away a portion of the vessel wall ahead of it. Beware
from the vessel while the vessel stays in place. of branches on the backside of the vessel, par-
Tissue can be teased, or pushed, or cut away. ticularly with veins, because the branching pat-
Tissue can be gently spread and divided with tern is less constant.
electrocautery. Adhesions around vessels are Sometimes a loop is placed around a vessel to
dealt with according to their consistency. Normal aid retraction. If used, the vessel must only be
developmental adhesions can be moved bluntly. retracted gently because loops can cause damage.
Stringy adhesions are cut with scissors. Dense Do not retract a vessel with a double loop around
8 Fundamentals of Surgical Hemostasis 121
it. Silicon loops slide on the vessel wall and may clamped end of the vessel is then tied or suture
not retract as well as a fabric tape (“umbilical” or ligated (“stick tied”) (Fig. 8.2).
“core” tape). Fabric tape does not slide, but can 3. A suture can be passed around the vessel, and,
injure the vessel, especially if dry. while gently pulling up on the suture, one jaw
Once identified and dissected, vessels can be of a clamp can be placed in the opening behind
controlled in several ways: the vessel where the suture is. The clamp is
moved down along the other side of the vessel
1. Sutures can be passed around the vessel and and closed. The suture is tied. The vessel is
tied before the vessel is divided between the divided, and the clamped end is either ligated
ties (“tying in continuity”). If the vessel is or suture ligated (Fig. 8.3).
sturdy, it can be cut before the ties are cut. If 4. A vessel can be suture ligated in place before
the structure is tenuous, the suture should be it is divided (Fig. 8.4).
cut before the vessel is cut so that the tie does
not fall off (Fig. 8.1). The most appropriate of these techniques will
2. Two clamps can be placed on the vessel which depend upon the nature of the vessel, the length
is then divided between the clamps. Each of vessel that is available, the amount of space
a b
Passing suture around First Completed tie

target vessel
c d
Passing second suture around Two completed ties prior to vessel

target vessel transection
Fig. 8.1 (a–d) Depicts the steps of “tying in continuity.” (a) Passing suture around target vessel. (b) First completed
tie. (c) Passing second suture around target vessel. (d) Two completed ties prior to vessel transection
122 D. J. Deziel
a b
Placement of Two Vessel cut prior to ligation

clamps on vessel
c d
Passing suture around Completed tie

clamp
e f
Passing needle through First knot thrown with

vessel assistant helping with
exposure
Fig. 8.2 Depict the steps of vascular control with divi- Completed tie. (e) Passing needle through vessel. (f) First
sion between clamps: (a–d) free hand tying, (e–h) suture knot thrown with assistant helping with exposure. (g)
ligature. (a) Placement of two clamps on vessel. (b) Vessel Passing suture around clamp. (h) Completed suture
cut prior to ligation. (c) Passing suture around clamp. (d) ligation
g h
Passing suture around Completed suture ligation

clamp
Fig. 8.2 (continued)
a b
Passing suture Placing clamp on vessel

around vessel
c d
One side tied Vessel transected prior to ligating other side
Fig. 8.3 Vascular control clamp-tie-divide-tie method (a–d). (a) Passing suture around vessel. (b) Placing clamp on
vessel. (c) One side tied. (d) Vessel transected prior to ligating the other side
124 D. J. Deziel
a b
Passing needle Suture prior to tying

through vessel
c d
Ligation in process Ligation complete
Two sides ligated prior to

transection
Fig. 8.4 Depicts technique to obtain vascular control vessel after first throw. (d) Ligation complete. (e) Two
with suture ligature (a–e). (a) Passing needle through ves- sides ligated prior to transection
sel. (b) Suture prior to tying. (c) Suture passed around
there is to work in, and to what extent the vessel suture ligature (stick tie). If there is any doubt, a
will retract once divided. Tying, clamping, stick tie will be the safest method to secure a ves-
cutting, ligating, and suture ligating are the
sel. Put the needle through the vessel near the
maneuvers necessary to perform these tech- center. Pass the suture around the heel and place
niques; each has nuances. a throw. Pass the heel of the needle around the tip
When tying a suture down on a vessel in con- of the clamp (deflect the tip with the shaft) and tie
tinuity, do not place the first throw too tightly down under the tip side. The tie must come down
because the suture can cut through the vessel; below the site where the vessel was pierced by
atherosclerotic vessels can crack and dissect. Use the needle. Do not pull up on the suture. With
one-handed throws with the second throw in the double ligation, the stick tie should be outside of
same direction as the first and then cinch the the first tie or over it. An exception to suture liga-
suture down gently, but securely, and then place tion of arteries is when the artery will be anasto-
the squaring throw. It is useful to first tie the side mosed because the proximal vessel must not be
of the vessel that you are less worried about in damaged.
order to feel how the vessel reacts to the suture. There is not always the luxury of having a
This tactile sense can guide safe management of well-exposed vessel with adequate space to
the “business side.” clamp or to pass two ties. One example is divi-
When clamping a vessel, close the clamp gen- sion of the ascending lumbar vein off of the iliac
tly and slowly. Check the degree of pressure on vein during exposure for spine surgery. In this
the vessel with each increment of closure. The situation, the iliac side of the ascending lumbar
clamp needs only to occlude flow, usually only vein can be stick tied in continuity. Put the needle
two or three steps up, more will cause injury. through the vein, and then reverse the needle and
When cutting a vessel, leave at least one to pass the heel under the vessel and tie on top. The
two millimeters outside of the tie or clamp. Close other side of the vein can be managed with a sim-
the scissors slowly. Only cut what you can see. A ple ligature or stick tie or clip. If there is no room,
vessel that is to be anastomosed should be cut it can just be cut and pressure applied with a
sharply with a blade. hemostatic agent such as gelfoam with
When tying a vessel that has been clamped thrombin.
and divided, the index finger should be brought A few tips for the management of specific ves-
down on the suture in an orientation perpendicu- sels may be useful.
lar to the shaft of the clamp and the suture tied at
the tip of the clamp where there is space. Do not 1. Mesenteric vessels
push the finger down parallel to the shaft or Do not punch blindly through the mesen-
behind (under) the clamp where there is no space. tery with hemostats. Identify the vessels by
Your hand must not push on the clamp or push dividing the peritoneum, and, with one hand
down on the vessel. This will cause unwanted behind the mesentery, pinch to feel the vessels
stretch and tension on the clamped tissue. When and dissect the fat away with a clamp.
using a suture on a clamp as a passer, be certain 2. Hepatic veins
that the suture is properly loaded at the tip of the Dissect initially until you are sure that you
jaws. Pass the suture around the shaft of the can get a vascular clamp on the caval side of
clamped vessel so that the knot will come down the hepatic vein. If possible, during a liver
at the tip of the clamped vessel. Tie toward your- resection, complete the division of the hepatic
self and at the tip, not away from yourself or at parenchyma before taking the hepatic vein(s).
the heel of the clamped vessel. Place a vascular clamp such as a Satinsky or
Named arteries, in general, should be doubly renal clamp on the hepatic vein with the tip of
ligated on the source side with one tie being a the clamp toward yourself. To create more
126 D. J. Deziel
room on the vein, place a blunt Mixter clamp removing the clamp. With either method, it is
around it, and gently strip the vein away from advisable to have another needle with suture
the cava toward the side coming out. loaded and ready in case it is needed.
Cut the vein directly on the clamp that is
coming out in order to leave as much vein out-
side of the clamp on the caval side as possible, 8.1.4 Technical Considerations
at least 2 mm. The clamp on the specimen side to Stop Bleeding
can be oversewn and the suture tightened as
the clamp is removed. If there is no adequate There are useful principles for achieving hemo-
room, the specimen side of the vein can be stasis when bleeding occurs. These include man-
ligated with an O suture. However, you then agement of injured vessels by suture techniques
need to place a suture ligature over the silk to and methods for control of diffuse bleeding from
lock it; otherwise it will fall off. raw surgical surfaces and maneuvers for emer-
The end of the divided vein on the caval gent occlusion of major arterial inflow.
side is oversewn with running suture (typi-
cally 4-0 or 5-0, single-armed prolene). The 8.1.4.1 Pressure and Suture
suture is placed on the vein outside of the When unexpected bleeding occurs, the first
clamp, away from the cava. Start at one end, maneuver, always, is to apply direct pressure.
place three throws after the first bite, and put a This can be with a finger, a blunt instrument, a
small clamp (“snap,” “mosquito”) on the end sponge, a laparotomy pad, or other tissue.
of the suture. Run the suture one direction, Temporary proximal and distal tamponade of
and then back, and then tie the suture with the large veins, such as the inferior vena cava or por-
vascular clamp still on the vein. When the tal vein, can be obtained with sponges on ring
clamp is removed, there may be bleeding, so forceps (“stick sponge”). Bleeding often occurs
be prepared to take additional bites. To do when operating in a hole, so do not dig a deeper
this, the needle of the running suture can be hole. Do not try to grasp for vessels that cannot
reloaded in the needle holder. Alternatively, a be seen, or blindly place clamps or clips or
fresh needle with new suture can be loaded to sutures. Simply apply pressure, suction the blood
provide more length. The snapped end of the to clear the field, and assess the magnitude of the
suture can be used to pull up on the vessel so situation. You will need exposure. If there is
that it does not retract if additional suturing is major bleeding, you will need help. Call for
necessary. another surgeon early. Alert the anesthesia and
3 . Portal vein nursing teams to ready the resources that may be
During tumor resection, control the portal required.
vein and its branches as well away from the Assess whether the bleeding is from a vital or
tumor site as possible. Some prefer to pass a non-vital vessel. A non-vital vessel can be read-
loops around the vessel for proximal and dis- ily dealt with; a vital vessel must be repaired
tal control. When the portal vein is divided without compromising flow.
during hepatic resection, there may not be suf- When the end of a bleeding vessel is visible,
ficient room to oversew the remaining end compress it from the side with a forceps; do not
outside of the vascular clamp as described for try to grab the end. Put a right-angled clamp on
the hepatic vein. In this circumstance, a run- the vessel and either tie or stick tie it, depending
ning suture can be placed under the clamp by upon its size and on how well it is exposed. If you
two methods. The jaws of the clamp can be cannot see the true substance of the vessel, stick
sewn over and over with the suture and the tie it. When bleeding is from the side of a vessel,
clamp gently removed as the suture is tight- a “figure of 8” stitch can be placed over it, or a
ened. Alternatively, the suture can be run back suture can be placed on either side. Sometimes,
and forth under the clamp and tied prior to two right-angled clamps can be placed, one from
each side so the tips touch or overlap slightly, and the presacral plexus. If available, large sheets of
the clamps can be oversewn. When the vessel is gelfoam can be placed first. Pack the bleeding
not well seen, your finger or a blunt forceps can site tightly with unfurled rolls of Kerlix gauze.
focally tamponade the bleeding and you can The rolls are 13 ft long. Usually, two or three
suture under it. If there is a lateral injury to a vital rolls are needed. The end of each roll is brought
vessel, such as the portal vein or superior mesen- out separately through a lateral counter-incision
teric vein, carefully place a small vascular clamp or through a portion of the primary incision.
so as not to occlude the vessel. If the defect is When packing, you will need to keep track of the
limited, a primary repair may suffice. If there is rolls in the sequence that they were placed so that
any risk for stenosis, a vein patch is used. the most superficial roll can later be removed first
Blind suturing is to be avoided but, on occa- and the deepest roll last. A simple way to mark
sion, may be unavoidable. Some circumstances them is to tie one knot on the roll to come out
where it may be required include bleeding from first, two on the second, and so on.
the cut surface of the liver or from a difficult ret- The rolls are usually removed at the bedside
roperitoneum or pelvis, particularly during redo beginning within about 24 h. They can be damp-
operations. It is more applicable for control of ened with dilute hydrogen peroxide that is
bleeding that is primarily venous. allowed to soak in. Then, slowly, start to pull out
When it must be resorted to, use large needles the first and most superficial roll. Stop if fresh
(an MH needle works for liver), and take mass blood and clots emanate. A burgundy color is
suture bites. Avoid blind suturing near critical good. Only one roll is removed at a time, but they
structures. A rare exception might be in a crash- should all be out by about the second postopera-
ing, hypotensive patient if tamponade or inflow tive day. When the last roll is out, a brief sigh of
control cannot be achieved. In this desperate sce- relief is permitted.
nario, rapid suturing, including even what you do
not want to suture, may prevent the immediate 8.1.4.3 Inflow Control
demise of the patient. There are ways to stem rapid abdominopelvic
hemorrhage by temporarily occluding aortic
8.1.4.2 Diffuse Bleeding inflow. Supraceliac control can be obtained in the
There are several methods for managing diffusely abdomen at the level of the diaphragm. The aorta
bleeding surfaces. Application of local hemo- is located above the stomach to the right of the
static materials and pressure is often effective. esophagus. Go through the gastrohepatic liga-
We have long had success with gelfoam soaked ment and feel for the aorta deep between the dia-
in thrombin as the topical hemostatic preparation. phragmatic crura overlying the spine. Try to see
Gelfoam is derived from denatured animal skin it, if possible; the muscle of the diaphragm can be
gelatin and alone has no intrinsic hemostatic cut. Compress the aorta firmly with your hand or
action. However, it serves as an efficient and fist or with a stick sponge. Take a long vascular
absorbable carrier for thrombin. Laparotomy clamp and, with the jaws closed, put the tip on the
pads work better than sponges for pressure on top spine. Move the clamp to your right (the left side
of the gelfoam/thrombin because the interstices of the patient) until just past the spine, and open
of the lap pad are smaller. The argon beam coag- the jaws to spread the tissue. Close, lift the clamp
ulator is useful for superficial bleeding over a up slightly, open the jaws, put it back down, and
broad area. clamp the vessel.
Gauze packing can successfully tamponade When the aorta cannot be clamped on the
bleeding from difficult surfaces, especially when abdomen, keep it manually compressed while
the patient is coagulopathic. Examples include you or an assistant quickly opens the left chest.
bleeding from liver injury and from the retroperi- Do an anterior thoracotomy in the left 6th or 7th
toneum in cases of necrotizing pancreatitis or ret- interspace. Lift the lung. The aorta is under the
roperitoneal hematoma and pelvic bleeding from esophagus (which is to be avoided). Manually
128 D. J. Deziel
feel for the aorta which can be tactilely identified Cut a length of red rubber catheter as a Rumel
as a rubbery structure even when it is essentially tourniquet. The diameter of the catheter should
non-pulsatile. Open the pleura, and finger dissect be large enough to allow the end of the catheter to
to get your thumb and finger around the vessel fold around the tissue when tightened. While
and clamp it. holding the tape in the left hand, advance the
On occasion, if there is no other good access, catheter down over the umbilical tape. This is
it may be possible to establish supradiaphrag- done with a clamp in the right hand held perpen-
matic occlusion of the aorta by a retrograde dicular to the catheter. The thumb of the right
approach. Expose the infrarenal aorta and make a hand pushes the clamp down against the end of
small transverse aortotomy. If you have the lux- the catheter to advance it over the tape. Do not
ury, advance a 30 cm3 aortic occlusion balloon. If pull up on the tape; there should not be move-
desperate, take a large clamped Foley1 catheter, ment of the tissue upward. When the catheter has
push it up the vessel above the diaphragm, and cinched the tissue adequately, close the clamp on
inflate the balloon. There will still be some col- the tape at the top of the end of the catheter.
lateral bleeding, but this maneuver may afford Clamp the tape only; do not clamp on the
enough time to continue. catheter.
Rapid control of inflow to the iliac artery may
be necessary. A particular example is with trocar
injury during an attempted laparoscopic opera- Take-Home Points
tion. Make a midline incision and compress the • Know the anatomy.
aorta against the spine at the pelvic inlet. • Proximal and distal control.
Unrelenting pelvic hemorrhage during opera- • Respect the integrity of blood vessels
tions for trauma or resection or large malignan- when dissecting, clamping, and
cies can be slowed by ligation of both internal ligating.
iliac arteries at their origin. • Control bleeding by direct pressure first.
The Pringle2 maneuver will temporarily con- • Control serious bleeding with compo-
trol liver bleeding from hepatic arterial and portal sure, exposure, and assistance.
venous sources [1]. Encircle the hepatoduodenal
ligament by getting the index finger of your left
hand into the foramen of Winslow behind the
hepatoduodenal structures with your thumb on Legion of Honor
top. Divide adhesions if present, and open the The author wishes to recognize the follow-
lesser sac so that your thumb and fingertips touch. ing master surgeons whose shared lifetime
The hepatoduodenal ligament can be occluded of operative experience contributed to the
with a vascular clamp or a Rumel3 tourniquet. principles distilled in this chapter:
Position an angled PV clamp through the finger Alexander Doolas MD
opening from your right with the handle on the Marshall D. Goldin MD
left side of the patient. Alternatively, pass an Martin Hertl MD, PhD
umbilical tape through the opening with either a Keith W. Millikan MD
clamp or two fingers. Wider tape is preferred so it
does not cut through the tissue when tightened.
Reference
1
Frederic Eugene Basil Foley (1891–1966), American
urologist 1. Pringle JH. Notes on the arrest of hepatic hemorrhage
2
James Hogarth Pringle (1863–1941), Australian born due to trauma. Ann Surg. 1908;48:541–9.
Glasgow surgeon
William Ray Rumel (1911–1977), American cardiotho-
3
racic surgeon
Fundamentals of Energy
Utilization in the Operating Room 9
Amin Madani and Carmen L. Mueller
9.1 Introduction copy, while half of the surgeons know of a col-

league who has experienced a similar event [3].
Energy devices are ubiquitously used for almost In addition, hundreds of millions of dollars are
all operations. These include traditional electro- spent annually for medical-legal claims related to
surgical monopolar devices to more advanced inadvertent electrosurgical burn injuries [4, 5].
bipolar sealing devices and ultrasonic dissectors. This chapter summarizes the most common
Despite their utility to achieve hemostasis, dis- energy devices, potential injuries that can occur
sect tissue planes, and ablate lesions, the operator from their utilization, and steps that can be taken
should bear in mind their potential to cause intra- to mitigate their risk.
operative injuries and should take the necessary
steps to mitigate the risks of iatrogenic injury.
Energy devices in minimally invasive surgery can 9.2 Electrosurgery
be especially hazardous due to the fact that a sig-
nificant portion of the instruments are located Electrosurgery is the most common form of energy
outside the field of view and can lead to unex- (i.e., “Bovie”), which is radiofrequency (RF) alter-
pected energy diversion. Other injuries include nating current that is applied across tissues. The
operating room fires and interference with rapid oscillation of polarities across the cells and
implantable devices, such as pacemakers and car- tissues causes a resultant elevation in intracellular
diac defibrillators. temperatures from the frictional forces of rapidly
Adverse events related to energy devices are a moving ions. This leads to various effects on the
significant public safety issue. In the case of elec- tissues, including vaporization, desiccation, and
trosurgery, injuries are estimated to occur at an protein coagulation. Contrary to its commonly
incidence of approximately 40,000/year [1] or used misnomer “cautery,” electrosurgery does not
approximately 1–2 per 1000 operations during actually apply passive transfer of heat to tissues
laparoscopy [2]. As many as one-fifth of the sur- and instead produces currents that have the poten-
geons have reported personally experiencing a tial to be diverted to other conductors and subse-
stray electrosurgical burn injury during laparos- quently cause electrosurgical burn injuries.
All electrosurgery is bipolar by nature, mean-
ing that two electrodes are attached to the patient
A. Madani · C. L. Mueller (*) to create a closed-loop circuit, without grounding
Department of Surgery, McGill University, the patient (also a common misconception)
Montreal, QC, Canada (Fig. 9.1). Nevertheless, the position and function
e-mail: carmen.mueller@mcgill.ca

130 A. Madani and C. L. Mueller
All RF Electrosurgery is “Bipolar”

Monopolar vs Bipolar Instrumentation
Monopolar Instruments
Active
Electrode
Patient
Low “Pure”
Voltage (“Cut”) 30
“Blend”
Electrode
1
Electrode High Voltage (“Coag”) 0 Dispersive
2 Electrode
Bipolar Instruments
Patient
Two Active
Electrodes
Fig. 9.1 Schematic of energy circuit differences between monopolar and bipolar electrosurgical devices
of the electrodes can vary, allowing the surgeon These tools are ideal when dissecting through
to use a monopolar or bipolar system. In a mono- highly vascularized tissues, such as omentum or
polar setup, the surgeon utilizes one electrode mesentery.
(“active electrode”) in the surgical field as a In most settings, the ESU is set at a specific
handheld device, whereas the second electrode is power (e.g., “30 coag,” “30 cut”), delivering pre-
attached to the patient outside the field of view as set energy through the circuit per unit time, irre-
a large pad that disperses the current on a large spective of whether “cut,” “coag,” or “blend”
surface area (“dispersive electrode”). These elec- functions are used to activate the device. While
trodes are then connected to the electrosurgical the device is activated and energy is being deliv-
unit (ESU)—the large generator that delivers RF ered, these different buttons modulate the current
energy at defined levels of power, current, and/or in different ways, whereby the end result is that
voltage. In a bipolar setup on the other hand, both there is significantly greater voltage (and there-
electrodes are active electrodes, which are fore thermal effect) with the “coag” mode com-
included within the instrument itself without the pared to the “cut” mode (Fig. 9.2). A common
need for a dispersive electrode—making it a very misconception is that “cut” mode is used for
useful tool for achieving hemostasis of tissue that “cutting” and that “coag” mode is used for tissues
is grasped between both electrodes. In addition, desiccation, whereas in fact “coag” is used most
many bipolar devices have advanced configura- commonly for tissue dissection. In fact, both
tions, such as the ability to measure the tissue modalities vaporize tissues that come into con-
impedance between the jaws of the two active tact with the active electrode tip. The difference
electrodes to ensure optimal hemostasis, as well however is the resultant collateral thermal spread,
as cutting blades to divide desiccated tissue. which is substantially more when the “coag”
9 Fundamentals of Energy Utilization in the Operating Room 131
Outcome: Minimal Collateral Coagulation

• Low voltage
• 100% Duty Cycle (Pure “Cut”)
• Electrode Speed- Relatively fast - Keep in steam envelope
Outcome: Modest Collateral Coagulation

• Moderate voltage
• 100% duty cycle (Pure “Cut”), or “Blend”
• Electrode Speed - Moderate - Keep in steam envelope
Outcome: Modest Collateral Coagulation: Carbonization
• High voltage
• Low duty cycle; “Coag” Output
• Electrode Speed - Slow - Keep in steam envelope
Fig. 9.2 Schematic of tissue injury created using different electrosurgical monopolar device settings
mode, or a higher power on the ESU (e.g., “coag due to their unfamiliarity by surgeons. Since the
60” as opposed to “coag 30”), is used. Whereas in bulk of the instrument is located outside the field
some cases the collateral thermal spread is bene- of view on a monitor, these instruments often
ficial in order to avoid small bleeding vessels, in come into contact with other structures without
other circumstances, it may be safer to use a the knowledge of the operator (Fig. 9.3). It is not
lower power setting or the “cut” function when uncommon to assume that as long as the metal tip
dissecting in the vicinity of a critical structure of a fully insulated instrument is clearly seen on
such as the common bile duct, phrenic nerve, or a monitor without being activated near any criti-
ureter. It is also advisable to avoid using high- cal structures, those inadvertent injuries will not
energy settings on the skin, minimize desiccation occur. This assumption is wrong. Stray current
of the skin edges, and optimize wound healing. can travel anywhere along the shaft of the instru-
ment, regardless of whether the insulation is fully
intact or not. In fact, most current diversion inju-
9.3 Adverse Events ries are not initially recognized and lead to
delayed patient manifestations, such as diffuse
Electrosurgical injuries can be categorized based peritonitis and intra-abdominal sepsis in a post-
on their mechanism: current diversion injuries, operative patient with a bowel injury [7–9].
active electrode injuries, and dispersive electrode Insulation failure is a very common source of
injuries [6]. injury during minimally invasive surgery [3, 10,
Current diversion injuries are extremely dan- 11], such that insulated instruments may possess a
gerous during minimally invasive surgery, mostly break in insulation somewhere along their shaft
Table 9.1 Recommendations for decreasing the risk of

electrosurgical injuries, as adopted from the Society of
American Gastrointestinal and Endoscopic Surgeons’
Fundamental Use of Surgical Energy™ curriculum (http://
www.fuseprogram.org) [6]
• Use the lowest power setting necessary for the
intended tissue effect
• Use the current with the lowest voltage possible for
the intended tissue effect (i.e., “cut” as opposed to
“coag”)
• Use active electrode monitoring systems for
inspecting insulation on electrosurgical instruments
• Avoid activation of electrosurgical devices in open air
• Use brief (2–3 s) intermittent activations
• Activate the instrument only when the active
electrode is entirely in the field of view
• Use either all metal or all plastic cannulas
Fig. 9.3 Induced currents capacitive coupling • Clear the electrode tip of built-up eschar (increases
the risk of current arcing)
• Avoid bundling cords and various instruments
causing possible current diversion. It is important together
to recognize that defective insulation tends to be • Place unused electrosurgical devices in an insulated
invisible to the naked eye or with careful inspec- holster
tion. Moreover, smaller insulation defects lead to
smaller areas of contact with tissues and therefore vating the device in such a manner, all current
greater concentration of current and resultant will be diverted in this alternative pathway as
thermal effect. Current standards recommend rou- opposed to its intended circuit. For example, acti-
tine screening for insulation failure using special- vating the hook in midfield during laparoscopic
ized active electrode monitoring systems [12]. cholecystectomy may divert the current to the
Capacitive coupling and antenna coupling are nearby duodenum or common bile duct, rather
phenomena whereby active electrodes, once acti- than to the tissue intended to be dissected. In con-
vated, transmit and receive electromagnetic trast, if contact is made with the target tissue, the
waves to other adjacent conductors (virtue of the current will prefer the intended trajectory as it is
fact that they conduct alternating current), with- the path of least resistance, and the current and
out direct contact through nonconductive media resultant thermal effect through the alternative
(such as air or by touching fully insulated instru- pathway is minimized and often negligible.
ments). These can be anything from surrounding Furthermore, it is advised to avoid bundling wires
wires, the laparoscope, other instruments in the to other conductors such as the laparoscope cam-
surgical field, and even electrocardiogram moni- era cord or towel clamps and to use the lowest
toring wires. The consequence is that the adja- energy (lowest power and voltage) necessary to
cent conductor, which was previously not obtain the intended tissue effects [6].
electrically active, induces the electromagnetic Finally, current diversion can occur through
wave into a current—a current that can now travel direct coupling, a mechanism through which one
to other unexpected sites and cause potential conductor makes direct contact (or arcs current)
injuries outside the field of view [13–15]. Various with another conductor. In some instances, this is
steps can be taken to decrease the risk of current done intentionally, such as when a bleeding
diversion (Table 9.1). It is imperative to empha- vessel is grasped between the jaws of forceps and
size the importance of avoiding open-air activa- the active electrode is activated while making
tion of electrosurgical devices, such that the contact with the forceps, causing vessel sealing.
active electrode is activated without actually Nonetheless, this can also occur inadvertently if
making contact with the target tissue. Should the the instrument is activated while making contact
situation occur where current is diverted, by acti- with another conductor (such as the laparoscope
or another non-insulated metal instrument) that is passing through the patient, eliminating the risk
in contact with non-target tissues. of electrosurgical burns and electromagnetic
Other forms of injuries occur in relation to the interference with other devices, such as pace-
active electrode, such as with collateral thermal makers. Nonetheless, ultrasonic devices are noto-
spread with higher-voltage settings (e.g., “coag” rious for causing very high temperatures at the tip
mode instead of “cut” mode or “coag 40” instead of the instrument. This can be problematic during
of “coag 25”) or direct injury from residual heat minimally invasive surgery where there is a lack
at the tip of the instruments, even after a period of of tactile feedback. The operator should be cog-
activation. This form of injury is much more nizant of this and avoid using the tip of the instru-
common in laparoscopy and especially more ment as a grasper (such as to move bowel in the
concerning with the use of advanced bipolar and peritoneal cavity) as this can lead to delayed inju-
ultrasonic devices, whose tips can reach tempera- ries with dire consequences.
tures well above the threshold necessary to cause
cell death. Furthermore, injuries can occur in
relation to the dispersive electrode, whose func- 9.5 rgon Beam Plasma
A
tion is to act as the return electrode to the ESU. Coagulator (APC)
Given that it transmits the same current as that
which travels through the active electrode, it is The APC is a form of monopolar energy device
important that the pad sticks very well over a that uses the current to ionize argon gas and to arc
large surface area to keep the current density at a current from the active electrode tip to the target
minimum and avoid burn injuries at that site. tissues without making actual contact with the tis-
sues. This requires high-voltage energy and leads
to superficial desiccation of tissue with minimal
9.4 Ultrasonic Energy Devices penetration by “spraying” current on the target—a
process called fulguration. Fulguration can also
Ultrasonic devices convert electrical energy to be achieved with traditional monopolar electro-
mechanical energy allowing the instrument tip to surgery using high-voltage settings and is particu-
vibrate at extremely high frequencies. As the larly useful for bleeding raw surfaces, such as on
energy is applied to the tissues between the jaws the liver and spleen. APC can also be used during
of the instrument, this leads to a frictional force endoscopic procedures for controlling superficial
that causes vaporization, desiccation, and protein mucosal lesions [16]. Risks include excessive
coagulation. There are various factors that deter- buildup of argon gas in the peritoneal cavity, gas
mine the type of tissues effect. The most impor- embolism, and abdominal compartment syn-
tant is the frequency of blade excursion, with a drome. The lowest effective flow rate should be
higher frequency (often denoted as “MAX”) maintained, and if this form of energy is used dur-
leading to more efficient cutting but less hemo- ing laparoscopic surgery, it is advisable to consis-
stasis and lower frequency (“MIN”) causing tently maintain one port open.
more hemostasis but less efficient cutting. Other
factors include the degree of compression of the
tissues between the jaws, with greater compres- 9.6 Energy-Related Emergencies
sion improving cutting but decreasing hemosta-
sis, as well as the tension on the tissues (such as 9.6.1 O
perating Room Fires
from lifting to provide more efficient cutting). and Explosions
One of the reasons why ultrasonic devices
have proven very versatile is the fact that the Hundreds of operating room fires occur every
lower blade (oscillating blade) can also be used year in the USA alone, and while these are rela-
in a manner similar to a scalpel for tissues that are tively rare and mostly minor, approximately 5%
under sufficient tension. Their advantage over are associated with disfiguring injuries or death
electrosurgery also includes the lack of current [17]. The surgical team should be properly
trained in fire prevention strategies and be famil- gen (such as nasal prongs and oxygen masks, as
iar with institutional protocols to deal with such opposed to supraglottic airways or endotracheal
unexpected events (Table 9.2). intubation), which can lead to oxygen tenting
Three factors are required for a fire to occur. under the drapes. Lastly, gastrointestinal sur-
First, there needs to be a source of heat or igni- geons and endoscopists should be aware that
tion (spark). In the operating room, the most bowel content contains various explosive com-
common source is electrosurgery. Other sources pounds, such as hydrogen-air mixtures and meth-
include laser, the fiber-optic light cable, or the ane. Mannitol can lead to the production of
light source during laparoscopy. During laparo- methane gas and is therefore contraindicated as a
scopic procedures, the surgical team should be bowel preparation [18, 19].
careful not to place the light source in contact
with the drapes, as even a few seconds is suffi-
cient time for it to set fire to the drapes. Instead, 9.6.2 M
anaging Operating Room
the light source should be placed on “standby” Fires
before the start of the case and subsequently
turned off before disconnecting it from the lapa- Responding to a fire in the operating room
roscope at the end of the case. The second ele- requires a coordinated effort by all members of
ment for a fire is the need for a fuel source, the operating team, including surgeons, anesthe-
examples of which include the drapes or alcohol- siologists, and nurses [20]. First, flow of oxygen
based prepping agents. It is important not to should be immediately stopped, followed by dis-
apply the surgical drapes until flammable liquids connection of the breathing circuit. While this is
have fully dried and any pooling of prep fluid is occurring at the head of the bed, another team
removed. Lastly, there needs to be an oxidizer member should immediately remove all burning
(e.g., oxygen or nitrous oxide). Approximately material off the patient (including the endotra-
50% of fires tend to occur in “oxygen-enriched cheal tube in the case of an airway fire).
zones” near the head, neck, and upper chest [17]. Subsequently, the fire should be extinguished
The team can minimize the risk of fires by keep- using either the fire extinguisher or saline from
ing oxygen concentrations below 30% whenever the nurse’s table. Finally, as a team member acti-
possible and limiting the use of open-source oxy- vates the fire alarm and notifies the appropriate
authorities, the patient should have their breath-
ing restored (may require re-intubation) using
Table 9.2 Strategies for decreasing the risk of operating
room fires, as adopted from the Society of American room air and their injuries managed.
Gastrointestinal and Endoscopic Surgeons’ Fundamental
Use of Surgical Energy™ curriculum (http://www.fusepro-
gram.org) [6]
9.7 Special Considerations
• Minimize the use of open oxygen (e.g., face
masks, nasal cannula)
9.7.1 T
he Use of Energy in Patients
• Minimize oxygen concentration and beware of
oxygen enrichment under the drapes with Implantable Devices
• Do not apply drapes until flammable prepping
fluid has fully dried Energy devices can also cause electromagnetic
• Remove spilled and pooled prepping agents interference (EMI) with implantable electronic
• Connect the fiber-optic light cable before devices in patients, most commonly with cardiac
activating the light source
implantable electronic devices (CIED), such as
• Turn off the light source before disconnecting the
light cable pacemakers, ventricular assist devices, and defi-
• Seal the surgical site tightly from oxygen source brillators. While interference can also occur with
tenting under the drapes other devices, including various nerve and spinal
• Use the lowest possible power and voltage for the cord stimulators, infusion pumps, cochlea
intended tissue effect using energy devices implants, and many others, CIEDs are particu-
larly problematic due to the millions of patients dissection is above the umbilicus and the patient
who are currently treated with a CIED and the is pacemaker dependent.
potential cardiovascular effects that can result In most instances, the patient will present pre-
from interference. Potential effects of EMI operatively, in which case surgeons should ensure
include inappropriate triggering, reprogramming that the appropriate consultation with an anesthe-
or inhibition of the pacemaker or defibrillator, siologist and/or cardiologist takes place. Often, the
unintended asynchronous pacing, and generation pacemaker needs to be reprogrammed to an asyn-
of electrical current in the wires, causing arrhyth- chronous mode to avoid unintended inhibition of
mias or thermal tissue injury [21]. its function when EMI is mistaken as cardiac
The most common source of EMI is from RF activity, among patients who are pacing dependent
electrosurgery—specifically monopolar devices, and when the surgical site is in the vicinity of the
including those used in open surgery, minimally mediastinum. However, reprogramming should
invasive surgery, endoscopic procedures, radio- usually be avoided in patients who are prone to
frequency ablation procedures, and electrocar- ventricular tachyarrhythmia. Also, rate-adaptive
diographic monitors. Of note, ultrasonic devices functions and anti-tachyarrhythmia functions in
generate mechanical energy as opposed to elec- patients with defibrillators may need to be sus-
tromagnetic energy and are therefore safer in pended to avoid being triggered in the presence of
patients with CIEDs. Also, bipolar instruments EMI. In such cases, the entire surgical team should
cause significantly less interference and are also be aware of these alterations on the day of the
recommended over monopolar devices. operation, with temporary pacing equipment and
Because the mechanism of action of EMI with defibrillators immediately available, in the event
CIEDs is similar to that which occurs with cur- that the patient requires resuscitation.
rent diversion injuries (i.e., antenna coupling and Rarely, it may be neither feasible nor practical
capacitive coupling), similar recommendations to obtain preoperative consultation for patients
are advised for surgeons wishing to minimize the with CIEDs who require emergency surgery. In
risk of interference. These include using the addition to the aforementioned precautions, a
lowest-energy settings necessary to get the magnet can also be placed overtop the CIED on
intended tissue effects (e.g., using lower power the patient’s chest to shield it against any
settings and low-voltage current such as “cut” EMI. For pacemakers, this may result in asyn-
whenever possible) and ensuring that the active chronous pacing, whereas for defibrillators, it can
electrode cord does not cross the chest wall in the often temporarily disable the anti-tachyarrhythmia
vicinity of the implanted device. Furthermore, functions. While removal of the magnet normally
during setup of the patient, the team should make restores the CIED back to its original function,
sure that the intended current vector through the this may not always be the case, and permanent
patient (path from the active electrode to the dis- damage may ensue. A cardiology consultation
persive electrode) does not cross the CIED sys- should be sought postoperatively.
tem to cause interference. This can be achieved
by keeping the dispersive electrode as close as Conclusion
possible to the surgical site where the active elec- Surgical energy devices are extremely useful
trode is activated and as far away as possible for a broad range of applications in the operat-
from the CIED [22]. In fact, animal studies sug- ing room. To date, various forms of energy
gest that increasing the distance between the exist in a number of different configurations.
active electrode (energy source) and CIED Yet, despite their proven usefulness, they
decreases EMI in a dose-response fashion up to remain a source of iatrogenic injury. It is
10 cm [22]. Also, whenever possible, monopolar imperative that operators acquaint themselves
laparoscopic instruments ought to be substituted with the appropriate utilization of each device,
in favor of either an ultrasonic dissector or the many pitfalls that can occur, and steps to
advanced bipolar instrument—especially if the take to use such devices safely and effectively.
9. Polychronidis A, Tsaroucha AK, Karayiannakis AJ,

Take-Home Points Perente S, Efstathiou E, Simopoulos C. Delayed
perforation of the large bowel due to thermal injury
• Electrosurgical energy devices vary in during laparoscopic cholecystectomy. J Int Med Res.
the type of energy used and the manner 2005;33:360–3.
in which that energy is delivered to the 10. Montero PN, Robinson TN, Weaver JS, Stiegmann
tissues to create a desired effect. GV. Insulation failure in laparoscopic instruments.
Surg Endosc. 2010;24:462–5.
• Knowledge of the differences between 11.
Tixier F, Garcon M, Rochefort F, Corvaisier
electrosurgical devices allows the oper- S. Insulation failure in electrosurgery instrumen-
ator to select the best tool for the desired tation: a prospective evaluation. Surg Endosc.
application. 2016;30:4995–5001.
12. Vancaillie TG. Active electrode monitoring. How

• Each type of device can cause undesir- to prevent unintentional thermal injury associated
able effects (adverse events) and the with monopolar electrosurgery at laparoscopy. Surg
operator must familiarize themselves Endosc. 1998;12:1009–12.
with the possible adverse outcomes 13. Jones EL, Robinson TN, McHenry JR, Dunn

CL, Montero PN, Govekar HR, Stiegmann
associated with each device to be used. GV. Radiofrequency energy antenna coupling to com-
mon laparoscopic instruments: practical implications.
Surg Endosc. 2012;26:3053–7.
14. Robinson TN, Barnes KS, Govekar HR, Stiegmann
GV, Dunn CL, McGreevy FT. Antenna coupling-
Suggested Readings -a novel mechanism of radiofrequency electrosur-
gery complication: practical implications. Ann Surg.
Feldman LS, Fuchshuber P, Jones DB. The SAGES man- 2012;256:213–8.
ual on the fundamental use of surgical energy (FUSE). 15. Townsend NT, Jones EL, Paniccia A, Vandervelde
New York: Springer; 2012. J, McHenry JR, Robinson TN. Antenna coupling
explains unintended thermal injury caused by com-
mon operating room monitoring devices. Surg
Laparosc Endosc Percutan Tech. 2015;25:111–3.
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Fundamentals of Stapling Devices
10
Christina Souther and Kenric Murayama
10.1 History of Stapling device and was lighter than Hultl’s version [2–4].
This stapler also fired parallel staple lines similar
The design of the first surgical stapler with to Hultl’s product.
resemblance to our current devices is credited to In the 1930s, replaceable cartridges were
Humer Hultl in 1908 [1–4]. Prior to Hultl’s sta- developed by H. Friedrich so that multiple loads
pler, which applied four parallel lines of wire of staples could be fired in succession without
hooks [3, 4], Henroz had anastomosed dog bowel preparing an entirely separate device [1]. The
with metal rings in 1826, and John Murphy cre- simultaneous application of staples and division
ated the Murphy button in 1892 which again used of the stapled viscera was pioneered in the Soviet
rings to join structures [2]. Hultl’s device, how- Union during the 1950s through the 1970s [2].
ever, was similar to the staplers we use today. The Russian staplers also featured a staggered
Hultl’s reason for pursuing the development of a rather than a parallel staple line configuration
mechanical device for anastomosis was to control which was found to increase hemostasis. Mark
spillage of bowel contents in an effort to decrease Ravitch is credited with bringing staplers to
infection; he intended to create a device that widespread use in the United States and also opti-
would make operations cleaner, faster, and easier mizing the devices by allowing customization
to perform [2]. To produce the first surgical sta- based on tissue type and size [2]. He created mul-
pler, Hultl enlisted the assistance of Peter Fischer tiple different cartridges which could be loaded
who created the product which Hultl had envi- onto the same stapler base allowing for immedi-
sioned. His first device, although innovative, was ate customization for variable tissues during a
noted to be heavy and difficult to use by its opera- surgery. These cartridges differed both in staple
tors [2]. The stapler was also difficult to clean size and length of staple line creating the ability
between uses. Major improvements were made in to tailor the stapler to each specific tissue type
the 1920s by Aladar Petz, who used silver clips and length of tissue involved. He also developed
rather than thin steel wires [3, 4]. His “Petz the circular stapler allowing for end-to-end sta-
clamp” was notably easier to maneuver espe- pled anastomosis creation [1, 5]. Leon Hirsch,
cially during the application and removal of the who formed the United States Surgical
Corporation in the 1960s, contributed to the
C. Souther · K. Murayama (*) streamlining of surgical stapler function by opti-
Department of Surgery, John A Burns School of mizing the structure of the stapler and creating
Medicine, University of Hawaii at Manoa, disposable cartridges for easy and efficient load-
Honolulu, HI, USA ing of the staples [6].
e-mail: kenricm@hawaii.edu

138 C. Souther and K. Murayama
10.2 Mechanics of Stapling line [10, 11]. Short tight staples are also thought
to decrease the chance of forming a stricture at
The majority of surgical staplers in use today the site [7]; however prolonged compression may
form staples in a “B” shape when fired against increase the risk of local ischemia. In choosing a
the anvil [7]. The “B” shape of the staple was staple cartridge for a particular operation, the
designed to hold tissue securely but to allow thickness of the tissue must be considered
small vessels to pass through the staples allowing (Table 10.1). Creating a staple that is too tall can
for adequate perfusion [8]. The stapling device lead to gaps between the staple and tissue ulti-
first compresses the tissue to be stapled causing mately resulting in anastomotic leaks or bleeding
elongation of the tissue. Allowing time for full at the staple line [7, 10, 11]. However, a staple
compression and elongation of the tissue is which is too short can lead to anastomotic leaks
important for adequate staple line formation but as well, due to excessive compression of the tis-
compression for an extended period of time can sue leading to ischemia and subsequent break-
lead to tissue damage [1, 7, 9]. These consider- down of the anastomosis [7]. Another key feature
ations are important especially when using the of creating a robust stapled anastomosis is the
staplers that complete their compression when lack of force placed on the staple line during cre-
they are first closed. Other models do not fully ation [7, 8]. Sheer forces and torque can lead to
compress the tissue until they are fired so the tearing of tissue or misalignment of the staples
compression time cannot be altered as easily. leading to both immediate injury requiring imme-
Longer duration of compression prior to firing diate revision and also subtle damage that is not
the stapler has been associated with fewer anasto- recognized until the postoperative period during
motic leaks and more adequate hemostasis of the which complications arise. Easy firing of the sta-
staple line [7]. However, adequate compression pler is important to avoid placing additional force
does not only depend on duration; it is also or tension on the staple line during its creation.
affected by patient characteristics such as overall In open cases, to avoid applying additional
systemic health, including nutritional status and force to the tissues, the anvil can be inserted first
vascular supply. The tissue makeup is also impor- followed by the cartridge instead of attempting to
tant for adequate stapling. The ratio of liquid to align both ends simultaneously. Holding the sta-
solid components of the tissue and the elasticity pler steady with one hand or having an assistant
of the tissue play important roles as well [7]. stabilize the tissues that will be approximated can
Tissue with higher liquid content requires longer help to avoid tearing. The other hand should be
compression time to reduce the fluid at the site of used to fire the stapler slowly and smoothly,
stapling and allow the tissue to elongate evenly. avoiding jarring movements especially when
The longer compression time also allows the sta- reaching the end of the staple line. To open the
ple to form a tighter “B” shape which has been stapler, the trigger must be pulled back, and the
associated with decreased bleeding at the staple tissue must remain stabilized during this step so
Table 10.1 Staple height and tissue applications for common laparoscopic staplers
Covidien Small Large
Tissue Covidien tri-staple Ethicon Stomach bowel bowel Rectum
Thin- Gray 2 mm Gray White 2.6 mm
mesentery
Thin-vascular White 2.6 mm Gold X
Medium Blue 3.5 mm Gold/Purple Blue 3.6 mm X X X X
Medium- Gold 3.8 mm Purple Gold 3.8 mm X X X
thick
Thick Green 4.8 mm Green 4.1 mm X X
Extra-thick Black Black 4.2 mm X
10 Fundamentals of Stapling Devices 139
that inordinate force is not placed on the newly staplers are generally used near an end of the GI
created staple line. tract as the stapler itself must be inserted through
In laparoscopic cases, the staplers can be the tubular viscera and aligned with a preposi-
manipulated in multiple directions by articula- tioned anvil in the other end of the planned anas-
tion. Articulating the stapler prior to placing it in tomosis but can also be inserted via an
contact with tissues is ideal to avoid grasping the enterotomy. The introduction of circular staplers
tissue with the stapler as it is adjusted. The lapa- allowed for stapled anastomoses in areas where
roscopic staplers have a narrow end which acts as tissues are difficult to mobilize, making distal
the anvil; this narrow end should be inserted rectal stapled anastomoses possible and much
through any window in the tissue (e.g., between more facile [7].
an appendix and mesoappendix), and the larger
side should be applied externally to avoid forcing
the larger side of the stapler through a small 10.4 Applications of Surgical
opening. Staplers
The widespread use of surgical staplers over the

10.3 Current Devices last half century has led to adaptation of the tech-
nology for use in multiple organ systems and
Surgical staplers used today are largely dispos- various modes of operation. The original staplers
able and have become much easier to operate. were created for use in gastrointestinal surgery,
Most of the devices have both an open and a lapa- and much of the data regarding technical aspects
roscopic counterpart. Linear staplers are avail- of staple size choice and outcomes have been
able with multiple types of handles and cartridge derived from the field of bariatric surgery [7, 10,
configurations, allowing for tension-free 11]. Staplers are used frequently in bariatric sur-
application in various settings. The linear staplers gery: linear staplers for division of the stomach in
include both models which apply staple lines and sleeve gastrectomy and jejunojejunal anastomo-
divide the tissue between the staple lines during ses in gastric bypass and circular staplers for gas-
the firing (GIA staplers) and also models which trojejunal anastomoses in gastric bypass. Shorter
apply a staple line without any severing of tissue staple heights are associated with lower postop-
(TA staplers) [8]. These staplers require the oper- erative bleeding rates when circular staplers are
ator to divide the tissue sharply after firing the used for the gastrojejunal anastomosis [10, 11].
stapler. Both of these linear staplers are available Special attention must be paid to the size of the
in endomechanical versions as well for use in staples used on the stomach due to the varying
laparoscopy and thoracoscopy. A modification of thickness of the stomach in different anatomic
the linear stapler is a curved staple load fired in regions in contrast to the colon which tends to be
the same way with a blade between the staple more uniform in thickness. Longer staples are
lines, allowing for control and division of tissues generally used in the distal stomach as the distal
in difficult to reach areas, such as the rectum. The stomach tends to be thicker [7]. Long staple lines,
curve allows the stapler to be applied to a struc- although sometimes necessary, can cause addi-
ture deep in the pelvis or in another narrow area tional complications, especially leaks [12, 13]. In
without placing torque on the stapler and thus addition, a higher number of intersections of sta-
decreasing the risk for shear of the tissues [7]. ple lines are associated with a higher risk of leak
Circular staplers have been developed mainly [13]. This situation typically occurs when creat-
for the creation of end-to-end anastomoses. The ing a stapled anastomosis between two segments
circular staplers allow firing of staple lines cir- of bowel which already have stapled ends. This
cumferentially and also excise a ring of tissue increased risk can be mitigated by inverting one
allowing connection of the two lumens. Circular staple line into another [13].
Throughout the gastrointestinal tract, linear enlarged cystic ducts in biliary operations during
staplers can be used to divide the small bowel or which a clip cannot fit entirely across the duct
colon without spillage of contents, and curved [20].
staplers with long handles can be used to reach Pulmonary surgery has benefited from the use
deep into the pelvis to divide the distal sigmoid of staplers in lung resections [5, 7]. However, the
colon or rectum without placing tension on the air distribution in the lungs can make the thick-
colon or torque on the device. Circular staplers ness of the tissue more variable than in other
are used frequently for distal sigmoid or rectal organs. Since additional air is located in the
anastomoses. Ideally a single staple load is used periphery of the lung, the compression time and
to divide bowel as the use of multiple linear sta- pressure required during application of the sta-
plers for the same anastomosis can result in pler are lower than those required in more central
higher rate of anastomotic leak [7], making the portions of the lung which contain bronchial tis-
curved stapler that can traverse the rectum in one sue and more blood to displace prior to firing the
application safer. stapler [7]. Baseline pulmonary health must be
Esophagectomies and the subsequent anasto- considered when stapling lung parenchyma as
moses can be performed using both linear and the thickness can be affected by malignancies,
circular staplers. Emergent situations such as fibrosis, and chemical damage, while broncho-
bleeding esophageal varices can be managed pleural fistulae are more likely in emphysema-
with stapling devices as well by obtaining hemo- tous lung parenchyma [7]. Overall, the stapling
stasis using staplers to divide the esophagus and of lungs leads to better aerostasis than hand-sewn
control the bleeding, followed by reanastomosis pulmonary resections [7]. Methods including
using additional staplers after the enlarged veins folding over the edges of bronchi prior to anasto-
have been controlled [14]. mosis to decrease tension placed at the center of
Division of the pancreas can be simplified the staple line have been employed to improve
with the use of a stapler, and this method is com- the success rate of pulmonary stapling [21].
monly used for sealing the remaining portion of
the pancreas after distal pancreatectomy [15].
Appropriate choice of staple height [15] and ade- 10.5 Current Controversies
quate compression duration [7, 16] are important
for the prevention of pancreatic fistula in these Given that leaks or bleeding are dreaded compli-
cases. The thickness of the pancreas has been cations of endomechanical devices, the staple
found to independently predict formation of a lines can be reinforced by the use of several “but-
pancreatic fistula after stapled distal pancreatec- tressing” materials which can be absorbable or
tomy making the decision to use the stapler and permanent. Many surgeons advocate for their
the choice of cartridge significant [17]. use, but the need for reinforcement, as well as the
Linear staplers can be used in open and lapa- method providing the most benefit, is widely
roscopic hepatic resections both for the division debated. Some authors report no benefit in rein-
of the liver parenchyma itself and also for vascu- forcing staple lines [22]. In several studies,
lar control for the segment undergoing removal decreased leak rates and lower rates of bleeding
[18, 19]. As in other organ systems, the thickness have been seen after oversewing the staple line
of the liver can affect the success of staple line. In [23–26]. Some advocate using bovine tissue but-
vitro studies have suggested that the liver mea- tresses rather than simply suture reinforcements
suring more than 10 mm in thickness can have to the staple line [23–25]. There is some concern
other important factors influencing risk of staple for stenosis which can occur when additional
line failure including stiffness which does not sutures are placed, so care should be taken when
seem to play a role in the liver which is not as reinforcing staple lines to avoid decreasing the
thick [18]. Staplers have also been used to divide patency of the anastomosis [26].
10 Fundamentals of Stapling Devices 141
10.6 Summary 8. Ravitch MM, Steichen FM. Technics of staple

suturing in the gastrointestinal tract. Ann Surg.
1972;175:815–35.
The first surgical stapler designed by Hultl ini- 9. Nakayama S, Hasegawa S, Hida K, Kawada K, Sakai
tially designed to control spillage of bowel con- Y. Obtaining secure stapling of a double stapling
tents and improve asepsis paved the way for the anastomosis. J Surg Res. 2015;193:652–7.
10. Nguyen NT, Dakin G, Needleman B, Pomp A, Mikami
modern devices which make many operations D, Provost DA, Scott DJ, Jones DB, Gallagher S,
easier to accomplish and increase their efficiency. Gagner M, Murr M. Effect of staple height on gas-
Many organs can be divided and anastomosed trojejunostomy during laparoscopic gastric bypass: a
using stapling devices, and a variety of modifica- multicenter prospective randomized trial. Surg Obes
Relat Dis. 2010;6:477–84.
tions have been made to suit tissues of different 11. Sakran N, Assalia A, Sternberg A, Kluger Y, Troitsa
character and size. Surgeons must pay close A, Brauner E, Van Cauwenberge S, De Visschere M,
attention to mechanical aspects of staple applica- Dillemans B. Smaller staple height for circular stapled
tion, including each patient’s baseline health, gastrojejunostomy in laparoscopic gastric bypass:
early results in 1,074 morbidly obese patients. Obes
comorbidities, and tissue composition, to fully Surg. 2010;21:238–43.
obtain the benefits of these devices and avoid 12. Ito M, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda
complications by using the tailored stapling Y, Saito N. Relationship between multiple numbers of
products available for each clinical situation. stapler firings during rectal division and anastomotic
leakage after laparoscopic rectal resection. Int J Color
Dis. 2008;23:703–7.
Take-Home Messages 13. Lee S, Ahn B, Lee S. The relationship between the
number of intersections of staple lines and anas-
• Tissue depth and composition must be tomotic leakage after the use of a double stapling
technique in laparoscopic colorectal surgery. Surg
taken into consideration when choosing Laparosc Endosc Percutan Tech. 2017;27:273–81.
staple size. 14. Steichen FM, Ravitch MM. Mechanical sutures in
• It is important to avoid torque on the tis- esophageal surgery. Ann Surg. 1980;191:373–81.
sues when firing staplers. 15. Kim H, Jang J, Son D, Lee S, Han Y, Shin YC,
Kim JR, Kwon W, Kim S. Optimal stapler car-
• Surgeons should become familiar with tridge selection according to the thickness of the
stapling devices and their possible com- pancreas in distal pancreatectomy. Medicine.
plications despite the relative ease of 2016;95(35):e4441.
operating they provide. 16. Nakamura M, Ueda J, Kohno H, Aly MYF, Takahata
S, Shimizu S, Tanaka M. Prolonged peri-firing com-
pression with a linear stapler prevents pancreatic
fistula in laparoscopic distal pancreatectomy. Surg
Endosc. 2011;25:867–71.
References 17. Okano K, Oshima M, Kakinoki K, Yamamoto N,

Akamoto S, Yachida S, Hagiike M, Kamada H,
1. Baker RS, Foote J, Kemmeter P, Brady R, Vroegop T, Masaki T, Suzuki Y. Pancreatic thickness as a predic-
Serveld M. The science of stapling and leaks. Obes tive factor for postoperative pancreatic fistula after
Surg. 2004;14:1290–8. distal pancreatectomy using an endopath stapler. Surg
2. Klimczak A, Miroslawska-Kempinska B, Mik M, Today. 2013;43:141–7.
Dziki A. Evolution of the mechanical suture. Pol 18. Tsukane M, Kobayashi Y, Otsuka Y, Maeda T,

Przegl Chir. 2013;85:44–6. Yamazaki N, Watanabe H, Ando T, Kaneko H, Fujie
3. Olah A. Aladar Petz, the inventor of the modern surgi- MG. Effect of the thickness and nonlinear elasticity
cal staplers. Surgery. 2008;143:146–7. of tissue on the success of surgical stapling for laparo-
4. Robiscek F, Konstantinov I. Humer Hultl: the father scopic liver resection. Conf Proc IEEE Eng Med Biol
of the surgical stapler. J Med Biogr. 2001;9:16–9. Soc. 2014;2014:353–6.
5. Steichen FM, Ravitch MM. Mechanical sutures in 19. Yao D, Wu S. Application of stapling devices in liver
surgery. Br J Surg. 1973;60:191–7. surgery: current status and future prospects. World J
6. Kleinfield NR. U.S. Surgical’s checkered history. Gastroenterol. 2016;22:7091–8.
New York Times. May 13, 1984. 20. Odabasi M, Muftuoglu MAT, Ozkan E, Eris C, Yildiz
7. Chekan E, Whelan RL. Surgical stapling device-tissue MK, Gunay E, Abuoglu HH, Tekesin K, Akbulut
interactions: what surgeons need to know to improve S. Use of stapling devices for safe cholecystectomy in
patient outcomes. Med Devices. 2014;7:305–18. acute cholecystitis. Int Surg. 2014;99:571–6.
21. Aoki T, Ozeki Y, Watanabe M, Tanaka S. Cartilage 24. Mery CM, Shafi BM, Binyamin G, Morton JM,

folding method for main bronchial stapling. Ann Gertner M. Profiling surgical staplers: effect of staple
Thorac Surg. 1998;65:1800–1. height, buttress, and overlap on staple line failure.
22. Timucin A, Aras O, Karip B, Memisoglu K. Staple Surg Obes Relat Dis. 2008;4:416–22.
line reinforcement methods in laparoscopic sleeve 25. Shikora SA, Mahoney CB. Clinical benefit of gastric
gastrectomy: comparison of burst pressures and leaks. staple line reinforcement (SLR) in gastrointestinal sur-
JSLS. 2015;19:e2015.00040. gery: a meta-analysis. Obes Surg. 2015;25:1133–41.
23. Al HGN, Haddad J. Preventing staple-line leak
26. Taha O, Abdelaal M, Talaat M, Abozeid M. A ran-
in sleeve gastrectomy: reinforcement with bovine domized comparison between staple-line oversewing
pericardium vs. oversewing. Obes Surg. 2013;23: versus no reinforcement during laparoscopic vertical
1915–21. sleeve gastrectomy. Obes Surg. 2017;28(1):218–25.
Fundamentals of Drain
Management 11
Guillaume S. Chevrollier, Francis E. Rosato,
and Ernest L. Rosato
11.1 Introduction nephrostomy tube and the suprapubic catheter,

have been developed to decompress the
11.1.1 General Concepts obstructed kidneys and bladder, respectively.
When widespread soilage and peritoneal con-
The types, indications, and placement of drains tamination from a perforated viscus occur, spe-
are often confusing to the surgical trainee. In cialized drains are indicated through which
general, surgical drains are placed to evacuate irrigation and drainage can be obtained.
an unwanted collection of fluid, blood, or air. Recently, the use of intraoperatively placed
Intraoperatively, drains are placed to drain drains has been associated with higher rates of
infected areas and potential spaces at risk for postoperative deep space infection and fistula
fluid accumulation and secondary infection. As formation, calling into question their use in
a general rule, drains should never be placed routine surgical procedures.
with the goal to drain blood, as hemostasis Although evidence is relatively lacking out-
should be achieved by the completion of any side of plastic and breast surgery, some surgeons
case. Drains are also commonly utilized to advocate for the use of continued antibiotic pro-
decompress hollow organs such as the stomach phylaxis for the duration of certain postsurgical
and bladder during the perioperative recovery drains [1].
period when paralytic ileus or close monitoring
needs are common. Specialized drains placed
in the GI tract can serve to decompress seg- 11.1.2 History of the Surgical Drain
ments of bowel, preventing anastomotic dehis-
cence. Additionally, they can help control The origins of the surgical drain can be traced
potential areas of fistula formation from the as far back as 400 BC, specifically to
liver, biliary tree, and pancreas. Specialized Hippocrates, who first reported the use of cloth
genitourinary drains, such as the percutaneous and small tubes to drain infected spaces. For
centuries, passive drainage with makeshift
tools persisted, using such materials as animal
G. S. Chevrollier · F. E. Rosato · E. L. Rosato (*) bones, catgut, horsehair, cloth, glass, and metal
Department of Surgery, Sidney Kimmel Medical tubing. Passive drainage remained the only
Philadelphia, PA, USA form of operative drainage until the end of the
e-mail: Ernest.Rosato@jefferson.edu nineteenth century, when William Halstead

144 G. S. Chevrollier et al.
popularized the radical mastectomy. By raising Table 11.1 The French scale and gauge system
skin flaps during the mastectomy, a large French scale Gauge scale
potential space was created, which inevitably French Outer diameter Needle Outer diameter
filled with fluid and often required re-operative size (mm) gauge (mm)
3 1 32 0.24
drainage. It wasn’t until 1947, when a general
4 1.33 30 0.31
surgeon named David Murphey applied suction
5 1.67 28 0.36
to a perforated drain, that a successful post- 6 2 27 0.41
mastectomy drainage device became available. 7 2.33 26 0.46
Although Murphey’s system allowed only for 8 2.67 24 0.56
intermittent suction, rapid improvements and 9 3 23 0.64
modifications over the next decade would 10 3.33 22 0.71
allow for the application of continuous suction 11 3.67 21 0.81
to the surgical drain. Over the ensuing years, 12 4 20 0.90
various modifications have allowed the modern 13 4.33 19 1.07
14 4.67 18 1.27
surgeon to overcome such basic barriers as
15 5 17 1.47
drain clogging and collapse, leading to the vast
16 5.33 16 1.65
number of surgical drains and drainage sys- 18 6 15 1.83
tems available today [2]. 20 6.67 14 2.11
24 8 13 2.41
28 9.33 12 2.77
11.1.3 Drain Sizes 30 10 11 3.05
32 10.67 10 3.40
Drains are typically described in terms of their
size either on the French scale or the gauge
system. size is not reflective of intraluminal size or
flow rate [3].
11.1.3.1 The French Scale
Surgical catheters are generally sized using the 11.1.3.2 The Gauge System
French (Fr.) scale, which is a direct measure of The other commonly used scale is the gauge sys-
the catheter’s outer diameter. By definition, the tem, which also measures the outer diameter of a
size in French is equal to three times the cathe- needle, catheter, or drain, and is generally
ter’s external diameter in millimeters (mm), as reserved for describing the size of hypodermic
demonstrated by the equation below: needles. This scale was initially developed for
wire manufacturing and is mathematically much
Fr. = 3 ´ d , where d = outer diameter in mm
less intuitive than the French scale. On the French
For example, a 3 Fr. catheter has an outer scale, a rising value corresponds to a larger cath-
diameter of one millimeter, a 6 Fr. catheter has eter or tube size. By contrast, the gauge system
an external diameter of 2 mm, and so on. has an inverse relationship between gauge and
Practically speaking, the French size is a close size, where a higher gauge corresponds to a
approximation of the catheter’s outer circum- smaller catheter size (Table 11.1) [3, 4].
ference in millimeters, where a 10 Fr. catheter
has an outer circumference of approximately
10 mm and a 20 Fr. catheter has an outer cir- 11.2 Technical Considerations:
cumference of approximately 20 mm. It is Drain Types
important to note again that the French size is
reflective of a catheter’s OUTER circumfer- There are four common classes of drains: open
ence, and because the intraluminal diameter drains, closed drains, closed drains with suction,
depends mainly on wall thickness, the French and sump drains—with and without irrigation.
11 Fundamentals of Drain Management 145
11.2.1 Open Drains
Open drains are the oldest and simplest type of

surgical drain. These drains are placed into a col-
lection or open wound and drain either across a
pressure gradient or with the assistance of capil-
lary force to the outside environment, where the
drained fluids usually collect in an absorbent-
type dressing. The presence of the drain also pre-
vents skin closure or wound healing over the
deep tissue space, allowing for healing by sec-
ondary intention and prevention of abscess for-
mation or recurrence. Since the system is open to
the environment, this type of drainage system is
not sterile and is by definition considered con-
taminated. Examples of common open drains
include wound wicks, gauze wound packing,
Penrose drains, and setons. These drains are com-
monly used in heavily contaminated surgical
cases to prevent or treat a closed space infection.
11.2.2 Closed Drains
Closed drainage systems utilize a perforated

drainage catheter, which is connected to a drain-
age receptacle via a closed tubing system. The
entire system is isolated from the external envi-
ronment and is better protected from external
bacterial contamination. The drained fluids move
from the higher pressure (intra-abdominal) or tis-
sue space to the lower pressure (external environ-
ment). Drainage is often facilitated by movement,
cough or strain, which create a pressure gradient
to direct flow externally. These drains are utilized
by surgeons and interventional radiologists for
Fig. 11.1 Pigtail catheter with coiling, locking tip
the drainage of postoperative fluid collections
and for viscus decompression. Some examples of
closed drains are discussed below. removed, allowing the distal end of the catheter
to coil onto itself and form a locking tip, or “pig-
11.2.2.1 The Pigtail Catheter tail,” that allows it to remain inside a collection
The most common interventional radiology (IR) (Fig. 11.1).
drain is the pigtail catheter, which must be
inserted percutaneously under direct radiologic 11.2.2.2 Hollow Viscus Drains
supervision. Specifically, the pigtail catheter is Surgeons may also utilize closed drainage sys-
placed using the Seldinger technique over a wire tems intraoperatively to decompress a hollow
to guide the drain to its desired location. Once the viscus which may have a tenuous suture closure
drain is in correct position, the guidewire is and high risk of postoperative leak into the
a b c
Fig. 11.2 Hollow viscus drains with different retention mechanisms. (a) Mushroom catheter. (b) Malecot catheter.
(c) Foley catheter with balloon tip
p eritoneal cavity. These types of tubes are often applied. Prolonged use can lead to a permanent
used to decompress the biliary tree (T-tubes), fistula from the hollow viscus to the skin, which
gallbladder (mushroom catheter or Malecot cath- may require surgical closure.
eter) (Fig. 11.2a, b), stomach (gastrostomy tube
or G-tube) (Fig. 11.3), duodenal stump (duode- 11.2.2.3 Gastric Tubes
nostomy tube or D-tube), and genitourinary tract Special consideration should be given to the gas-
(Foley catheter, suprapubic catheter, and percuta- trostomy tube (G-tube), a very common yet often
neous nephrostomy tube) (Fig. 11.2c). These mismanaged drain. Although G-tubes can be
drains have flanges, extensions, or balloons placed for palliative decompression, they are
which help with drainage and retention within more often used for long-term enteral feeding
the lumen (Fig. 11.2). They are usually con- access. G-tubes allow for both decompression of
structed from soft rubber or silicone and there- the stomach by opening it to a drainage bag and
fore collapse and fail to drain if strong suction is “venting” and for feeding by injecting tube feeds
Fig. 11.3 Gastric tubes.

(a) Percutaneous a
endoscopic gastrostomy
(PEG) tube. (b) MIC G®
tube (Halyard Health,
Inc., Alpharetta, GA) Skin bumper
Intraluminal
flange
b Intraluminal
Skin bumper
balloon
directly into the stomach. G-tubes mainly come force to dislodge the gastric flange through the
in one of two forms: the percutaneous endoscopic tract and out through the skin. Once the PEG is
gastrostomy (PEG) tube or the MIC G® tube removed or dislodged, it cannot be replaced into
(Halyard Health, Inc., Alpharetta, GA), the main the tract, as the proximal flange cannot fit back
difference being the presence of a flange or a bal- into the tract. If replacement is desired and as
loon at the intracorporeal extremity of the cathe- long as the tract is well established, a MIC G-tube
ter (Fig. 11.3). can be reinserted. This tube is designed like a
Foley catheter with a balloon at the tip. This
11.2.2.4 The PEG and the MIC G-tubes design allows the introduction of the catheter
With endoscopic assistance, the PEG tube is from the skin, bypassing the need for endoscopy.
advanced down the esophagus and into the stom- Subsequent inflation of the balloon secures the
ach. Under direct endoscopic visualization, the tube within the gastric lumen (Fig. 11.3b). As is
tube is externalized by pulling it through the gas- the case with Foley catheters, it is important to
tric wall, abdominal wall, and overlying skin. A remember that the balloon should only be filled
plastic flange at the proximal end of the tube is with water and never with saline. Over time,
used to pull the gastric wall up to the abdominal saline will precipitate to form salt crystals that
wall and locked in place with a bumper applied to can perforate the balloon or clog the lumen of the
the skin surface (Fig. 11.3a). Within approxi- side port, preventing deflation of the balloon.
mately 14–21 days, the tract epithelializes and
the stomach scars to the abdominal wall, making 11.2.2.5 Troubleshooting the G-tube
bedside tube removal or exchange generally safe Two very common issues arising in patients with
thereafter. Once deemed appropriate for removal, G-tubes are dislodgment and obstruction. If the
the surgeon simply pulls on the tube with enough tube falls out of its tract after the 14–21-day
mark, a Foley catheter may be placed safely in

the tract to prevent it from closing or narrowing
until a new tube can be placed. For elderly or
malnourished patients, it can take up to 4–6 weeks
for the tract to mature. Once replaced, correct
position can be confirmed with simple ausculta-
tion of air injected into the stomach. Although
often unnecessary, placement can also be con-
firmed at the bedside by injecting contrast into
the G-tube and obtaining an abdominal X-ray.
Visualization of the gastric rugae confirms ade-
quate placement.
Another common problem encountered is
occlusion of the G-tube, often from administra-
tion of improperly crushed or dissolved medica-
tions or precipitation of tube feeds. Generally, Fig. 11.4 T-tube
this can be resolved by applying gentle positive
pressure with warm water into the obstructed there is no intra-abdominal extravasation of con-
lumen. If this fails, instilling a 50:50 mixtures of trast, confirming an intact and well-healed biliary
orange juice and soda and allowing it to percolate tree. A number of modifications can be made to
within the tube for 30 minutes often breaks up the the T-tube intraoperatively to facilitate place-
occlusion. Pancrelipase solution has also been ment, optimize flow within the tube, minimize
reported as an effective clog- busting agent. trauma to the biliary tree, and avoid a post-
Finally, if this fails, a specially designed de-clog- removal bile leak. The first option is to incise the
ging brush can be used; however, this is associ- T-tube along the length of its intraluminal portion
ated with a risk of damage to the tube and even to (Fig. 11.5b). A second option is to cut a “gutter”
bowel if improperly used. The same unclogging along this same intraluminal portion of the T-tube
principles can be applied to the more temporary (Fig. 11.5d). Others prefer to create a “notch” in
Dobhoff tubes, which are thin, single lumen cath- the segment of the drain that sits directly across
eters that are strictly used for feeding. Dobhoffs from the draining lumen at the top of the T
travel from the nose to either the stomach (naso- (Fig. 11.5e). These modifications allow the
gastric) or to the duodenum (nasoduodenal) if T-tube to fold on itself more easily with traction,
post-pyloric feeding is desired. facilitating removal. With all of these modifica-
tions, the intraluminal ends can also be beveled to
11.2.2.6 T-tubes facilitate insertion (Fig. 11.5c).
Another noteworthy tube with which the surgical
trainee must gain familiarity is the T-tube
(Fig. 11.4), which is most commonly used as a 11.2.3 Closed Suction Drains
platform for biliary tree reconstruction and bili-
ary anastomoses, as well as for decompression of Closed suction drains are among the most
biliary strictures and blockages. A T-tube is commonly used drains in the surgeon’s arma-
designed in the shape of the letter T, with the mentarium. These are classically utilized to drain
longer end of the tube (the base of the T) extend- potential spaces left after an extirpative proce-
ing from the biliary tree to the external environ- dure or infected spaces and abscesses. They also
ment. The two shorter ends (top of the T) lie play a role in the management of high-risk anas-
within the biliary tree at the site of anastomosis tomoses, where a controlled fistula may be
or repair. When removal is appropriate, a T-tube preferable to returning to the OR for revision
cholangiogram can be performed to ensure that or where there are limited revision options
Fig. 11.5 T-tube a d
modifications.
(a) Unaltered T-tube.
(b) Incision made along
intraluminal length.
(c) Beveled ends of
intraluminal portion. c
(d) “Gutter” creation
along length of
intraluminal portion.
(e) “Notch” creation in
middle of intraluminal
portion b e
(pancreaticojejunostomy or esophagojejunos- no evidence of any benefit derived from routine

tomy). Common drain styles include the Jackson- drainage of bowel anastomoses [5]. Drains
Pratt (JP) and Blake drainage systems. These should therefore not be used for routine anasto-
drains have channels or holes that facilitate drain- motic drainage.
age into the tube along their length. These are Finally, closed suction drains are not indicated
connected to a low-pressure suction bulb which to drain actively bleeding spaces. Relying on
maintains constant negative pressure, enhancing these drains to control and monitor bleeding and
the flow of fluids to the external receptacle hematoma formation is a mistake which can lead
(Fig. 11.6). to delayed recognition of significant hemorrhage,
hemorrhagic shock, and serious morbidity. The
11.2.3.1 P roper Use of the Closed prudent surgeon should achieve meticulous
Suction Drain hemostasis by the completion of the surgical
When placing these drains, care must be taken to procedure.
ensure that all side-holes and channels are con-
tained within the tissues. If this is not ensured,
external air will enter into the bulb from the 11.2.4 Sump Drains
drain’s externalized holes or channels, and the
drain will be unable to maintain suction. Closed Sump drains are designed with an additional
suction drains should never be connected to channel in the tubing which enables air to be
direct wall suction or unregulated vacuum. This drawn into the drained space and prevents col-
has been reported to cause direct suction injury to lapse of the tissues around the catheter. These
surrounding organs and vasculature, sometimes drains require constant suction to draw fluids out
with fatal consequences. The negative pressure of the desired space and into the suction canister.
and closed system minimize bacterial migration The inflowing air travels through a separate chan-
into the drained space. nel in the tube and prevents a vacuum seal from
Controversy exists over whether these drains forming around the drain while allowing the
may promote anastomotic leak and fistula forma- dependent fluid to travel into the drainage holes
tion if they are placed in proximity to a fresh and out through the tubing. This “sump” design
intestinal anastomosis. Further, there is currently enables continued evacuation of a space or organ
b c d e
Fig. 11.6 Closed suction drains. (a) Jackson-Pratt® (JP) (c) Flat BLAKE® (Ethicon US, LLC., Cincinnati, OH)
(Cardinal Health, Waukegan, IL) drain with attached tub- drain. (d) Round BLAKE® hubless drain. (e) Round per-
ing and suction bulb. (b) Flat Jackson-Pratt® (JP) drain. forated drain
over time and minimizes suction trauma from entering air to prevent fluid from backing up into
continuous vacuum pressure against a mucosal the air port and breaking the sump effect. It is
lining. Common examples are nasogastric (NG) imperative that the filter be placed in the correct
decompression tubes (Salem Sump) and triple- orientation to allow unobstructed airflow.
channel Davol drains (containing suction, sump,
and irrigation channels) for evacuation of 11.2.4.2 T he Nasogastric (NG) Tube
debris-
laden abscesses, as well as some long and its Proper Placement
intestinal decompression tubes (Fig. 11.7). NG tube placement is one of the most commonly
performed bedside procedures by the early surgical
11.2.4.1 Ensuring Proper Function trainee and, although very common, can have dev-
The key to successful decompression with this astating consequences if improperly placed. The
style of drain is to maintain a clear air inflow first step in placement is to approximate the appro-
channel, which enables constant sump drainage priate length of tubing by measuring the distance
of the space. This is usually confirmed by listen- from the tip of the patient’s nose, around the back
ing for the “whistling” of air through the inflow of the ear, and to the xiphoid process. In an awake
port. If the port is blocked, it can be cleared by a patient, the tube is lubricated with water-soluble
quick blast of air through the port with a bulb lubricant. The patient is asked to tilt their head back
syringe or slip-tip syringe. A one-way filter is allowing the tube to be gently advanced until the
often placed over the air intake port to filter the first level of resistance is felt, when the tip of the
Fig. 11.7 Salem Sump Suction port

drains. (a) Nasogastric a
(NG) tube. (b) Triple-
channel Davol drain
Air port
Intraluminal tip
tube is abutting the back wall of the oropharynx. At Prior to insertion, it is important to ask the
this point, the patient may gag, and it is important patient if they have had nasopharyngeal surgery
to give the patient the time necessary to adjust to in the past, as this may be a contraindication to
the presence of the tube in this location. When blind NG tube placement and may require otolar-
ready, the patient is instructed to bring their chin to yngology consultation for placement under direct
their chest, allowing for widening of the esopha- visualization. In these patients, blind advancement
geal opening and narrowing of the airway to avoid of the tube could result in penetration of the crib-
endotracheal placement. The tube is then gently riform plate and intracranial NG tube placement
advanced in a slightly downward direction to avoid with devastating neurological consequences.
the cribriform plate, while the patient is instructed
to swallow water through a straw, allowing for gen- 11.2.4.3 The Triple-Channel Sump
tle passage of the tube down the esophagus and Drain
across the gastroesophageal (GE) junction. Triple-channel Davol drains (Fig. 11.7b) are uti-
Placement can be confirmed by auscultation of air lized for decompression of debris-laden cavities
being injected into the stomach. A good indicator and abscesses which are likely to clog the aver-
that the tube is not in the airway is to ask the patient age closed suction drainage system. They employ
to phonate. If phonation is possible, the NG tube is a sump design which prevents the development
unlikely to be positioned through the vocal cords. of a vacuum seal and offer a third port through
Once proper position is confirmed, the tube is which continuous irrigation can be delivered to
secured to the nose with tape or can be bridled in break up solid particles in the cavity and facilitate
place in patients at risk of premature self-removal. their evacuation. These drains are often employed
Fig. 11.8 Securing of

the surgical drain with
360° wraps. (a) Initial
suture tied down to the
skin to approximate the
skin at drain site. (b)
Initial suture tied as air
knot to facilitate removal
and decrease patient
discomfort
Air knot
No air knot
a b
for drainage of infected necrotic tissues espe- around the drain 360° and tied again as a sur-
cially following debridement of infected pancre- geon’s knot. With each knot laid onto the drain
atic necroses as an alternative to open abdominal itself, one should observe an indentation into the
packing. drain material, ensuring that the suture is tight
enough to hold the drain securely in place, yet not
so tight as to occlude the lumen of the drain. This
11.3 General Drain Care 360-degree wrap can be repeated as many times
as desired. The anchoring stitch should be posi-
11.3.1 Securing the Surgical Drain tioned in such a way as to direct the drain inferi-
orly and laterally, making it more comfortable for
As a general rule, any surgical drain should be the patient and avoiding the potential for any
sutured in place to prevent accidental removal kinking of the tube postoperatively (Fig. 11.8).
with patient repositioning or ambulation.
Nonabsorbable suture is generally recommended.
Monofilament suture is commonly preferred, 11.3.2 “Cracking Back” the Surgical
offering a potentially lower risk of infection com- Drain
pared to braided suture, which can allow for bac-
terial trapping and growth within its braids. At times, it may be appropriate to slowly remove
If using the initial stitch to concomitantly a drain over a period of days (usually 1–2 cm/
close the drain incision, we recommend a single day) so that the drained cavity can slowly close
interrupted stitch across the incision, adjacent to down over time. This technique theoretically
the drain. When the incision is about the size of reduces the risk of fluid re-accumulation in a
the drain, a single interrupted stitch is placed to potential space and allows the tract to close down
the side of the incision and tied into an air knot so gradually from the inside out with application of
as to decrease pain at the site and make it easier negative pressure. To do this, the suture is cut
to remove when discontinuing the drain. After between the skin knot and the first drain knot, and
placement and tying of the initial skin stitch, both the remaining suture encircling the drain is
sides of the suture are passed circumferentially removed, leaving the drain unsecured with an
around the drain, and a surgeon’s knot is laid adjacent skin stitch still in place. The drain can
down onto the drain. The ends are then passed now be pulled back a desired length. Next, a new
piece of suture is passed within the loop of the out of the skin from the opposite side. Intuitively,
original skin suture. This new piece of suture is cutting both sides of the suture flush at the skin
then secured to the tube as described above in place the patient at risk of having retained suture
360-degree fashion. Intuitively, this process is that can be difficult to remove. Second, prior to
made easier if at the time of initial drain place- removal, the drain must be taken off suction so as
ment, it is secured with an air knot. to reduce the amount of stress applied to the sur-
rounding tissues. Third, the patient must be
instructed or distracted to “relax” the muscula-
11.3.3 “Milking” the Surgical Drain ture through which or around which the drain
may be traveling. This relaxation can be accom-
To ensure proper function of bulb-suction drains, plished by distracting the patient or with deep
these should be “milked” every 4–6 h to prevent breathing. Last, the rate of pull on the tube should
stasis within the drain, which could lead to even- be kept slow and constant. If excessive resistance
tual clot formation or accumulation of debris. To is felt, one should stop pulling on the drain and
do this, the drain is pinched with one hand just confirm that the patient is as relaxed as feasible.
above skin level, while the contralateral hand Sometimes, turning the drain 360° back and forth
secures the drain at skin level to avoid transmit- can also overcome any “catch” of the drain. Of
ting any pull to the skin sutures. The pinched fin- utmost importance, one should remember never
gers are then slid together down the length of the to readvance a drain into its tract once it has been
drain, milking any fluid or particles out of the pulled out, as any portion of exposed drain is
drain and into the bulb. To facilitate this p rocess, considered contaminated and should never be
liquid soap or alcohol swabs can be placed reinserted into its sterile tract. Finally, upon
between the fingers to reduce friction on the removal, the tip of the drain should be checked
drain. Proper drain care is critical to maintaining for integrity. When placing a drain with side-
adequate function and ensuring that the indwell- holes, if trimming a drain to size, it is advisable to
ing drain does not become a nonfunctioning cut the drain between two side-holes, as the side-
“dead” tube. holes themselves constitute the area of a drain
that is most prone to fracture. Ensuring that the
side-holes are intact at time of removal reassures
11.3.4 Removing the Surgical Drain the surgeon that no part of the drain has fractured.
If there remains any concern that a part of the
11.3.4.1 When to Remove drain may have fractured during removal, a plain
the Surgical Drain film should be obtained to confirm absence of a
The timing of drain removal remains debatable. retained foreign body.
The classic teaching is to remove a drain once it
drains less than 25–30 cm3 over a 24-h period;
however, this remains very much up to the oper- 11.4 Complications
ating surgeon and is highly dependent on the of the Surgical Drain
clinical scenario.
11.4.1 Managing the Fractured Drain
11.3.4.2 Drain Removal Technique and the Nonremovable Drain
Once it is determined appropriate to remove the
surgical drain, a number of key precautionary If drain fracture is confirmed radiologically at
measures should be taken to avoid any damage to time of removal, the indwelling portion must be
the tissues surrounding the drain and provide a retrieved. This can be accomplished with IR con-
relatively comfortable experience for the surgical sultation and attempted access through the exist-
patient. First, the securing suture is cut, remem- ing tract. If this fails, return to the operating room
bering to cut only one side and to pull the suture is mandatory for removal of foreign body. Rarely,
at the time of removal, one may find that the in the operating room can be applied. Lastly, a
resistance is simply too strong to overcome purse-string suture can be used to circumferen-
safely. If this happens, inadvertent drain suturing tially appose the bleeding tract to the drain itself.
at time of placement or excessive fascial tight- Coagulation parameters should be checked for any
ness around the drain must be suspected. One reversible causes. In the anticoagulated patient, it
should never attempt to overcome significant may be appropriate to hold anticoagulation and
resistance by simply overpowering the tube, as potentially even reverse it if deemed appropriate.
this can lead to significant visceral and tissue However, the risks of thrombosis must be weighed
damage. These two scenarios are often undis- against the risks of persistent bleeding, and this
cernible, and both require IR consultation for decision is highly individualized to the patient.
attempted removal under direct visualization. If
this fails, return to the operating room for con-
trolled retrieval should be performed. 11.4.4 Accidental Drain Removal
In addition to ensuring proper drain positioning

11.4.2 Fistula Formation and securing at time of placement, additional
steps can be taken to avoid accidental drain
At times, the surgical drain may start putting out removal. The cognitively altered patient is at par-
enteric contents when a fistula from either large ticularly high risk of premature drain removal.
or small bowel has formed. Depending on the When dealing with a delirious patient, it is pru-
patient’s clinical condition and on the output, this dent to use such adjuncts as an abdominal binder
may be managed conservatively but typically to cover the drain site and direct the drain out of
requires a complete work-up to rule out intra- the patient’s reach. If there is clinical concern
abdominal abscesses/collections. Once the out- that the patient may cause harm to his or herself,
put decreases to the desired daily amount, the then protective mitts and/or restraints may be
drain can be slowly “cracked back” as described appropriate. Unfortunately, not all accidental
above, allowing the tract to slowly close from the removals will be prevented, and if this occurs, the
inside out. site should first be dressed with an absorptive
dressing. The patient can either be observed
clinically or plans should be made for immediate
11.4.3 Bleeding at the Site replacement by interventional radiology depend-
ing on the clinical situation.
Bleeding from the site of the drain is another com-
monly encountered problem for the surgical
trainee, especially in the coagulopathic or antico- 11.5 Special Considerations: Tube
agulated patient. When bleeding is detected, gentle Thoracostomy and Negative-
pressure should first be applied in an attempt to Pressure Wound Therapy
achieve hemostasis. If hemostasis is not achieved (NPWT)
with continued pressure, gentle traction can be
placed on the tube in an attempt to identify the 11.5.1 Chest Tubes and Pleural Space
source of bleeding within the tract. If a bleeding Drainage
vessel is clearly identifiable, bedside cautery may
be used after application of local anesthetic, mak- 11.5.1.1 Chest Tube Basics
ing sure to avoid burning the skin or the drain Drainage of the pleural space is required for
itself. A simple figure-of-8 stitch may also be evacuation of air, blood, and fluid collections in
applied to control the bleeding vessel. If diffuse the thoracic cavity which may cause infection,
ooze is encountered or a bleeding vessel is not lung trapping, lung compression, or respiratory
identified, hemostatic agents similar to those used compromise with hemodynamic instability from
Atmospheric tube
Chest drainage
Wall suction
b a c
20 cm
2 cm
Collection Bottle Water Seal Bottle Suction Regulation Bottle
Fig. 11.9 Original three-bottle system for chest tube accumulation of fluid while keeping the underwater seal
drainage. (a) The “water seal” bottle acts as a one-way level constant in “water seal” bottle. (c) The “suction reg-
valve to allow evacuation of intrapleural contents. The ulation” bottle allows for increased negative pressure to be
tube in this bottle is conventionally kept 2 cm below applied safely to the pleural cavity and is conventionally
water. (b) The “collection bottle” allows evacuation and maintained with 20 cm of H2O
pressure buildup. Increased intrathoracic pres- (Fig. 11.9). The first bottle is the “water seal”
sure results in mediastinal shift, leading to bottle, which acts as a one-way valve to allow
decreased cardiac blood return and ultimately evacuation of intrapleural contents. An increase
cardiogenic shock. This tension pneumothorax in intrathoracic pressure with either expiration or
physiology is most commonly the result of a trau- coughing forces intrapleural fluid and air into the
matic or iatrogenic injury to the lung parenchyma chamber. Because of surface tension and the
resulting in one-way passage of air into the pleu- gravitational pull onto the column of water, reen-
ral space and subsequent increase in intrapleural try into the pleural cavity is prevented. In this first
pressure. The tension pneumothorax requires bottle, the distance between the end of the tube
immediate decompression. As a temporizing and the surface of the water is critical. The deeper
measure in the unstable patient, needle decom- the end of the tube sits below water, the greater
pression can be performed by inserting a the resistance to flow into the bottle. Therefore,
14-gauge angiocatheter in the second intercostal the tube is conventionally kept at a level approxi-
space in the midclavicular line until chest tube mately 2 cm below water. With accumulation of
thoracostomy materials become available. fluid, relying only on this single chamber system
Regardless of the indication for placement, once would result in incomplete decompression of the
properly positioned, the chest tube requires a pleural space as the resistance created by the rise
drainage system that will maintain negative intra- in fluid would eventually cause the pressure in
thoracic pressure and enable drainage and collec- the bottle to equilibrate with the intrathoracic
tion of the intrapleural fluids and air. pressure, preventing any further flow of intratho-
racic contents into the bottle.
11.5.1.2 The Original Three-Bottle The addition of a second bottle or “collection
System bottle” overcomes this challenge by allowing for
The original design for a chest tube drainage sys- the evacuation and accumulation of fluid while
tem was comprised of a three-bottle system keeping the underwater seal level at a constant
a Chest drainage b Wall suction Chest drainage

Wall suction
Atmospheric air
Suction
Control
Suction Control Water Seal Collection

Chamber Chamber Chamber Water Seal Collection
Chamber Chamber
Fig. 11.10 (a) Schematic representation of the three-bottle system integrated into a single unit. (b) Oasis™ dry suction
water seal chest drain (Atrium Medical Corporation, Hudson, NH)
2 cm in the first bottle. This prevents an increase ing or maintaining lung expansion. It is important
in resistance to flow from the pleural space with to understand that as long wall suction exceeds
evacuation of the chest cavity. −20 cm H2O, this conventional −20 cm H2O of
A third “suction regulation” chamber is intro- pressure is maintained across the entire system
duced into the system to allow for increased nega- irrespective of the amount of negative pressure
tive pressure to be applied safely to the pleural generated by wall suction.
cavity. In this chamber, an atmospheric tube is
required, running from the external environment 11.5.1.3 Today’s Chest Tube
into a predetermined height of water within the and Developing
third bottle. The height of water in this chamber Technologies
(typically 20 cm) determines the pressure that will Although today’s collection systems are much
be applied across the system into the pleural cav- more compact, the three-bottled design remains as
ity. When external suction is applied to the third a three-chambered device integrated into a single
chamber, air is drawn from the external environ- unit (Fig. 11.10a), such as the Oasis™ dry suction
ment into the atmospheric tube, and bubbling will water seal chest drain (Atrium Medical
occur once the pressure in the canister reaches Corporation, Hudson, NH) (Fig. 11.10b). Recently,
−20 cm H2O or the pressure equals to the height new medical devices such as the Thopaz® digital
of the water column in cm. As wall suction is chest drainage system (Medela LLC—Healthcare,
increased, a constant amount of negative pressure McHenry, IL) have been developed to accomplish
within the system is maintained by the increased the same physiology using digital technology and
entry of environmental air into the chamber, as built-in suction control.
manifested by increased amounts of bubbling
within the chamber. The atmospheric air entering 11.5.1.4 Chest Tube Insertion
the third chamber is immediately evacuated via Although the insertion technique is beyond the
the vacuum tube into the wall suction device. The scope of this chapter, it is important to recognize
now-constant level of negative pressure (−20 cm that insertion can be performed using either the
H2O) is transmitted to the other two chambers and open or closed technique. In the closed technique,
to the intrathoracic space, speeding up the evacu- a trocar is used to blindly insert the tube into the
ation of the pleural cavity and thereby accelerat- pleural space. This technique is fraught with
Fig. 11.11 Different
chest tube shapes. a b
(a) Curved chest tube.
(b) Straight chest tube
dangers and strongly discouraged, as it places the posteriorly and in a basilar location, as fluid will
patient at high risk of lung injury and damage to fall to dependent portions of the pleural cavity.
the great vessels from poorly controlled trocar Chest tubes placed for air should be positioned
insertion, which can have devastating conse- anteriorly and apically as air rises anteriorly in
quences. Instead, the open technique is a much the supine patient and apically when upright.
safer and precise method of chest tube insertion. These are designed in either straight or curved
Depending on the indication for placement, chest form to allow for easier positioning based on
tube location may vary. Traditionally recom- desired location (Fig. 11.11).
mended landmarks to safely place a chest tube
identify an area between the anterior and midaxil- 11.5.1.6 Applying Suction
lary lines in the fourth or fifth intercostal space. to the Chest Tube
The appropriate use and level of suction applied
11.5.1.5 Choosing the Appropriate to chest tubes remain heavily debated. Proponents
Chest Tube and Location of suction argue that suction should allow the
As a general principle, larger chest tubes should injured lung to re-expand and stay approximated
be placed for the evacuation of hemothoraces and to the chest wall, thereby speeding up healing of
empyemas, as smaller tubes are easily clogged by the inured lung. However, those who oppose the
clots or debris. Smaller tubes can be used for prolonged use of suction argue that negative pres-
evacuation of simple fluid and air. Generally, sure causes damage to the lung parenchyma and
chest tubes placed for fluid should be positioned prevents or slows the resolution of air leaks by
maintaining airflow through the injured distal air- daily amount of fluid drainage. When placed for
way. There is currently no consensus on how air evacuation, the surgeon can test for resolution
long and when to apply suction to the chest tube, of lung injury by testing for an “air leak.” In
and this aspect of management remains very doing so, the awake patient is asked to cough to
much dependent on the surgeon. generate a brisk rise in intrathoracic pressure. If
air bubbles are observed in the water seal cham-
11.5.1.7 Special Precautions ber, air is still evacuating the pleural space, and
Special consideration should be directed to chest thus, the lung has not yet healed. Removal of the
tube placement in patients with large hemothora- chest tube in the setting of an air leak would lead
ces and large pleural effusions. to a pneumothorax. In the intubated patient, the
same process can be observed during inspiration,
11.5.1.8 The Large Pleural Effusion when positive pressure is applied to the
One of the potential complications of chest tube airways.
placement in patients with large pleural effusions When removal of the chest tube is deemed
generally present for 3 days or more is the devel- appropriate, the tube should be pulled in early
opment of re-expansion pulmonary edema, which expiration. This is the phase of respiration when
can lead to severe respiratory compromise. This the lungs fill the chest cavity and there is no nega-
results from rapid re-expansion of a collapsed tive intrathoracic pressure to draw air into the
lung and is thought to arise secondary to increased pleural space, reducing the risk of a post-removal
alveolar permeability that results from overly pneumothorax. An occlusive dressing is typically
rapid lung re-expansion. This complication can applied until the tract is closed and air can no lon-
be avoided at the time of chest tube placement by ger enter the pleural space from the skin (usually
briefly clamping the chest tube after drainage of 24–48 h).
1.5 L of fluid to allow the lung time to adjust.
Intermittent re-clamping should be performed for
every 1.5 L drained. 11.5.2 Negative-Pressure Wound
Therapy (NPWT)
11.5.1.9 The Massive Hemothorax
When evacuating a large hemothorax, the volume 11.5.2.1 NPWT Basics
of blood evacuated should be carefully moni- Negative-pressure wound therapy (NPWT) and
tored. In certain specific instances, life- vacuum-assisted closure (VAC) therapy are
threatening hemorrhage is likely, and surgical becoming increasingly common adjuncts in the
exploration is therefore warranted to identify and treatment of both acute and chronic wounds.
repair the source of bleeding. The indications for Traditionally, the system is designed using a vac-
operative exploration are: uum pump, which applies negative pressure to a
porous material (sponge, gauze, foam, etc.)
• Evacuation of 1500 mL of blood at time of ini- placed directly within a wound (Fig. 11.12). This
tial placement system serves to contract the wound, reduce
• Chest tube output of 150–250 mL/h for 2–4 h edema, remove fluid and infectious material, and
• Persistent need for blood transfusions to main- promote tissue regeneration by promoting blood
tain hemodynamic stability [6] flow and fibroblast migration, accelerating granu-
lation tissue formation [7, 8]. Although not all
11.5.1.10 Chest Tube Removal wounds have been shown to benefit from the use
The timing of chest tube removal remains very of the wound VAC, recent evidence has shown
much up to surgeon and institutional preference, significant benefit in the treatment of vascular
as there is no clear evidence for optimal timing surgery patients, as well as in the treatment of
of chest tube removal. When placed for fluid burn wounds, skin grafts, and diabetic foot ulcers
evacuation, the decision is usually based on the [9–11].
a Wound edge b “Lily pad”

Suction tubing
Adhesive
film
Skin
Foam
Subcutaneous
fat
Muscle
Fig. 11.12 (a) Unprotected wound. (b) Wound containing indwelling sponge with overlying film and “lily pad” con-
nected to V.A.C.® (KCI—An Acelity Company, San Antonio, TX) therapy canister
a b c
d e
Fig. 11.13 Wound V.A.C.® application. (a) Sponge cut to defect created in the film directly overlying the foam.
appropriate size. (b) Sponge placed into wound. (e) “Lily pad” applied over defect and connected to
(c) Adhesive film applied over sponge and surrounding V.A.C.® machine
the skin, forming an occlusive dressing. (d) Dime-sized
11.5.2.2 Applying the Wound VAC An occlusive film is then applied to cover the
In applying the wound VAC (Fig. 11.13), a piece entire wound. A small dime-sized defect is cre-
of foam is cut to a size that is slightly smaller than ated in the film directly overlying the foam, and
the wound itself and laid within the wound bed. the tubing is connected to this defect via an occlu-
sive “lily pad” adapter. The tubing is then hooked

to the vacuum device, and negative pressure is Take-Home Points
applied to the desired level of suction ranging • The surgical trainee must become famil-
from −25 to −200 mmHg. Generally, this dress- iar with the various types, indications,
ing is changed every 2–3 days. Theoretically, with and appropriate placement of surgical
each dressing change, the wound bed heals and drains.
shrinks in size as it is gradually replaced by gran- • The French scale is generally used to
ulation tissue. The VAC is continued until the measure catheters and tubes and has a
wound can either be left unprotected or skin direct relationship to drain size, while
grafted depending on size and depth. the gauge system is generally used to
measure hypodermic needles and has an
11.5.2.3 Precautionary Measures inverse relationship to size.
for Applying the Wound VAC • The four common classes of drains are
With the traditional VAC, care must be taken to open drains, closed drains, closed drains
ensure that the surface of the indwelling sponge with suction, and sump drains with and
only comes into contact with subepidermal tissue, without irrigation.
as any contact directly onto the epidermis has • Chest tube thoracostomy is an essential
potential to cause skin necrosis with the applica- skill that must be familiar to all surgical
tion of suction. In general, the typical foam dress- trainees, and understanding how chest
ing should not be applied directly onto the nerves, tube drainage works is critical to proper
blood vessels, or viscera (with the exception of management of the chest tube.
open abdomen VACs—see Chap. 20) [7]. Ideally, • Negative-pressure wound therapy is a
only one single piece of sponge is laid into the rapidly advancing technology that is
wound to minimize the risk of inadvertently leav- quickly expanding in terms of its appli-
ing sponge within the wound. If multiple pieces of cation; however, despite its many theo-
sponge are required, they should be counted and retical advantages over standard wound
documented with each VAC change. Finally, care therapy, more prospective studies are
should be taken to avoid placing the lily pad on needed to truly elucidate its benefits in
weight-bearing areas of the body, as this can lead various patient populations.
to pressure ulcers. In such instances, as in the care • When postoperative bleeding is sus-
of sacral decubitus ulcers, for example, creation of pected on clinical grounds, remember
a “skin bridge” is generally recommended to that drain output can be very unreliable
extend a foam bridge away from the wound. Foam as drains can clot and fail to evacuate
is placed onto the healthy skin that is covered by accumulated blood.
occlusive dressing, and the lily pad is placed at the
end of this “bridge” on a non-weight-bearing area.
can decrease the rate of wound infections in cer-
11.5.2.4 Other Applications tain high-risk wounds [8]. Another new develop-
There are many variations in the design and ment is the open abdomen (OA) VAC to provide
applications of the original wound VAC. A num- temporary abdominal wall closure. This type of
ber of different types of foams exist, with differ- abdominal wall closure is discussed in further
ences in composition, porosity, and antimicrobial detail in Chap. 20.
properties. These developments have enabled the
application of negative-pressure wound therapy
to extend far beyond nonhealing or large postop- Suggested Reading
erative wounds. The incisional VAC allows for
atraumatic foam to be applied directly onto inci- Meyerson JM. A brief history of two common surgical
drains. Ann Plast Surg. 2016;77(1):4–5.
sions. Recent data suggest that incisional VACs
Urbach DR, Kennedy ED, Cohen MM. Colon and rec- a systematic review and meta-analysis. Ann Surg.
tal anastomoses do not require routine drainage: 1999;229(2):174.
a systematic review and meta-analysis. Ann Surg. 6. Mowery NT, et al. Practice management guidelines
1999;229(2):174. for management of hemothorax and occult pneumo-
Mowery NT, et al. Practice management guidelines for thorax. J Trauma Acute Care Surg. 2011;70(2):510–8.
management of hemothorax and occult pneumotho- 7. Dumville JC, et al. Negative pressure wound ther-
rax. J Trauma Acute Care Surg. 2011;70(2):510–8. apy for treating surgical wounds healing by sec-
Dumville JC, et al. Negative pressure wound therapy for ondary intention. Cochrane Database Syst Rev.
treating surgical wounds healing by secondary inten- 2015;6:CD011278.
tion. Cochrane Database Syst Rev. 2015;6:CD011278. 8. Acelity. KCI. An Acelity company negative pressure
wound therapy technology. 2017. http://www.acelity.
com/products/tech/vac. Accessed 22 June 2017.
9. Acosta S, Björck M, Wanhainen A. Negative-pressure
References wound therapy for prevention and treatment of
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1. Edwards BL, et al. Use of prophylactic postoperative Surg. 2016;104(2):e75–84.
antibiotics during surgical drain presence following 10. Kantak NA, Mistry R, Halvorson EG. A review of
mastectomy. Ann Surg Oncol. 2014;21(10):3249–55. negative-pressure wound therapy in the management
2. Meyerson JM. A brief history of two common surgi- of burn wounds. Burns. 2016;42(8):1623–33.
cal drains. Ann Plast Surg. 2016;77(1):4–5. 11. Hasan MY, Teo R, Nather A. Negative-pressure

3. Iserson KV. J.-F.-B. Charriere: the man behind the wound therapy for management of diabetic foot
“French” gauge. J Emerg Med. 1987;5(6):545–8. wounds: a review of the mechanism of action, clinical
4. Ahn W, Bahk J-H, Lim Y-J. The “gauge” system for applications, and recent developments. Diabetic Foot
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5. Urbach DR, Kennedy ED, Cohen MM. Colon and
rectal anastomoses do not require routine drainage:
Fundamentals of Flexible
Endoscopy for General Surgeons 12
Robert D. Fanelli
12.1 Introduction Once a set of tools improved the diagnostic

yield and target localization for lesions like intes-
Modern flexible endoscopes are marvels of medi- tinal tract cancers and sites of GI bleeding, there
cal science. Thin, highly flexible tubular devices has been a continual explosion in endoscopic
illuminated with powerful light sources, with practice since the advent of therapeutic endos-
channels for irrigation, suction, and lens clear- copy, and endoscopy has emerged as a mainstay
ance, which permit tissue sampling, injection of of clinical practice. During the 1970s and 1980s,
substances, and the introduction of adjunctive while many general surgeons focused on tradi-
devices like clips and stents, have dramatically tional surgical developments and their busy oper-
altered the landscape of surgical practice since ative practices, others continued the quest for
their widespread introduction. The introduction increasingly less invasive methods for the diag-
of new, less invasive procedures, those done nosis and treatment of common problems, as
endoscopically instead of surgically, changed demonstrated in Table 12.1. GI bleeding, intesti-
surgical practice forever. From the time that nal polyps, and common bile duct stones became
Ponsky introduced percutaneous endoscopic gas- the targets of these advancements, among other
trostomy (PEG) [1], McCune described endo- things, and before long surgeons found that endo-
scopic retrograde cholangiopancreatography scopic methods of treatment had changed the
(ERCP) [2], Sugawa used a flexible endoscope to
accurately identify the source of upper GI bleed-
ing during laparotomy [3], and Youmans Jr. used Table 12.1 The history of endoscopy is an important
a flexible endoscope to treat upper GI bleeding part of our rich surgical heritage
[4], surgeons without endoscopic skills suddenly Which were developed by surgeons? All of these major
became ill prepared for the future of general endoscopic innovations were:
surgery. Colonoscopy Turell
Endoscopic control of hemorrhage Gaisford,
Sugawa
Polypectomy Shinya, Wolf
Endoscopic retrograde McCune, Shorb
R. D. Fanelli
cholangiopancreatography (ERCP)
Department of Surgery, The Guthrie Clinic,
Sayre, PA, USA Variceal band ligation Steigman
Percutaneous endoscopic Ponsky,
The Geisinger Commonwealth School of Medicine, gastrostomy (PEG) Gauderer
Scranton, PA, USA Biliary stenting Sohendra
Albany Medical College, Albany, NY, USA

164 R. D. Fanelli
landscape of surgical practice. Continued devel- outcomes of gastrointestinal surgery. At its very
opment in the field of flexible endoscopy has basic level, the endoscope is a tool that, when
pushed boundaries of treatment beyond the oper- used to provide inspection at the conclusion of an
ating room, and other specialists have claimed operation involving GI tract reconstruction or
this tool and the set of procedures developed anastomosis, confirms for patients and surgeons
around it as their own, in an attempt to exclude that the intended goals of surgery have been
surgeons from practicing this art for the benefit of safely accomplished. At the very least, all sur-
their patients. The flexible GI endoscope, how- geons who operate on the GI tract should have
ever, owes its development to surgery and remains great facility with the use of endoscopes to leak
well entrenched in our discipline. test anastomoses, inspect mucosal surfaces for
ischemia, and gauge the appropriateness of
reconstructive procedures, like Nissen fundopli-
12.2 General Concepts cation, or the completeness of dissections impor-
tant to optimal outcomes, like during esophageal
It isn’t possible to provide anything but an intro- myotomy for achalasia. Intraoperative endoscopy
duction to a broad field like surgical endoscopy, has become a critically important part of GI sur-
which includes numerous primary and adjunctive gery [8]. Without robust experience with these
procedures, through a chapter in a textbook. basic endoscopic approaches, surgeons will not
Whole texts have been devoted to each of the flex- be positioned to move forward with progressive
ible endoscopy procedures commonly employed therapies, like peroral endoscopic myotomy
in practice, and the reader interested in more than (POEM), peroral pyloromyotomy (POP), or
the fundamental viewpoints presented herein is endoscopic mucosal resection (EMR), for exam-
advised to seek additional information from the ple, or other procedures that rely on the flexible
recommended reading list, below, and other endoscopy platform.
sources. Acquisition of endoscopic skills requires Rural surgeons have long found that surgical
direct clinical exposure, an immersion experi- endoscopy is an important part of their practices
ence, and use of a validated tool to assess compe- as they often provide patients with screening,
tence after training has been conferred by an diagnostic, and therapeutic services that other-
expert endoscopist [5]. This is the role of the wise would not be available in their communities.
Flexible Endoscopy Curriculum developed by the A 2005 publication revealed that rural surgeons
American Board of Surgery, Inc. (ABS), to guide were observed to have performed more endo-
the acquisition of skills in this set of techniques scopic procedures than operative procedures,
central to the past, present, and future of surgery. important to their communities and practices, and
Assessment requires the measurement of accom- that these skills in flexible GI endoscopy are an
plishment against a validated yardstick, and sur- essential component to general surgery practice
geons are fortunate to have access to assessment in rural regions of the United States [9]. The
through the Fundamentals of Endoscopic Surgery results of this same publication, summarized in
program and testing modules, produced by the Table 12.2, demonstrated also that while rural
Society of American Gastrointestinal and surgeons performed more endoscopy than their
Endoscopic Surgeons (SAGES), the first such urban colleagues, the number of flexible GI
program ever created for the objective assessment endoscopy procedures performed by urban sur-
of endoscopy skills regardless of specialty [6]. geons was substantial as well and concluded that
This program removes economic bias from endoscopy remains an important tool for surgical
assessment and credentialing determinations and patient care in all situations. Regardless of
promotes a patient-first approach by ensuring that practice setting, surgeons are encouraged to

standards of training and achievement are met [7]. maintain their endoscopy skills and incorporate
The inclusion of flexible GI endoscopy within these skills into practice for the benefit of their
surgical practice improves the performance and patients and communities.
12 Fundamentals of Flexible Endoscopy for General Surgeons 165
Table 12.2 Comparison of cases reported by urban and Table 12.3 Surgical procedures already replaced by
rural general surgeons applying for ABS recertification endoscopic approaches (partial list)
Rural Urban p Value Esophagus Foreign body removal
General 211 305 <0.0001 Stricture management
Endoscopy 220 77 <0.0001 Palliation of malignancy
Gynecology 18 5 <0.0001 Variceal hemorrhage management
Obstetrics 6 1 0.0003 Achalasia
Laparoscopic 94 119 0.016 GERD (early)
n = 421 n = 114 Barrett esophagus
Adapted from Heneghan et al. [9] Stomach Hemorrhage management
Pyloric obstruction
Gastroparesis
At the time of this writing, great uncertainty Foreign body management
exists about future policies that will be central to Enteral feeding access
the American healthcare system. Regardless of Obesity (early)
Pancreaticobiliary Management of
which plan emerges as the framework that will choledocholithiasis
guide how we care for patients in this country Biliary stricture management
going forward, putting flexible GI endoscopes in Periampullary neoplasm (benign)
the hands of surgeons makes sense economically. Complicated pancreatitis,
Evaluations of the healthcare labor force suggest walled-off pancreatic necrosis
that combining the capabilities of specialists, and Pseudocyst drainage
tearing down traditional silos of care, may be Colon Polypectomy
Intestinal hemorrhage
more efficient and may improve the quality and
Colonic stricture
expedience of care [10]. Surgeons who combine
Acute colonic obstruction
their extensive knowledge and experience in the Management of hemorrhoid
treatment of conditions and symptoms like gas- disease
troesophageal reflux disease, gastrointestinal
hemorrhage, GI malignancy, and dysphagia and
abdominal pain, as some examples, are likely to ing and endoscopic ablation for patients with
provide a more economically efficient approach Barrett esophagus, for example, and the use of
to the care of these patients when involved early, EMR or endoscopic submucosal dissection
as they have the broadest array of diagnostic and (ESD) for those with early rectal or esophageal
therapeutic capability available to be deployed cancer. Traditional surgical approaches will con-
for the benefit of the patient. By eliminating tinue to be less commonly necessary, and less
delays and costly but not always additive consul- invasive therapies based on the flexible GI endos-
tations with other specialists, the surgeon is able copy platform will emerge as new standards in
to swiftly assemble an evaluation that benefits the our approach to many patients. Surgeons who do
patient in a cost-efficient manner. not develop and maintain their skills in surgical
While there is no question that incorporating endoscopy will miss the opportunity to partici-
flexible GI endoscopy into surgical practice pate in the next epoch of our specialty.
serves the needs of our patients today, it will be Another important example an evolution that
an increasingly important set of skills for future surgeons must participate in is the burgeoning
generations of surgeons. Numerous surgical pro- field of bariatric endoscopy. While there are few
cedures that already have been replaced by endo- at present who would argue that any of the cur-
scopic approaches are listed in Table 12.3. The rently available endoscopic therapies for obesity
flexible endoscope has emerged as an exciting compare with the effectiveness of gastric bypass
platform upon which future minimally invasive and sleeve gastrectomy, new technical develop-
surgical procedures will be based. Consider the ments, combinations of pharmacologic and
positive impact of effective colonoscopic screen- endoscopic approaches, and therapeutic
166 R. D. Fanelli
improvements will develop, and there is great central to their field of practice is what will serve
likelihood that an endoscopic treatment model patients best.
will emerge that serves the needs of many There is no question that the best time for sur-
patients well [11]. In order for surgeons to geons to learn to perform flexible GI endoscopy
remain relevant to their patients in all areas of procedures is within the structured learning envi-
our specialty, we must embrace the flexible ronment of their residency and fellowship train-
endoscopy platform and apply its principles lib- ing. This is why SAGES and the ABS have taken
erally in preparation for a future that incorpo- such measures as developing FEC and FES pro-
rates these techniques in ways we might not even grams that seek to increase the endoscopic com-
imagine presently. petence of our surgical workforce going forward
in order to maximally benefit patients. Surgeons
who did not learn endoscopy during their training
12.3 Practical Considerations must make special efforts to attain this knowl-
edge and skill and gain clinical experience. The
Unless a surgeon in training sets out to master pursuit of fellowship opportunities is available to
flexible GI endoscopy, and pursues specialized surgeons able to take time away from their prac-
training opportunities, it is unlikely that she is tice, and individualized programs of instruction
going to acquire the skills necessary to offer full and assessment are possible as well but vary from
spectrum diagnostic and therapeutic endoscopy locale to locale. Mentorship is a hallmark of the
to her community of patients. However, the surgical community, and surgeons interested in
incorporation of flexible GI endoscopy into sur- further training and ongoing education aimed at
gical practice should not be seen as an all or none achieving mastery of new skills are advised to
proposition. It is completely reasonable that a seek out mentorship arrangements that will work
foregut surgeon or bariatric surgeon will develop best in their individual environments.
expertise in upper endoscopy, as the minimum,
and offer those services to patients to address
preoperative, intraoperative, and postoperative 12.4 Specific Procedures
concerns and forego the dedicated additional
training that would be required to add ERCP to Although it would be an impossible task to dis-
their practice. Similarly, a colorectal surgeon cuss in detail each of the basic and advanced
would be expected to develop and maintain endoscopic techniques that are incorporated into
expertise in colonoscopy as a minimum, although a full spectrum surgical endoscopy practice that
given the significant plasticity seen in specialty might include expertise in EGD, enteroscopy,
practices, maintaining skills in upper GI endos- ERCP, EUS, and colonoscopy and their adjuncts
copy may be warranted [12]. Although I support as its mainstays, for most surgeons, the funda-
the notion that surgical endoscopists develop a mental procedures that will be employed are
broad range of skills and recognized expertise in EGD and colonoscopy. These will be detailed
as many endoscopic procedures as possible, we below.
all tailor our skill sets to the needs of our com-
munities, to our clinical interests, and to the par-
ticular circumstances of our careers. Surgeons 12.4.1 Esophagogastroduodenoscopy
are encouraged to begin broadly and acquire the (EGD)
wide-ranging set of endoscopic skills that will
support them in offering patients an optimal EGD provides for detailed inspection of the
choice of procedures and superb clinical out- mucosal surfaces of the esophagus, stomach, and
comes, but if that is not possible, or not feasible early duodenum. This study is indicated for the
given one’s area of subspecialization, then main- evaluation of symptoms that persist despite
taining expertise in the endoscopic procedures conservative treatment, alarm symptoms such as
dysphagia and odynophagia, and surveillance of

treated malignancy or premalignant conditions or
in lieu of radiographic or other evaluation where
the therapeutic advantage of endoscopy adds
value [13].
Consent for EGD is based on a discussion of
the potential risks associated with the procedures,
the potential benefits to be gained, and the alter-
natives for investigation or treatment that might
be used instead. Patients are selected according
to local standards of the unit where EGD will be
performed, but general health and airway assess-
ments are important to the appropriate selection
and treatment of patients. Nasal oxygen, com-
plete cardiac, oximetry, and, increasingly, capno-
graphic monitoring are utilized, and intravenous
access is established for the administration of
both fluids and sedative agents and rescue medi-
cations when needed.
Equipment is selected and tested prior to any
endoscopic procedure, and in particular, the
planned procedure is central to these selections.
Fig. 12.1 The head of the endoscope is held in the left
Each endoscope has at least one working channel
hand, index finger poised to insufflate, suction, or cleanse
through which endoscopic tools are deployed, the lens. Proper balance is important to ergonomic
and it is important that the endoscopist ensures function
that the selected endoscope will accept the tools
necessary for the planned procedure (Fig. 12.1). with advancement into the distal stomach, but
Once the equipment has been selected and tested, this can be accomplished more easily if the
an appropriate pre-procedure safety check com- endoscopist rotates themselves slightly toward
pleted, and the patient sedated either by the their right to face toward the head of the patient,
endoscopist or an anesthesiologist, the procedure so that the endoscope advances along the greater
may begin. curvature of the stomach. This maneuver aligns
The endoscope is advanced under direct vision the scope with the pylorus, and after inspection,
at all times, and carbon dioxide insufflation, pre- the pylorus then is intubated to examine the
ferred over room air insufflation because of its duodenum.
more rapid absorption that results in improved Throughout most of an upper endoscopy,
patient comfort, is used to distend the lumen of torque on the shaft of the endoscope is effective
the organ being inspected in order to provide the in exposing mucosal surfaces to the left and right
best view possible and aid in complete inspection of center, for inspection. As the endoscope is
of the mucosal surfaces. As the endoscope is advanced through the duodenal bulb, the direc-
advanced over the base of the tongue, it is passed tional wheels of the endoscope become more
into the proximal esophagus and directed into the important. As the endoscope advances toward the
center of the lumen as it is advanced distally second portion of the duodenum, the endoscopist
(Fig. 12.2). Mucosal surfaces are inspected along once again takes an oblique step forward with the
the way, noting pathology and securing samples left foot, rotates her body toward her right, and
for biopsy as needed. The endoscope is then rotates the large directional wheel counterclock-
advanced into the stomach and advanced toward wise and the small directional wheel clockwise,
the pylorus. Novice endoscopists often struggle delivering the tip of the endoscope into the
168 R. D. Fanelli
a b c
d e f
g h i
Fig. 12.2 (a) The vocal cords are seen superior to the abnormalities using narrow bandwidth illumination. (f)
esophageal introitus (red arrow), where the endoscope After advancement along the greater curvature, the pylo-
will be introduced. (b) The esophageal introitus yields to rus is inspected from the antrum. (g) The duodenal bulb is
gentle insertion and insufflation as the gastroscope is evaluated after gentle advancement of the gastroscope
advanced. (c) The body of the esophagus is inspected and through the pylorus. (h) The descending duodenum is
observed, noting mucosal abnormalities, altered peristal- inspected after advancement of the gastroscope. Note the
sis, and other abnormalities. Note that the gastroscope biliary ampulla on the medial wall (red arrow). (i)
remains centered in the lumen. (d) The esophagogastric Retroflexed view of the esophagogastric junction demon-
junction is inspected for erosions, metaplasia, gaping, and strates the gastroscope entering the stomach in the region
other abnormalities using white light. (e) The esophago- of the hiatus. Note the small hiatus hernia (red arrow)
gastric junction is inspected for metaplasia and other
descending duodenum. This is the deepest extent shaft of the endoscope is slightly rotated clock-
of insertion in the average procedure, and the wise during withdrawal. Great care should be
careful observation of mucosal surfaces contin- taken to avoid taking biopsies from the medial
ues during slow withdrawal of the endoscope, wall in order to avoid inadvertent biopsy of the
and samples for biopsy are obtained as needed major or minor papillae.
using a biopsy forceps designed for the endo- The endoscopist should develop a systematic
scope in use. Care should be taken to inspect for approach to mucosal inspection, so that there is
pathology, obtain tissue samples that will be great consistency in the quality of examination.
helpful in diagnosis, and observe all important Once the duodenal inspection has been com-
anatomic structures, like the major papilla, seen pleted, retroflexion is accomplished by rotating
more easily on the medial duodenal wall if the the large directional wheel counterclockwise
while laying the head of the endoscope over copy hold advantage over other screening
toward the left and withdrawing the endoscope methods.
shaft back toward the hiatus. This position per- One measure necessary to perform colonos-
mits inspection for and measurement of a hiatus copy that is not required for EGD is bowel prepa-
hernia, and careful inspection will most often ration. Although there are numerous commercial
permit delineation between sliding and parae- bowel preparations available, they can be sorted
sophageal hernias. into two general categories; high-volume lavage
Once anteflexed, the now forward facing preparations and split-dose preparations. The lat-
endoscope is used to decompress the stomach of ter are generally better tolerated and are more
excess insufflation, and the esophagogastric junc- effective in cleansing the colon, but the former
tion is inspected once again. Narrow bandwidth are less expensive and more likely to have lower
illumination, present in high-definition endo- patient copay levels. It is recommended that sur-
scopes, shifts the spectrum of light emitted and is geons performing colonoscopy emphasize to
useful in identifying mucosal changes associated patients the critical importance of a complete
with Barrett esophagus. The esophagus is thor- bowel preparation. Without adequate preparation
oughly inspected, and as the endoscope is within advance of colonoscopy, achieving near com-
drawn, once the pharynx is cleared, the suction plete mucosal inspection will not be possible, and
button on the endoscope should be kept depressed the risk of a missed lesion is increased.
until some fluid is suctioned through the channel Consent for colonoscopy is based on a discus-
and the gastroscope safely laid on a back table for sion of the potential risks associated with the pro-
reprocessing. This simple maneuver keeps fluids cedure and its adjunctive measures, the potential
from dripping on the patient and staff, and onto benefits to be gained, and the alternatives for
the shoes of the endoscopist, while the endoscope investigation or treatment that might be used
is transitioned from bedside to back table. instead. Patients are selected according to local
Photo documentation is an important part of standards of the unit where colonoscopy will be
each endoscopic procedure, and it is generally performed, but general health and airway assess-
accepted that capturing images of (1) the esopha- ments are important to the appropriate selection
gogastric junction using white light and narrow and treatment of patients. Nasal oxygen, com-
bandwidth illumination, if available, (2) the ret- plete cardiac, oximetry, and, increasingly, capno-
roflexed view of the gastric cardia and hiatus, (3) graphic monitoring are utilized, and intravenous
the forward view facing the pylorus, and (4) the access is established for the administration of
duodenal bulb and (5) descending duodenum are both fluids and sedative agents and rescue medi-
a reasonable standard to achieve in most, if not cations when needed.
all, upper endoscopy procedures. Equipment is selected and tested prior to any
endoscopic procedure, and in particular, the
planned procedure is central to these selections.
12.4.2 Colonoscopy Each colonoscope has one working channel
through which endoscopic tools are deployed,
Colonoscopy provides for detailed inspection of and it is important that the endoscopist ensure
the mucosal surfaces of the colon, and as often as that the selected colonoscope will accept the
technically feasible, the terminal ileum. This tools necessary for the planned procedure, and
study is indicated for the evaluation of symptoms that the tools that might be needed are of a length
that persist despite conservative treatment, alarm sufficient to match that required for use through a
symptoms such as bleeding, and surveillance of colonoscope. Once the equipment has been
treated malignancy or premalignant conditions selected and tested, an appropriate pre-procedure
and, most commonly, for screening for polyps safety check completed and all monitoring
and colorectal cancer where the combined diag- devices have been attached and baseline mea-
nostic and therapeutic capabilities of colonos- surements recorded, the patient then is asked to
170 R. D. Fanelli
Fig. 12.4 The right hand glove is kept clean by using a

fresh gauze pad for manipulation of the shaft of the colo-
noscope. Contaminating the directional wheels, snares
and biopsy forceps, and air and suction buttons with lubri-
cant adds unnecessary difficulty to colonoscopy
Fig. 12.3 The head of the colonoscope is held between
the upper right arm and chest wall (red arrow), the tip in
the double-gloved right hand, and the colonoscope shaft taken to maintain as clean the operational head
and electronic umbilicus are gently looped without twists and control wheels of the colonoscope; contami-
in preparation for the introduction of the colonoscope
nation with fluids or lubricant makes handling the
colonoscope significantly more challenging
lie in the left lateral decubitus position, and the throughout the remainder of the procedure. The
patient is sedated either by the endoscopist or an colonoscope is advanced under direct vision at all
anesthesiologist. times, and carbon dioxide insufflation, preferred
Water-soluble lubricant then is dabbed onto over room air insufflation because of its more
the anus using a gauze pad, administered by the rapid absorption that results in improved patient
endoscopist using the right hand. One glove is comfort, is used to distend the lumen of the colon
worn on the left hand and two are worn on the in order to provide the best view possible and aid
right hand (Fig. 12.3). As the head of the colono- in as complete an inspection of mucosal surfaces
scope is held between the right upper arm and as is possible.
lateral chest with its shaft forming a gentle The colonoscope is advanced throughout the
U-shaped loop beside the surgeon, the endosco- colon under direct vision, inspecting the mucosal
pist uses the left hand to elevate the right buttock surfaces both during insertion and withdrawal.
of the patient and uses the right hand, holding the Several anatomic regions in the colon can prove
tip of the colonoscope, to first perform a digital challenging during insertion, particularly the
rectal examination and then to introduce the colo- often-tortuous sigmoid colon, the splenic flexure,
noscope into the rectum. The outer right glove and the hepatic flexure, but loop reduction,
then is removed and discarded, and the head of limited insufflation, external support, and other
the colonoscope held in the left hand while the nuances learned over time will permit complete
right hand, grasping the colonoscope using a intubation and inspection in the overwhelming
gauze pad, is used to advance and withdrawal the majority of patients. Once the cecum has been
colonoscope (Fig. 12.4). Great care should be reached, it is usually identified by the confluence
of the three teniae coli in the cecal pit, leading to ation, and often, the orifice into the ileum can be
the appendiceal orifice seen at the base of the seen. Gently maneuvering the colonoscope
cecum. The ileocecal valve will be seen as a more toward this lumen, and insufflating while advanc-
pronounced fold than the others, often fatty in ing slightly, will permit intubation of the terminal
appearance with a slightly more yellow color- ileum in a majority of patients (Fig. 12.5).
a b c
d e f
g h i
j k l
Fig. 12.5 (a) Cecal intubation is recognized by the con- most patients, and (h) the sigmoid colon has noticeably
fluence of the teniae coli, (b) the appendiceal orifice, and thicker folds than the more proximal colon. (i) Visual
(c) the ileocecal valve. (d) The dimpled surface of the ileo- inspection of the anal canal supplements digital rectal
cecal valve (red arrow) permits entry into (e) the terminal examination performed at the outset, and (j) retroflexion
ileum with just the right amount of tip deflection, insuffla- within the rectal vault completes the distal examination.
tion, and colonoscope advancement. The (f) hepatic flex- (k) Visualization of a small polyp (red arrow) is enhanced
ure and (g) splenic flexure are recognizable landmarks in using (l) narrow bandwidth illumination for confirmation
172 R. D. Fanelli
The colon is carefully inspected again during

withdrawal, taking care to visualize each mucosal Take-Home Message
surface as thoroughly as possible. Biopsies should Flexible GI endoscopy is an important set
be taken when indicated, using appropriately con- of skills for the general surgeon. Mastery,
figured biopsy forceps, and polyps should be as in all forms of procedural intervention,
removed using standard polypectomy techniques. requires training, assessment, current prac-
The decision to perform hot or cold polypectomy tice and experience, and continuing educa-
is based on patient factors, polyp size and mor- tion. The surgeon planning to incorporate
phology, endoscopist experience, and anatomic endoscopy into clinical practice in a mean-
location. Traditionally, therapeutic maneuvers ingful way should strive for excellence in
and specimen acquisition have been performed all aspects of patient care related to this
during withdrawal, but polypectomy, biopsy, and undertaking and should determine which
tissue sampling may be done safely during inser- particular endoscopic procedures are
tion of the colonoscope as well [14]. Tissue essential to their current and future patient
removed using any of these techniques routinely service. Specifically, surgical endoscopists
is sent for histopathologic analysis, although there must master the principles of patient selec-
has been recent enthusiasm for discarding obvi- tion, pre-procedure evaluation, and seda-
ously benign tissues, to reduce costs [15]. After tion and should familiarize themselves
the entirety of the colonic mucosa has been with the many useful evidence-based
inspected as precisely as possible, the colono- guidelines that inform these processes [13].
scope is withdrawn to the level of the dentate line, Surgical endoscopists should strive for
inspecting circumferentially, and the colonoscope excellence in the performance of those
retroflexed within the rectum by rotating the large endoscopic procedures germane to their
directional wheel counterclockwise while slowly patient populations and should master
and gently advancing the colonoscope into the adjunctive therapeutic measures and proce-
mid-rectum. Often, rotating the colonoscope by dures, recognition of pathology, and man-
its shaft will assist in this maneuver. Once ante- agement of lesions encountered. The
flexed again, the suction button on the endoscope management of complications, arrange-
should be depressed to decompress the colon and ment of appropriate follow up based on
rectum and should be kept depressed until some findings and pathology, and expertise in the
fluid is suctioned through the channel and the recovery needs of patients undergoing
colonoscope safely laid on a back table for repro- endoscopic procedures all are central to
cessing. This simple maneuver keeps fluids from expertise in this field. Whether choosing to
dripping on the patient and staff, and onto the offer basic endoscopy services, like EGD
shoes of the endoscopist, while the colonoscope is and colonoscopy, or advanced procedures
transitioned from bedside to back table. that include enteroscopy, ERCP, and EUS,
Photo documentation is an important part of surgical endoscopists should approach the
each colonoscopy, and it is generally accepted acquisition and maintenance of skills in
that capturing images of (1) the cecal pit, (2) ileo- flexible GI endoscopy the same way they
cecal valve, (3) terminal ileum, (4) and retro- would approach any set of procedures cen-
flexed view of the rectum serve as a minimum tral to their practice.
suggested standard. To this, photos of all pathol-
ogy encountered are highly advised, and some
endoscopists early in their experience will
include photos of the splenic and hepatic flex- Recommended Reading
ures, transverse colon, and other anatomic fea-
Zetka JR Jr. Surgeons and the scope. Ithaca: ILR Press;
tures as well. 2003.
Marks JM, Dunkin BJ. Principles of flexible endoscopy 8. Fanelli RD. Intraoperative endoscopy: an important
for surgeons. New York: Springer; 2013. adjunct to gastrointestinal surgery. Tech Gastrointest
Ponsky JL. Atlas of surgical endoscopy. St. Louis: Mosby Endosc. 2013;15(4):184–90.
Year Book; 1992. 9. Heneghan SJ, Bordley JT, Dietz PA, Gold MS,
Jenkins PL, Zuckerman RJ. Comparison of urban and
rural general surgeons: motivations for practice loca-
tion, practice patterns, and education requirements. J
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Fundamentals of Prosthetic
Materials for the Abdominal Wall 13
Udai S. Sibia, Adam S. Weltz, H. Reza Zahiri,
and Igor Belyansky
13.1 Introduction and biologic types. Mesh characteristics such as

chemical composition, pore size (i.e., micropo-
The earliest hernias were repaired by primary rous or macroporous), filament structure (i.e.,
closure of the defect with catgut, silk, or metal monofilament or multifilament), and biodegrad-
wire [1]. Without the use of mesh, primary defect ability influence the intensity of the foreign body
closure alone was demonstrated to be associated reaction elicited by the mesh material and are
with higher rates of hernia repair failure [2, 3]. important characteristics to consider when select-
Benjamin Pease, a surgeon and innovator, first ing a prosthetic material for your patients. The
sought to incorporate prosthetic materials in following sections will help define important fea-
hernia repair when he filed a patent titled tures of various mesh products available today
“Nonmetallic Mesh Surgical Insert for Hernia and the parameters to consider when selecting
Repair.” Several years later, Usher would be them.
the first to describe the use of this patented mate-
rial (polypropylene mesh) for hernia repair [4].
The use of polypropylene mesh was furthered 13.2 General Concepts
by Lichtenstein for inguinal hernias [5].
Contemporary surgical practice enjoys the lux- The principles of functional tissue engineering
ury of choosing from a vast pool of mesh prod- are the foundation to manufacture hernia mesh
ucts, which have consistently been shown to [9]. Mesh is either “knitted” or “woven.” Knitted
reduce recurrence rates compared to primary meshes are continuous filaments looped around
closure alone [6–8]. While experts and studies another [10]. Woven mesh contains a series of
have attempted to define the ideal mesh and its parallel strands alternatively passed over and
characteristics, data supports proper mesh and under another series of parallel strands to be posi-
patient selection for optimal outcomes post- tioned perpendicularly to each other. Synthetic
hernia repair. meshes, except expanded polytetrafluoroethylene
Mesh products are broadly categorized into (ePTFE), are usually knitted and more porous
synthetic permanent, synthetic bioabsorbable, and flexible than woven meshes [11].
Mesh weight and pore size are key aspects
U. S. Sibia · A. S. Weltz · H. R. Zahiri of mesh design. The weight of the mesh
I. Belyansky (*) depends on the weight and amount of material
Department of Surgery, Anne Arundel Medical
Center, Annapolis, MD, USA
used (weight/unit area) [12]. Mesh can be
e-mail: ibelyansky@aahs.org lightweight (typically 33 g/cm2), medium

176 U. S. Sibia et al.
weight (~60 g/cm2), or heavy weight (~100 g/ lower long-term rates of chronic pain as opposed
cm2). Small pore sizes impede soft tissue to heavyweight mesh [31–33]. Notably, mono-
ingrowth and normal healing granulomatous filament lightweight mesh has a high incidence
reactions which can lead to encapsulation of of mechanical failure in open incisional hernia
the entire mesh leading to stiffness and reduced repairs [34]. The next sections will describe
flexibility. Access to antimicrobial agents and individual characteristics of the different types
host immune cells to bacteria is also impeded of synthetic mesh.
with small pore-sized mesh [13, 14]. For that
reason, microporous synthetic meshes such as 13.3.1.1 Polyester
ePTFE are difficult to salvage from infection Polyester mesh is synthesized using alcohol and
and frequently require explantation [15–17]. carboxylic acid [35]. It is biocompatible, hydro-
Larger pore sizes (>75 μm) allow infiltration philic, strong, durable, and resistant to most
by macrophages, fibroblasts, blood vessels, chemicals. Studies have demonstrated higher
and collagen [12]. rates of tissue regeneration compared to PP mesh
All meshes trigger an immune response after [36, 37]. Polyethylene terephthalate (PET) is a
implantation [18]. Although an acute inflamma- semi-aromatic copolymer that was an early poly-
tory response is an important step in the wound ester mesh used in the repair of inguinal and
healing process [19], chronic inflammation can abdominal hernias [38]. However, some have
lead to mesh-related complications of erosion, found that PET mesh may be prone to hydrolytic
migration, and contracture [20–23]. Filament degradation reducing its mechanical strength
structure and chemical composition of mesh can over time [39].
influence the intensity of the foreign body reac- Mesh infection is a dreaded complication of
tion. Monofilament polyester mesh elicits a prosthetic hernia repair. Some synthetic meshes
reduced foreign body reaction compared to mul- such as Parietex (PCO) composite mesh™
tifilament polyester mesh or monofilament poly- (Medtronic, USA) have multifilament structural
propylene mesh in a rodent model [24]. The properties designed to promote tissue ingrowth.
biocompatibility of mesh is important to its In the setting of an infection, multifilament poly-
design and is measured by the quantity of macro- ester meshes are very difficult to salvage and
phages and granulocytes, granuloma size, vascu- often result in chronic wound infections requir-
larization, collagen deposition, and mesh ing complete surgical resection of infected mesh
migration [25]. [40, 41].
Monofilament lightweight polyester mesh
such as Parietex TCM (Medtronic, USA) has
13.3 Mesh Types been reported to have a higher incidence of
mechanical failure in open incisional hernia
13.3.1 Synthetic Permanent Mesh repair [34]. Newer constructs such as Versatex™
(Medtronic, USA) and Symbotex™ (Medtronic,
The use of synthetic permanent mesh is stan- USA) are monofilament, macroporous, medium-
dard practice to repair most hernia defects. weight meshes that offer improved textile
Polymeric materials commonly used to manu- strength, mesh integration, and favorable tissue
facture permanent mesh include polyester, poly- ingrowth [42]. ProGrip™ (Medtronic, USA)
propylene (PP), ePTFE, and more recently meshes are self-fixating meshes which may
polyvinylidene fluoride (PVDF). The benefits of result in decreased postoperative pain associ-
synthetic mesh are well described. Monofilament ated with traditional tack fixation. They are
mesh elicits a reduced inflammatory and foreign composed of a textile PET and microgrip poly-
body reaction and offers better bacterial clear- lactic acid material. Self-fixating mesh is par-
ance when compared to multifilament mesh [24, ticularly useful during inguinal hernia repair
26–30]. Lightweight macroporous mesh is which carries a risk for nerve and vascular injury
thought to have greater tissue integration and due to tack fixation.
13 Fundamentals of Prosthetic Materials for the Abdominal Wall 177
13.3.1.2 Polypropylene products have been promoted to be used in con-

Polypropylene mesh is the most commonly taminated fields to address hernia defects [50],
implanted synthetic surgical mesh, with more than although there is a paucity of literature regarding
one million implanted annually worldwide [43]. long-term outcomes when used for this indica-
The mesh offers high chemical resistance, good tion. Once implanted, the mesh provides the
mechanical stability, and durable strength at a low structural framework for the remodeling of the
cost [44]. It is inert, hydrophobic, biocompatible, abdominal wall by host tissues, which restores its
and resistant to biological degradation [45]. support. Depending on the specific mesh, they
The choice of mesh for clean-contaminated/ are fully resorbed within 2–36 months [51].
contaminated ventral hernia repair remains Accurate long-term recurrence rates with absorb-
debatable. Recent studies have shown that mac- able mesh remain to be determined, although
roporous, medium-weight meshes may be used they are likely higher when compared to syn-
safely in the retromuscular space with signifi- thetic mesh [52].
cantly lower wound morbidity and more durable There are several synthetic bioabsorbable
outcomes versus a similar cohort of biologic mesh products available on the market. Gore
repairs in clean-contaminated ventral hernia Bio-A (WL Gore and Associates, USA) mesh is
repairs [46]. This is likely secondary to improved comprised of polyglycolic acid and trimethylene
bacterial clearance and faster integration of mac- carbonate and has been shown to be efficacious
roporous synthetics. in terms of long-term recurrence and quality of
life for contaminated ventral hernia repairs [53].
13.3.1.3 Expanded It may be an alternative to biologic and synthetic
Polytetrafluoroethylene permanent meshes in these complex repairs.
(ePTFE) Phasix™ (Bard Davol Inc., USA) and TIGR®
Polytetrafluoroethylene is a synthetic fluoropoly- Matrix (Novus Scientific, USA) are newer prod-
mer produced by free radical polymerization of ucts that degrade over several months [54–58].
tetrafluoroethylene [35]. It is highly hydrophobic Phasix™ is a monofilament mesh, while TIGR®
and does not degrade in the abdominal wall. Matrix is a multifilament copolymer of glycolide,
Studies have shown mesh fragmentation, fracture lactide, and trimethylene carbonate. In vivo stud-
lines, and detachments in the presence of bacte- ies have shown that the extent of adherent bacte-
rial contamination [17]. ria corresponds to the estimated filament surface
area [40]. The increased surface area of multifila-
13.3.1.4 Polyvinylidene Fluoride ment meshes may therefore promote the persis-
(PVDF) tence of bacteria resulting in chronic infections.
Polyvinylidene fluoride is produced by the polym-
erization of vinylidene difluoride [35]. It is highly
inert and thermoplastic and exists in four different 13.3.3 Biologic Mesh
crystalline phases, exhibiting different physio-
chemical and mechanical properties [47]. The Biologic mesh products are generally harvested
mesh is durable and more resistant to hydrolysis from allogenic (i.e., human) or xenographic (i.e.,
or degradation than PET [48]. PVDF retains bovine, porcine, and equine) collagen sources
92.5% of its strength after 9 years of implantation and are comprised of a variety of tissues (i.e.,
[49]. dermis, pericardium, and small intestine
submucosa) [35, 51]. The species and types of
tissue define the structural and compositional
13.3.2 Synthetic Bioabsorbable Mesh properties of the biologic mesh. The mode of pro-
cessing (i.e., cross-linking process) determines
Bioabsorbable mesh products are single- or the mechanical properties of mesh, with cross-
double-
layered monofilament polymers that linked mesh being stronger than non-cross-linked
gradually degrade over time [35]. These mesh mesh. A variety of biologic mesh products with
Table 13.1 Properties of biologic mesh

Trade name Manufacturer Species Tissue type Intentionally cross-linked Sterilization method
AlloDerm, LifeCell Corp., Human Dermis No Not terminally
X-Thick Branchburg, NJ sterilized
AlloMax C.R. Bard/ Human Dermis No Low-dose gamma
Davol, Inc.,
Warwick, RI
CollaMend C.R. Bard/ Porcine Dermis Yes 1-ethyl-(3- Ethylene oxide
Davol, Inc., dimethylaminopropyl)-
Warwick, RI carbodiimide (EDC)
hydrochloride
CollaMend C.R. Bard/ Porcine Dermis Yes (EDC) Ethylene oxide
FM Davol, Inc., (fenestrated)
Warwick, RI
FlexHD Ethicon, Inc., Human Dermis No Decontamination with
Somerville, NJ ethanol and peracetic
acid (not terminally
sterilized)
Fortive RTI Biologics, Porcine Dermis No RTI’s Tutoplast®
Inc., Alachua, Tissue Sterilization
FL Process with low-dose
gamma irradiation
GraftJacket Wright Medical Human Dermis No Not terminally
Technology, sterilized
Inc., Arlington,
TN
OrthADAPT Synovis Equine Pericardium Yes (proprietary) Proprietary
Orthopedic and
Woundcare,
Irvine, CA
PeriGuard Synovis Surgical Bovine Pericardium Yes (glutaraldehyde) Ethanol and propylene
Innovations, St. oxide
Paul, MN
Permacol Covidien, Porcine Dermis Yes (hexamethylene Gamma irradiation
Norwalk, CT diisocyanate)
Strattice-firm LifeCell Corp., Porcine Dermis No E-beam
Branchburg, NJ
SurgiMend TEI Bovine Dermis No Ethylene oxide
Biosciences, (fetal)
Inc., Boston,
MA
Surgisis, Cook Medical, Porcine Small No Ethylene oxide
Biodesign Bloomington, intestine
IN submucosa
Veritas Synovis Surgical Bovine Pericardium No E-beam
Innovations, St.
Paul, MN
XenMatrix C.R. Bard/ Porcine Dermis No E-beam
Davol, Inc.,
Warwick, RI
©Novitsky YW, SpringerLink. Hernia Surgery. Cham: Springer International Publishing; 2016
different characteristics are available for hernia sues [51]. Biologic mesh undergoes a decellular-
repairs (Table 13.1). ization process to prevent a host’s immune
Decellularization is the process of removing response against the implanted mesh. Residual
cells and cellular debris from the harvested tis- donor cellular debris can lead to an inflammatory
response in the recipient causing fibrosis. contaminating organisms include Staphylococcus

Depending on the species and tissue, there are epidermidis, Escherichia coli, anaerobes/
many ways of processing biologic mesh. These Enterococcus, Pseudomonas, Proteus, and
include acidic or basic solutions, chelating agents Klebsiella. Many factors including patient
[59, 60], detergents [61–63], enzymes [64, 65], comorbidities, history of wound complications,
hypertonic or hypotonic solutions [66, 67], sol- operative urgency, operative complexity, techni-
vents [61, 62, 68], and toxins [69]. cal approach, and mesh selection influence mesh
Mesh degradation is prevented by cross- infection rates [94–97]. Mesh type and construct
linking of acellular scaffolds to increase material may also impact rates of infection post-surgery.
stability in vivo [70]. Cross-linking is achieved Overall, PP mesh has been associated with infec-
with chemicals. These include carbodiimides tion rates of 2.0–4.2% [98, 99] compared to 0.5–
[71–74], glutaraldehyde [75–77], and hexameth- 9.2% for ePTFE used in open hernia repairs
ylene diisocyanate [75]. The harvested collagen [100–102].
matrix in turn facilitates cellular repopulation
and neovascularization of the implanted field to
form granulation tissue and subsequent epitheli- 13.4.1 Preventative Measures
alization. This process may be further enhanced
through the addition of growth factors to the Prevention is the best strategy to avoid bacterial
matrix. Autologous tissue grafts such as fascia contamination of the prosthesis during the initial
lata and dura mater may also be used in certain implantation [97]. Below is a list of technical
cases for abdominal wall defects when contami- considerations to minimize the risk of mesh
nation or risk of infection is high [78–80]. infection:
Allogenic mesh has higher recurrence rates
than xenographic mesh [81]. Porcine dermal col- • Maintaining meticulous surgical technique
lagen mesh has been reported to have lower rates • Minimizing dissection and tissue undermining
of seroma formation, decreased morbidity, lower with selective use of closed suction drains to
failure rates, and longer time to failure in con- eliminate large dead spaces
taminated or infected fields when compared to • Minimizing mesh handling
allogenic dermal or porcine intestinal collagen- • Minimizing contact between mesh and sur-
based mesh [82, 83]. Heavily cross-linked por- rounding operative environment including the
cine dermal mesh offers a heightened foreign skin
body reaction and an early inflammatory response • Donning new gloves when handling mesh for
[84, 85]. Lighter cross-linked porcine mesh has implantation
fewer adhesions and complications [86]. Cost is a • Careful assessment of the wound to ensure
major barrier to the widespread use of biologic good vascularization and absence of necrotic
mesh [87]. Furthermore, literature is inconclu- debris
sive on the advantages of biologic mesh over syn-
thetic mesh in the contaminated field [88–90].
13.4.2 Antibiotic Prophylaxis
13.4 Special Considerations: In vitro studies indicate that biofilm formed by

Prevention of Infectious common bacteria such as S. aureus and E. coli
Complications plays a critical role in antimicrobial defense
mechanism. Some studies have indicated a pos-
Literature reports infection rates for abdominal sible reduction of deep infections after inguinal
wall hernia repairs from 0.5 to 30% [80, 91], with hernia repair with application of a single dose of
onset of infection up to 39 months after implanta- cefamandole applied directly to the wound or
tion [92, 93]. The most common contaminating gentamicin placed on the mesh in vivo or in vitro
organism is Staphylococcus aureus [94]. Other [103–105]. Others have indicated that biofilms
may be reduced with the use of diclofenac and known to prevent adhesions when placed in direct
ibuprofen, which may reduce infectious compli- contact with visceral loops.
cations [106]. These studies have helped to form The use of non-antibiotic agents with antimi-
the foundation for antibiotic prophylaxis and crobial properties has recently gained attention
antibiotic-coated mesh products. because it minimizes the emergence of resistant
However, antibiotic prophylaxis in elective her-
strains [122]. For example, natural peptides are
nia repair remains a debated topic. The 2009 currently being used on catheters for their antimi-
European Hernia Society guidelines recommend crobial activity, which may also benefit prosthetic
avoiding the use of prophylaxis in low-risk patients
hernia repair [123]. Lysostaphin is a bacterial
but consider it in patients at a high risk (>4–5%) of
endopeptidase which when coated onto PP
surgical site infections [107]. Nevertheless, a meshes contaminated in vitro or to collagen bio-
review of 85,033 patients in the Herniamed meshes in a contaminated subcutaneous implant
Registry revealed that antibiotic prophylaxis sig- model has shown antimicrobial properties against
nificantly reduced the risk for postoperative infec-
Staphylococcus [124–126]. Biopolymers are
tious complications [108]. As expected, this benefit
effective at preventing the formation of
was less pronounced in laparoscopic procedures methicillin-resistant Staphylococcus aureus
which utilize much smaller wounds. Current prac- (MRSA) biofilms [127]. Allicin is a natural com-
tice largely mandates at least one dose of prophy- pound that inhibits the growth of Staphylococcus
lactic antibiotics 1 h prior to incision [109]. epidermidis [128]. An antiseptic triclosan, often
applied onto PP mesh, has been shown to reduce
the incidence of SSIs [129–132].
13.4.3 Other Strategies to Counter Recently, the use of thin porous PP mesh,
Mesh Infection implanted in the retromuscular space, has been
described to be a safe alternative to biologic
In vitro studies have shown that antibiotic-coated meshes in contaminated wounds [46]. This
mesh products are effective at reducing the risk allows permanent repair of the hernia defect
for postoperative SSIs [110–117]. Gentamicin- without incurring higher mesh infection rates.
coated PVDF mesh is effective against all strains
except gentamicin-resistant Escherichia coli
[110–113]. Vancomycin-coated polyester and PP 13.4.5 Mesh Explantation
meshes are effective against Staphylococcus
aureus and Staphylococcus epidermidis [114– Mesh explantation is commonly indicated with
118]. PP-coated ofloxacin or ofloxacin-rifampin resistant mesh infection [133]. Several studies
mesh has limited cytotoxicity and effectively have correlated mesh explantation with the use of
combats gram-positive and gram-negative organ- ePTFE mesh, onlay position, and enterotomy dur-
isms [115, 119]. One must always be cautious ing surgery and postoperative surgical site infec-
with the use of antibiotics to prevent the emer- tions [94, 134]. Conservative treatments such as
gence of new antibacterial-resistant strains. antimicrobial agents and drainage of fluid collec-
tions may allow salvation of the mesh repair when
polyester and PP mesh is used in the repair but
13.4.4 Novel Strategies to Counter rarely for infected ePTFE mesh [1, 135].
Mesh Infection
Hydrophobic anti-adhesive substances such as 13.5 Technical Considerations

polyvinylpyrrolidone, polyethylene glycol, poly-
ethylene oxide, and polydimethylsiloxane sub- 13.5.1 Technical Approach
stantially reduce the number and strength of
microorganisms adhering to prosthetic surfaces The field of abdominal wall reconstruction for
[113, 120, 121]. Polydimethylsiloxane is also complex hernias has historically employed open
techniques to restore the abdominal wall anatomy of biologic mesh is that it predisposes patients
[136–138]. Open approaches, while efficacious for latent hernia recurrences. Recent studies
when performed properly, have been associated have challenged these data contingent on an
with higher perioperative morbidity and longer important technical point [46, 147]. In clean-
length of hospital stays [139–143]. Recently, the contaminated cases, the use of medium-weight
revolution of minimally invasive surgery (MIS) macroporous synthetic mesh offers the advan-
has extended to encompass the field of abdominal tage of a more durable repair with improved
wall reconstruction. Although MIS approaches bacterial clearance and faster integration into
are technically more demanding, they have been the abdominal wall when positioned in the ret-
shown to reduce wound morbidity, expedite return rorectus or preperitoneal spaces [46]. While the
of bowel function, and decrease hospital length of technical and financial significance of these
stay. Furthermore, MIS repairs may substantially findings may be tremendous [148], it is impor-
decrease overall hospital costs [144, 145]. These tant to note that development of retromuscular
findings have in turn fueled new interest in adopt- or preperitoneal space is more time-consuming
ing minimally invasive techniques using laparo- and technically challenging. Prospective multi-
scopic and robotic platforms to address hernias, center trials are needed to confirm the reproduc-
increasing 40% since 2009 [146]. ibility and lower morbidity associated with
these techniques when performed in clean-
contaminated fields.
13.5.2 Mesh Selection
The selection of mesh for clean-contaminated or 13.5.3 Mesh Implantation

contaminated fields during ventral hernia repair
remains debatable. The advantage of biologic Mesh may be implanted as onlay, inlay, retrorec-
mesh in contaminated operative fields is that it tus sublay, or underlay relative to the defect
may reduce the need for additional procedures (Fig. 13.1). Inlay mesh is secured to the defect
aimed at mesh explantation. The disadvantage fascial edges. This technique, although com-
a b
c d e
Fig. 13.1 Diagram of ventral hernia and mesh positioning (a) onlay mesh, (b) inlay mesh, (c) retrorectus sublay mesh,
(d) underlay preperitoneal, (e) underlay intraperitoneal © Novitsky YW. Hernia Surgery. Cham: Springer; 2016
monly used in the past, may be falling out of reduced incidence of chronic postoperative pain
favor due to high recurrence rates [136, 149]. (>3 months), impacting up to 27% of patients
Underlay techniques secure the mesh either to [157–168]. The pathophysiology of chronic pain
the peritoneum intraperitoneally or, more associated with transfascial sutures is thought to
recently, to the posterior rectus sheath preperito- stem from entrapment of neurovascular fibers
neally. The intraperitoneal underlay technique running in between internal oblique and transver-
allowed direct contact between mesh and visceral sus abdominis muscles [160–165]. Patients with
contents of the abdomen leaving the repair prone transfascial suture mesh fixation may be 12 times
to adhesions, mesh erosion, fistulas, and bowel more likely to report pain at the 6-month follow-
obstruction [150]. The retrorectus repair, up when compared to those with fibrin glue mesh
popularized by Rives and Stoppa, countered this fixation [165].
problem by placing the mesh between the rectus While some studies have correlated the use of
abdominis muscle and its fascia [151–153]. A glue fixation with increased seroma rates [166],
2013 systematic review of 62 articles of ventral recent studies have contradicted those findings
hernia repairs concluded that the hernia recur- [164, 165, 167]. Hernia recurrence rates con-
rence rates were the lowest for retrorectus (5%) tinue to be one of the most important outcome
and underlay (7.5%) mesh placements when measures in quality in hernia care. In retromus-
compared to onlay (17%) or interposition (17%) cular repairs, it has been reported that the use of
placements [154]. fibrin glue does not increase the rate of hernia
The increasing utilization of minimally inva- recurrence when compared to transfascial fixa-
sive techniques along with recent data supporting tion [165]. The recurrence rate for fibrin glue
primary closure of the abdominal wall defect to fixation of mesh in the retromuscular position at
enhance mesh incorporation has led to modifica- a median follow-up of 1 year is 2.5% [166]. It
tions of the traditional sublay placement of mesh. remains to be seen whether recurrence rates
One of the most significant developments in this increase at longer follow-ups. The key to the use
realm has been laparoscopic transversus abdomi- of glue fixation in retromuscular or preperitoneal
nis release to reconstruct the linea alba [151, 155, spaces is adequate dissection to develop an ade-
156]. Additionally, the MIS approach with mesh quate space for wide mesh placement. There is
implantation into the retrorectus or preperitoneal yet no long-term data regarding complete elimi-
spaces have allowed for superior repair of more nation of fixation in combination with retromus-
complex defects with reduced morbidity for cular dissection.
patients. Therefore, the retrorectus and the more Macroporous synthetic meshes rapidly inte-
recently described preperitoneal mesh placement grate into the retromuscular space [168, 169].
are likely the safest options for hernia repair, as Once integrated, mesh implant serves to provide
long as the surgeon is trained and is facile with the needed shear forces to off-load the tension on
these techniques. the defect closure, and the use of transfascial fix-
ation may be less important. Heavyweight and
biologic meshes take longer to integrate than
13.5.4 Mesh Fixation macroporous meshes [168, 169]; therefore, many
still recommend the use of transfascial or more
Mesh fixation techniques are many and can range permanent fixation methods with heavyweight
from transfascial sutures to adhesive agents. and biologic meshes.
While transfascial fixation has been deemed a Inconsistent with current cost containment
more stable approach to secure mesh, the use of efforts, the immediate costs associated with
fibrin sealant or other biologic glues in place of use of adhesive fixatives may be as high as
transfascial sutures has been reported as an alter- $1000 per case [165]. It remains to be deter-
native, with support from studies that suggest mined if the costs incurred with use of fixatives
8. EU Hernia Trialists Collaboration. Mesh compared

Take-Home Points with non-mesh methods of open groin hernia repair:
systematic review of randomized controlled trials.
• Mesh reinforcement is seen by most as Br J Surg. 2000;87:854–9.
the standard of care in most hernia 9. Butler DL, Goldstein SA, Guilak F. Functional tissue
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157. Hirsch H, Nagatomo K, Gefen J, et al. Mesh fixa- for hernia repair and mesh integration. J Biomed
tion with fibrin sealant in totally extraperitoneal Mater Res A. 2014;102(1):295–302.
hernia repair. J Laparoendosc Adv Surg Tech A.
2016;27(3):259–63.
Fundamentals of Basic
Laparoscopic Setup 14
Marc Rafols, Navid Ajabshir, and Kfir Ben-David
14.1 Introduction optics, once the video computer chip allowed for
projections and magnification of images on a
Laparoscopic surgery has rapidly expanded dur- monitor, laparoscopic surgery expanded expo-
ing the last few decades but has been around for nentially. The first laparoscopic cholecystectomy
more than a century. Earliest reports of endos- was performed by French physician Mouret in
copy of natural orifices date back to 936–1013 1987. Technological advances in instrumentation
A.D. in medieval Spain where an Arabian by the and laparoscopic devices continue to grow in all
name of Albukasim was performing primitive fields of surgery [1, 2].
esophagoscopies to remove foreign bodies and
possibly early cystoscopy. During the early
1800s, Philipp Bozzini is credited with creating 14.2 General Concepts
one of the first endoscopic devices used to exam-
ine the urethra, female bladder, rectum, ear, 14.2.1 Preoperative Evaluation
mouth, and nasal cavity. Reports also indicated and Patient Selection Criteria
that Bozzini’s device may have been used to
examine the peritoneum of corpses via minilapa- When deciding whether laparoscopic surgery is
rotomies. Throughout the 1800s many physicians the best option for the patient, the surgeon must
and scientist have been accredited with the devel- take a thorough medical history. Pertinent ques-
opment of more sophisticated endoscopies tions include any prior abdominal, pelvic surgery,
including Desormeaux, Nitze, and Kussmaul. radiation exposure, radioactive implants, joint
But it was George Kelling, in 1901, that was the prosthesis, or arthritis that may limit patient posi-
first to use a laparoscope to examine the perito- tioning, significant pulmonary, or cardiac condi-
neal cavity as a procedure he labeled celioscopy. tions that might be affected by pneumoperitoneum
It was not until the 1930s that laparoscopy was or anesthesia, any deep vein thrombosis (DVT)
used for interventional procedures such as lysis or coagulation disorders, and any previous com-
of adhesions and diagnostic biopsy. Laparoscopy plications/reaction to anesthesia in previous sur-
laid latent until the 1970s when gynecologists geries. One must also inquire about medication
began using it routinely. After the advent of fiber history, particularly chronic steroid use, as this
may interfere with healing and may require stress
M. Rafols · N. Ajabshir · K. Ben-David (*) doses during the perioperative period. Cardiac or
Mount Sinai Medical Center, Comprehensive Cancer pulmonary medications should be continued at
Center, Miami Beach, FL, USA the time of surgery.
e-mail: kfir.bendavid@msmc.com

190 M. Rafols et al.
Physical exam should be performed prior to inguinal hernias, large abdominal/pelvic masses
any surgery. Attention to prior incisions, hernias, that may limit working space, or severe cardio-
masses, location of tenderness, presence of peri- pulmonary disease [4].
tonitis, and rectal or vaginal exams when neces- Coinciding abdominal findings require extra
sary are imperative for accurate diagnosis. precautions and may even preclude one from
A routine cardiac and pulmonary workup should being able to undergo laparoscopic surgery.
include a chest X-ray and electrocardiogram with Previous hernia repairs may pose a particular
a cardiologist clearance when required. The problem as trocar insertion may cause injury to
American Society of Anesthesiologists (ASA) any bowel that is adherent to the mesh or trauma
classification is important for laparoscopic sur- to the mesh itself. Patients with distended bowel
gery as patients that fall into ASA classes 4 and 5 are also at risk for intestinal injury, and attempts
may not be candidates for a laparoscopic for nasogastric decompression should precede
approach as they may not be able to tolerate the operative intervention. Care must also be taken
physiologic changes that accompany pneumo- when entering the abdomen in patients with his-
peritoneum [3]. tory of peritonitis or pelvic inflammatory disease
During the preoperative discussion, the sur- which both increase the risk of adhesions and
geon must review the risks and benefits of under- inadvertent enterotomy. The presence of any
going laparoscopic surgery. Special attention abdominal aortic aneurysms must be noted prior
must be given to the expected postoperative to inserting trocars as inadvertent damage will be
course, the associated complications, the possi- devastating. Hepatosplenomegaly could also
bility of having to convert to open surgery, and potentially lead to massive hemorrhage if either
the anticipated recovery time. Informed consent organ is accidentally damaged during trocar inser-
must include the possibility of conversion to open tion. Cirrhotic patients generally have an increased
or any other anticipated procedures that may pos- risk of coagulopathy intraoperatively, and the
sibly be performed during the surgery. appropriate blood products should be readily
The patient’s body habitus is also important to available in the operating room if bleeding is
preoperative planning. Obese patients can have a expected. Also patients with ascites may need
very thick abdominal wall and may require lon- special attention to fluid and colloid replacement.
ger trocars and special considerations when cre- Ascites leaking out of port sites postoperatively
ating pneumoperitoneum safely. In thin patient, can result in delayed healing and increased risk of
the close proximity of the aorta and inferior vena infection. Efforts to medically control ascites
cava (IVC) to the abdominal wall poses a risk of prior to surgery should be made, if possible.
injury when entering the abdomen. Techniques
for avoiding injury to the aortoiliac vasculature
are direct visualization with open Hasson 14.2.2 Operating Room Setup
approach, using an optical trocar, placing Veress
needle at Palmer’s point, and elevating the Basic room setup is reflected in Fig. 14.1.
abdominal wall; all of these will be further elabo- Typically, a tower console will house the insuffla-
rated later in the chapter. tor, energy source, and camera interface with its
Laparoscopic surgery is not amenable to every light source (Figs. 14.2 and 14.3). Aligning these
patient. Absolute contraindications for laparo- in a single area allows for consolidation of the
scopic surgery include inability to tolerate lapa- necessary connections as a single track from the
rotomy, hypovolemic shock, or inability for the operative field to the console. With up to seven or
facility to provide appropriate postoperative care. more connections, disorganization and entangle-
Relative contraindications include inability to ment can lead to difficult maneuvering of instru-
tolerate general anesthesia, long-standing perito- ments, will frustrate the surgeon and operating
nitis which increases risk of bowel injury during room staff, and ultimately compromise the sur-
trocar insertion, large incarcerated ventral or gery and safety of the patient.
14 Fundamentals of Basic Laparoscopic Setup 191
Fig. 14.1 Basic
operating room lay out Gas, light source console
Anesthesia
Monitor #1
Monitor #2
Surgeon’s
Assistant Surgeon
Scrub Assistant Instrument Tray
Energy Source
console
Video monitors should be positioned across vering of the bed in the Trendelenburg or reverse
from the operating surgeon and ideally, multiple Trendelenburg positioning. This allows gravity to
screens can be strategically positioned so that all assist in mobilizing intra-abdominal contents to
participants, including the anesthesia team, surgi- facilitate visualization. If working on the esopha-
cal assistants, and circulating nurse, may view and gus or left liver, patient positioning may need to
be aware of how the surgery is progressing. Room be in lithotomy position, with legs in stir-ups and
lighting should be actively adjusted based on the the surgeon positioned in-between the legs. For a
stage of the procedure. Initially, overhead and sur- retroperitoneal approach, such as nephrectomy or
gical lights should be on, as would occur in any retroperitoneal aortic surgery, the best exposure
typical open surgical approach. Once intra-abdom- is achieved by placing the patient in the lateral
inal access is established, overhead lights should decubitus position and then flexing the table at
be dimmed and surgical lights shut off. The dark- the waist to spread the lateral plane as well as the
ened room will contrast against a brightly lit screen intercostal space for thoracoscopic access.
and will allow for best and safest visualization of
the operative field. At the conclusion of surgery,
room lights and surgical lights are turned on again 14.2.4 Surgeon Positioning
to facilitate closure of the abdominal wall layers.
The surgeon is positioned opposite the surgical
field and across from the video monitor. He or
14.2.3 Patient Positioning she should have an uncompromised vantage point
to safely accomplish the goals of the operation.
Patient positioning often depends on the opera- Often, assistants will be asked to hold the camera
tive field needed. Most laparoscopic surgeries or retract tissue. With limited space, a great deal
require the patient to be in the supine position. of flexibility and dexterity is necessary to do this
Some procedures may require temporary maneu- effectively.
14.2.5 Instruments
There exist a wide variety of instruments used in

laparoscopic surgery, and the list grows daily,
also due to the growth of hybrid procedures
which may require combining laparoscopic tech-
niques with ultrasonography, endoscopy, or fluo-
roscopy. It is important to have a number of these
instruments and modalities readily available,
including instruments for a potentially open
approach. Nowadays, most instruments used in
traditional, open surgery are available for use in
laparoscopic surgery with the necessary size and
length modifications that allow for functionality,
despite entry via 5–12 mm ports. Unfortunately,
many of these are limited in their degrees of free-
dom [wrist-like motion] forcing the laparoscopic
surgeon to adjust his or her technique. This limit-
ing factor and subsequent learning curve forced
upon the surgeon is one reason for the delay in
widespread adoption of minimally invasive lapa-
roscopic surgery when it was first being per-
formed. Fortunately, increases in volume have
proportionally increased new medical devices
such as knot pusher, Bovie hook, Endo Catch
bag, and Endo Stitch™. Figure 14.4a–i depicts the
basic essential equipment to perform laparo-
Fig. 14.2 Energy source console scopic surgery.
a b
Fig. 14.3 (a) Video monitor console with gas, light, and camera source. (b) Insufflator monitor
14.2.6 Establishing increased postoperative pain, they may prove to

Pneumoperitoneum be more of a nuisance. Several options exist for
establishing pneumoperitoneum such as Air,
In order for appropriate visualization and maneu- N2O, helium, neon, argon, and CO2. The latter
vering to take place within the abdomen, creating has been the most studied and used. It is impor-
a surgical field with adequate separation of tis- tant to consider both the gas-specific and
sues is required. This is primarily done by insuf- pressure-specific effects of each option, espe-
flating the workspace cavity with a gaseous cially since these substances may absorb into the
substance. Mechanical lift devices do exist; how- patient’s circulatory system to different extents
ever, due to their bulk, inferior exposure, and and subsequently induce dangerous physiologic
a b
c d
e f
Fig. 14.4 Assorted basic equipment. (a) Laparoscopes (bottom) degree laparoscope. (e) Scope warmer. (f)
(top), light source (left), and camera (right). (b) Trocar. (g) Grasping instruments. (h) Scissors. (i)
Insufflation tubing. (c) Suction irrigator. (d) 0 (top) and 30 Maryland
responses. Those with poor absorption such as myocardial stress [5]. The physiologic changes
the inert gasses have an increased risk for gas associated with CO2 pneumoperitoneum will be
embolus. With CO2 on the other hand, diffusion discussed later in this chapter.
into the patient’s tissue can result in hypercarbia When deciding upon where to initially gain
and ensuing acidosis, increased afterload, even entry, it is important to consider what may be
found underneath the skin. The surgeon’s first 14.2.6.1 Veress Needle
choice is at the umbilicus. The umbilical stalk In the virgin abdomen, one method of gaining
naturally converges the tissue planes, and an entry to the abdomen is with the use of a Veress
approach here will minimize the depth of tissue needle (Fig. 14.5). This spring-loaded needle is
layers traversed. Alternatively, in patients with designed to retract its pointed end upon interface
previous surgical scarring especially at the mid- with resistance. Thus, when the surgeon “pops”
line, access via Palmer’s point (3 cm below the through the abdominal wall fascia and then the
left costal margin, midclavicular line) may pro- peritoneum, it is understood that there now exists
vide safe entry in avoiding potentially adhered direct access from the environment to the perito-
loops of bowel. neal space. Anterior retraction or lifting of the
Fig. 14.5 Veress needle

abdominal wall layers, such as with two penetrat- either side of the incision can be achieved with
ing towel clamps, away from the viscera can two clamps or stay sutures allowing for elevation
facilitate safe entry. The gaseous substance of away from intra-abdominal organs and a safe
choice can flow via the needle’s shaft and insuf- incision through the fascia and peritoneum. Now,
flation of the abdomen begins. With pressure a blunted trocar (Fig. 14.6) may be advanced into
feedback monitoring on the insufflation console, the abdomen. Replacing the clamps with suture
low (<5 mmHg) starting pressure ensures the that can be wrapped around the trocar for added
needle’s tip is outside of abdominal wall layers. security is the final step prior to passing the trocar
Further, the surgeon may instill normal saline and tip into the abdominal cavity. If preferred, a clean
note the ease with which it enters the abdomen. finger swipe can add reassurance prior to trocar
Infiltrating with normal saline and noting clear entry.
fluid return on aspiration confirm the needle tip
rests outside loops of bowel. 14.2.6.3 Optical Trocar
Once the abdomen is appropriately inflated to A hybrid of the aforementioned approaches is
15 mmHg, standard trocars, e.g., 5 or 10 mm in peritoneal cavity access with a direct optical see-
diameter, may be introduced with a now mini- through trocar. Here, the 0° laparoscope is placed
mized possibility of organ injury. Trocar tips are within the transparent 5 mm trocar, and the sur-
generally aimed away from the sacral promon- geon is able to visualize the abdominal wall lay-
tory and the great vessels. Often, the initial trocar ers as the trocar rotates and separates the fascia
placement is performed under direct laparoscopic and muscle fibers. Guided entry is performed fol-
visualization through an optic trocar. Once this is lowing small skin incision made wide enough to
placed, the remaining trocars are placed under accommodate the trocar. Then, a twisting motion
direct visualization as they are inserted through with controlled entry is performed with visual-
the abdominal incisions. ization of each abdominal wall layer with the end
point here being visualization beyond the perito-
14.2.6.2 Hasson Technique neal lining and within the abdominal cavity. This
When a patient has had multiple previous abdom- technique may be combined with Veress pneu-
inal surgeries, it is advisable to gain entry via a moperitoneum prior to entry, though insufflation
more direct route in the event adhesions from may also begin after trocar entry.
previous surgeries have developed and fixed
loops of bowel or other organs are against the
peritoneal surface. The initial incision is then 14.2.7 Troubleshooting Common
made adjacent to or within the umbilicus. Problems
Dissection is carried down through Camper’s and
Scarpa’s fascia into the paucity of abdominal There exist a number of common hiccups that
wall musculature at midline which allows entry can easily derail the progress of a surgery. Many
into the peritoneal cavity. Securing the fascia on of these will resolve with a quick fix; however,
Fig. 14.6 Blunted
trocar for Hasson
technique
the procedure may be severely hampered with- 14.2.8.1 Gas-Specific Effects

out knowledge of such remedies. For instance, CO2 is readily absorbed into the circulatory sys-
when establishing and maintaining pneumoperi- tem and carried to the alveoli. The diffusion coef-
toneum, high-pressure readings could signal ficient of CO2 is 20 times greater than that of
insufflation of an incorrect tissue plane, i.e., oxygen making it very soluble in the blood. The
within the abdominal wall and hollow viscus. It lungs eliminate CO2 during expiration by increas-
is best to begin insufflating the abdomen with a ing minute ventilation which is the primary
low-flow setting (e.g., 3 L/min). If the monitor mechanism of eliminating CO2. Also, the bone
reads an unexpectedly high pressure, insufflation can buffer up to 12 L of CO2. Normally these
should be immediately stopped, and the trocar mechanisms prevent hypercarbia and respiratory
should be repositioned followed by careful acidosis. However, when the limits of the body’s
exploration of all underlying organs. Once in the buffers are overwhelmed, there will be an
correct tissue plane, insufflation can be expe- increased arterial P CO2 and an abrupt increase in
dited with a “high flow” rate (e.g., 40 L/min). end-tidal CO2. This will eventually lead to a
For reference, a typical insufflator monitor is decrease in the serum pH. These changes can be
depicted in Fig. 14.3b. seen in patients with severe cardiopulmonary dis-
Further, when initially viewing via a laparo- ease in the first 15–20 min of pneumoperitoneum,
scope, the temperature difference between the after which a steady state will be achieved. These
room and the abdomen will produce fogging of physiologic changes may also be seen during
the lens until these equalize. To prevent this, a long cases. In these circumstances, the anesthesi-
scope warmer (Fig. 14.4e) can be employed to ologist may require the patient to come off pneu-
adjust the temperature of the lens and defogging moperitoneum and hyperventilate the lungs.
solution can be applied to the scope’s tip. To Off-loading CO2 may be achieved by an increase
expedite having a clear view once inside the respiratory rate or tidal volume, keeping in mind
abdomen, a gentle and brief wiping of the cam- that a respiratory rate greater than 20 breaths per
era against the liver, peritoneum, or omentum is minute may cause worsening of hypercapnia sec-
safe. Other reasons why there may be a subpar ondary to poor oxygen exchange. If the tidal vol-
image include if the camera is out of focus or the ume is increased too much, barotrauma or
light adjustment was not previously white excessive movement of the surgical field may
balanced. result. Severe respiratory acidosis is uncommon
if patient has normal pulmonary function, but it
could lead to tachycardia as well as an increase in
14.2.8 Physiologic Effects systemic vascular resistance and blood pressure,
of Pneumoperitoneum thus leading higher myocardial oxygen demand
and risk for cardiac ischemia. Changes in cere-
The most common gas used for pneumoperito- brovascular autoregulation can also be seen with
neum is carbon dioxide (CO2) because it is rela- high serum CO2 levels [3, 4].
tively cheap and widely available, suppresses
combustion, is rapidly absorbed into the perito- 14.2.8.2 Pressure-Specific Effects
neum, and is easily eliminated from the body. Pneumoperitoneum can also increase intra-
Nonetheless CO2 pneumoperitoneum has a phys- abdominal (IA) pressures and can affect the car-
iologic effect on the human body. These effects diovascular, pulmonary, and renal organ systems
can be divided into chemical gas-specific or [5]. Increased IA can decrease renal blood flow,
mechanical pressure-specific effects. During the glomerular filtration rate, and urine output.
procedure monitoring of cardiac rhythm, oxygen Frequently there is an observed intraoperative
saturation, end-tidal CO2, heart rate, blood pres- oliguria secondary to decreased renal venous
sure, and urine output is critical to safe laparo- flow [6]. This is immediately reversible when
scopic surgery. pneumoperitoneum is completed at the end of the
case. Pneumoperitoneum can also indirectly appropriate distance from each other. This cre-
increase renin and antidiuretic hormone levels ates space and allows for efficient movement
leading to sodium retention and free water absorp- within the abdomen. Trocars placed within 3 cm
tion. On the other hand, this effect can take up to of each other are not only redundant but facilitate
1 h to reverse. collision of instruments within the abdomen.
Elevated IA pressure affects the cardiovascu- Ideally, there should be at least 10 cm between
lar system in many ways. One of the benefits of the surgeon’s right and left hands.
laparoscopic surgery is that insensible fluid loss Although the camera can technically be placed
is much less when compared to open abdominal in any of the ports that accommodate its size, one
surgery. Nonetheless, during laparoscopic sur- port should intentionally be designated as the
gery intravenous fluids are required for fluid camera port. A commonly used analogy is that of
shifting occurs with lower extremity venous the baseball diamond, where first and third base
pooling, third spacing, as well as blood loss. In are the surgeon’s right and left hands, respec-
hypovolemic patients, excessive IA pressure may tively, second base is the target organ, and this
compress the inferior vena cava and reduce blood leaves home plate to be the designated camera
return to the heart and thus preload and cardiac port (Fig. 14.7).
output. This, combined with reverse Prior to making any incision, the surgeon
Trendelenburg positioning, promotes venous sta- must be mindful of several additional factors
sis and venous thrombosis. It is important to pre- which may not result in a perfect diamond,
vent venous thrombosis on a patient to patient though would be ultimately be more beneficial
basis. This includes sequential compression for the patient. For example, incisions within
devices (SCD) and chemical prophylaxis includ- previous scars or hidden within natural creases
ing agents like heparin or low molecular weight and folds make for a better cosmetic outcome for
heparin. For quick procedures >60–90 min, the patient with the avoidance of a new, visible
excessive deep vein thrombosis (DVT) prophy- scar. Further, prodding the outside surface of the
laxis is not warranted since the risk of DVT is abdomen while visualizing the indentation made
significantly low [4]. from within can assist in avoiding placement of
Increased IA pressure on a paralyzed dia- a trocar within potentially dangerous territory,
phragm is transferred to thoracic cavity. This such as within an area of dense adhesion that
increases the filling pressure in both the right and may contain viscera. Figures 14.8 and 14.9 dem-
left atrium. This can be avoided by maintaining onstrate typical trocar placement for laparo-
the IA pressure <20 mmHg [7]. Increased intra- scopic appendectomy and cholecystectomy,
thoracic pressure may also increase the peak respectively.
inspiratory pressure, making barotrauma more
likely. However, even in patients with chronic
obstructive pulmonary disease, ruptured blebs 14.3 Alternative Approaches
resulting in pneumothorax are rare after laparo-
scopic surgery. 14.3.1 Single-Incision Laparoscopic
Surgery (SILS)
14.2.9 Trocar Positioning SILS has recently entered into the limelight of
general surgery. The concept of SILS has been
Trocar placement is paramount to a seamless around for some time. As early as the 1970s, Dr.
operation. When not thoughtfully planned ahead Raimund Wittmoser, the “father” of modern tho-
of time, the surgery may be wrought with frustra- racoscopic surgery of the autonomic nervous sys-
tion at the expense of patient safety. Several car- tem, used a single-intercostal incision through
dinal guidelines exist that the surgeon should which he inserted a multifunctional port which
bear in mind. First, trocars should be placed with contained all the instruments and optics. Since
Fig. 14.7 “Baseball
diamond” analogy for
trocar placement for, as
an example,
laparoscopic
cholecystectomy
Fig. 14.8 Typical
trocar placement for
laparoscopic
appendectomy
12mm
5mm
5mm
there have been multiple published articles estab- various surgical procedures using this technique.
lishing its resourcefulness as a standard of lapa- The foundation of SILS is the use of a single tro-
roscopic surgery, many surgeons have attempted car site where multiple laparoscopic instruments
Fig. 14.9 Typical
trocar placement for
laparoscopic
cholecystectomy
5mm
3-5mm
3-5mm
12mm
are manipulated via a multiport system. c holecystectomy. Comparable results have been
Placement of the trocar at the umbilicus allows reported for SILS versus traditional four-port
for minimal visible scar and thus theoretically cholecystectomy. Rivas et al. reported operating
more aesthetically appealing than traditional lap- times of 50 min always attaining a critical view
aroscopic surgical scars. However, many sur- using a two-port and three-port SILS technique
geons have questioned its practicality for routine under experienced hands [8]. Acute cholecystitis
use over traditional laparoscopic surgery. The is a factor associated with a lower success rate
ideal patient for SILS is one with lower body 59.9 vs 93.0% and longer operative time of 78 vs
mass index (BMI), early disease, and no previous 70 min. A BMI >30 was also associated with
abdominal surgery. longer operative times [9]. A recent meta-analy-
SILS appendectomy has been described in sis pooling ten randomized control studies evalu-
many pediatric cases, but as the patient size and ated SILC vs laparoscopic cholecystectomy and
weight increase, as does the difficulty of the profound that although there were improved postop-
cedure and conversion rates. Adult SILS appen- erative pain and cosmesis scores, there was a sig-
dectomy was reviewed in a large meta-analysis of nificant increase in major complications (CBD
randomized control studies. The result was lon- injury, requirement for reexploration, and large
ger operating time and higher rate of conversion. vessel injury) with a relative risk of 3.0 as well
There were no differences between the two as an increase in minor complications. Operation
groups in visual analogue pain scores, doses of times were significantly longer in the SILC
analgesics, overall complication rates, wound group with a mean difference added time of
infection, or cosmesis. 23 min. No difference was noted in requirement
One of the most commonly performed SILS for conversion to open or addition of extra port
surgeries is the single-incision laparoscopic sites were noted [10].
14.3.2 Extracavitary MIS retracted laterally to allow a 10 mm blunt trocar.

Either a blunt dissection (Fig. 14.10a) or by bal-
Extracavitary laparoscopic surgery is a technique loon dissector (Fig. 14.10b) is then used to
that uses balloon attached to a laparoscopic cam- develop the preperitoneal space under direct
era to develop a space in the extraperitoneal or visualization. Once this potential space has been
extrafascial plane and then use low-pressure created, the extraperitoneal space is insufflated to
insufflation to maintain it open. Extracavitary 10 mm hg to avoid excessive subcutaneous
laparoscopic surgery uses the same instrumenta- emphysema. This results in a surgical field/work-
tion as traditional laparoscopic surgery. Not entering space that is reduced, but it avoids the com-
ing the peritoneum will avoid the risk of adhesion plications associated with intraperitoneal
formation. Also, insufflation of extraperitoneal laparoscopic surgery like adhesions and trocar
space is associated with less physiologic distur- site hernias and reduces risk of intestinal damage
bances than pneumoperitoneum. Yet, CO2 may and post-op ileus.
produce extensive subcutaneous emphysema if
high pressures are used during insufflation. Direct
absorption of CO2 into the subcutaneous space 14.3.3 Hand-Assisted Laparoscopic
may lead to metabolic acidosis. Surgery (HALS)
Gaining access to the extracavitary space may
be performed by two different techniques, via At times, the goals of surgery are unable to be
balloon dissection or subcutaneous laparoscopic/ fully met while exclusively employing the lapa-
endoscopic devices. Balloon dissection is the roscopic approach. This is especially true when
most commonly employed technique for good the operation necessitates the use of tactile feed-
for extraperitoneal hernia repair and the retro- back such as in feeling for tumor. Several sys-
peritoneal approach used for adrenalectomy, tems (Fig. 14.11: GelPort™, Applied Medical)
lumbar discectomy, necrotic pancreatectomy, and exist that allow the surgeon inserts his or her
occasionally for para-aortic lymph node hand through a large, airtight port which main-
dissection. tains pneumoperitoneum. This, of course, neces-
Totally extraperitoneal hernia repair is the sitates a larger abdominal wall incision upwards
most frequent extraperitoneal MIS performed. of 7–8 cm. Proponents of HALS argue it may
An infraumbilical incision is made contralateral assists with the learning curve of laparoscopy,
to the hernia site. The anterior rectus sheath is retraction, blunt finger dissection, allows for
incised transversely, and the rectus muscle sin rapid control to bleeding vessels, and can be used
a b
Fig. 14.10 (a) TEP direct access with blunt dissection. (b) Balloon-assisted dissection
Fig. 14.11 Hand-
assisted GelPort™
before full conversion to laparotomy. It has also pneumoperitoneum proceeds with a rapid stretch-
been shown to be advantageous by reducing ing of the peritoneal membrane. This may lead to
operating time and conversion rates while main- a vasovagal response with bradycardia and hypo-
taining all the oncological principles and patient tension necessitating immediate desufflation and
safety [11, 12]. possible addition of fluids and/or a vagolytic.
Furthermore, once the abdomen is expanded
to include an extra 4–6 L at a pressure of
14.4 Patient and Safety 12–16 mmHg, venous return via the inferior vena
Monitoring cava may become compromised. This is espe-
cially true in the patient who is positioned in
From anesthetic induction to extubation, patient reversed Trendelenburg [13]. With venous pool-
safety monitoring is paramount. Laparoscopy ing within the lower extremities, a substantial and
adds new challenges both the surgeon and anes- replicable risk exists for deep-venous thrombosis
thesiologist should keep in mind. To start, initial which should be avoided with intraoperative
sequential compression devices or preoperative patient may only require laryngeal mask airway
anticoagulation. rather than conventional endotracheal tube intu-
Mentioned earlier is the risk for gas emboli, bation [13].
less likely with CO2 pneumoperitoneum, though
still a serious possibility. An uncharacteristic
hypotensive episode should warrant suspicion 14.5.2 Pregnancy
which may unfortunately be confused for the
vasovagal response of pneumoperitoneum. A Several factors should be considered prior to and
“mill wheel” murmur may become apparent by during laparoscopic surgery in the pregnant
listening with an esophageal stethoscope, and the patient. Surgical intervention should aim to
patient should be placed in the Trendelenburg ensure mother’s safety without inducing a great
and left lateral decubitus position to trap the gas amount of fetal risk. First and foremost, the sur-
in the apex of the right ventricle, allowing for geon must consider timing. Laparoscopy can be
immediate aspiration via central venous catheter performed safely during any trimester of preg-
access. nancy, though waiting until the second trimester
At the conclusion of the operation, it is imper- may reduce the rates of spontaneous abortion and
ative that all trocars are removed under direct preterm labor, specifically in laparoscopic chole-
visualization. A trocar that perhaps injured an cystectomy [14, 15].
epigastric vessel upon entry may partly mask Initial trocar placement should be based on
bleeding for the duration of the surgery. fundal height. To avoid direct injury to the uterus,
Postoperative hypotension, a profound drop in it is prudent to begin with a subcostal trocar. All
hemoglobin and hematocrit, and out of propor- three aforementioned techniques for placement,
tion abdominal pain the next morning will then i.e., Veress, Hasson, or optical trocar, can be used
leave the surgeon scratching his or her head only when starting at the subcostal margin, and an
to realize the critical error was failing to visualize underlying fundus is clearly not palpable.
each trocar removal. However, when discovered Insufflation may begin once access is safely
at the time of surgery, intervention may include established. Insufflation pressure between 12 and
direct pressure or full-thickness abdominal wall 15 mmHg is considered safe and has not increased
suture. adverse outcomes for the patient or fetus, and it
should be noted the physiologic contractions of
pregnancy induce a far greater intra-abdominal
14.5 Special Considerations pressures [16].
Pregnancy inherently induces a hypercoagula-
14.5.1 Pediatrics ble state which leads to DVT or PE in 0.5–3.0/1000
pregnancies [17]. Abdominal pressures exceeding
Laparoscopic surgery in the pediatric population 14 mmHg can significantly alter femoral vein
is carried out very similar to that of the adult hemodynamics (diameter, cross-sectional area,
population. It is no surprise that instrumentation peak systolic flow) when compared to a low-pres-
and insufflation should be scaled down due to sure insufflation of 8 mmHg [18]. Unfortunately,
size. Trocar diameters for traditional approaches studies accounting for the combined hypercoagu-
rarely exceed 5 mm. Otherwise, techniques such lable effects, and subsequent adverse outcomes, of
as single- incision laparoscopic appendectomy pneumoperitoneum during pregnancy are lacking
are commonplace and employ a single, 10 mm at this time.
trocar. With less abdominal wall girth and subcu-
taneous tissue, usually, pediatric laparoscopic
surgery can be accomplished with insufflation 14.5.3 Elderly
pressures of 8 mmHg rather than 15 mmHg.
With inguinal hernia repairs even, muscle relax- Limitations for surgery in the elderly have more
ation may prove to be unnecessary, and the to do with recovery than the actual procedure.
Decreased mobility hampers recovery and allows to diaphragmatic stretching is usually self-limited
for the milieu of postoperative risks that increase and should be treated the same as incisional pain.
morbidity and mortality which is certainly exac- It is expected that this will last 1–3 days, and this
erbated by a large, open incision. The advent of may be reduced by evacuating pneumoperito-
laparoscopic surgery has facilitated, most pro- neum at the conclusion of surgery. A systematic
foundly, the acute postoperative period where review of 31 studies determined that low-pressure
decreased pain, earlier mobility, and hastened pneumoperitoneum, low insufflation rate, and
discharge from the hospital have been repeatedly active gas aspiration were effective strategies to
demonstrated. With this, what were once consid- reduce the incidence or severity of shoulder pain
ered too dangerous of surgeries for a frail, elderly after laparoscopic cholecystectomy [20]. Any
patient may be accomplished when an open inci- unusual increases in pain after hospital discharge
sion is now out of the equation. The concern lies should be evaluated to determine the etiology.
with whether or not the benefits gained outweigh
the theoretical cost of a longer operation which
may induce greater physiologic demands. Indeed, 14.6.3 Diet
the evidence supports improved outcomes with
laparoscopic surgery and the elderly; in fact, they Resumption of a normal diet depends mostly on
have the most to gain from this approach [19]. the patient and procedure performed rather than
whether or not the surgery was laparoscopic. For
routine surgeries, i.e., appendectomy or chole-
14.6 Postoperative Care cystectomy, regular diet is usually tolerated as
and Complications soon as postoperative day 1. Recommending a
normal diet only until after demonstration of
14.6.1 Nausea resumed bowel function is a typical rule when
surgery involved anywhere along the gastrointes-
In laparoscopic surgery, postoperative nausea tinal tract. Of course, this is an oversimplifica-
and vomiting (PONV) may be increased when tion, and dietary restrictions should proceed on
compared to open surgery. The etiology is often an individualized patient basis, taking into con-
multifactorial and can be due to anesthetic tech- sideration functional levels at baseline.
nique used, postoperative pain and pain manage-
ment, and factors intrinsic to the patient. Risk
factors which may lead to PONV include female 14.6.4 Activity
gender, young age, lower ASA risk score, history
of PONV or motion sickness, nonsmoking, pre- Like postoperative pain, return to normal activity
operative anxiety, and increased procedure length is expedited with the employment of laparoscopic
with the use of volatile anesthetic agents. surgery, and the two of these go hand in hand. Use
Prevention of PONV, such as with antiemetics or of factors that impair wound healing (steroids,
reduction in opioid use, can make the patient chemotherapy, immunosuppression, and tobacco
more comfortable and hasten their recovery. use) should be taken into consideration when
instructing patients on when to resume normal
activity. Ultimately, the best judgment for dictat-
14.6.2 Pain ing activity will come from the patient listening to
cues of pain and discomfort sensed by their body.
There exist numerous studies which demonstrate
reduced pain after laparoscopic surgery com-
pared to the open approach. As with open sur- 14.6.5 Wound Care
gery, liberal use of a liposomal based local
anesthetic can prevent some of the patient’s pain. The most obvious advantage of laparoscopic sur-
The unique finding of referred shoulder pain due gery is the size of wound created. Incisions of
5 mm or less require only closure at the cutane- 2. Nezhat C, Nezhat C, Nezhat F. Nezhat’s video-
assisted and robotic-assisted laparoscopy and hys-
ous level, which is typically achieved with one teroscopy. Cambridge: Cambridge University Press;
subcutaneous suture to reapproximate the edges 2013. p. 1–6.
of the wound. Larger than 10 mm, it is recom- 3. Schwartz SI, Charles Brunicardi F, Andersen
mended that the peritoneum be reapproximated DK. Schwartz’s principles of surgery. New York:
McGraw-Hill Education; 2015.
as well. The surgeon may also choose to use liq- 4. Fleshman JW, Fowler DL, Whelan RL. The SAGES
uid adhesive and/or steri-strip bandages for rein- manual of perioperative care in minimally invasive
forcement. It is important to instruct the patient surgery. New York: Springer; 2006. p. 25–32.
to keep the skin dry for 24–48 h. Redness or dis- 5. Grabowski JE, Talamini MA. Physiological
effects of pneumoperitoneum. J Gastrointest
charge or increasing pain and swelling are signs Surg. 2009;13:1009. https://doi.org/10.1007/
that healing has gone awry, and these should be s11605-008-0662-0.
addressed promptly. These are often signs of 6. Hazebroek EJ, de Vos tot Nederveen Cappel R,
seroma, infection, hematoma, and/or hernia. Gommers D, et al. Antidiuretic hormone release
during laparoscopic donor nephrectomy. Arch Surg.
Avoidance of sun exposure and the liberal use of 2002;137:600. Discussion 605.
ultraviolet protection will reduce the darkening 7. Sackier JM, Nibhanupudy B. The pneumoperitoneum-
and subsequent visibility of scars. physiology and complications. In: Toouli JG, Gossot
D, Hunter JG, editors. Endosurgery. New York:
Churchill-Livingstone; 1996. p. 155.
14.6.6 Injuries 8. Rivas H, Varela E, Scott D. Single-incision
laparoscopic cholecystectomy: initial evalua-
tion of a large series of patients. Surg Endosc.
Many injuries may not be readily obvious at the 2009;24(6):1403–12.
time of surgery and only present in the postopera- 9. Antoniou SA, Pointner R, Granderath FA. Single-
tive period. Injuries to hollow viscera such as the incision laparoscopic cholecystectomy: a systematic
review. Surg Endosc. 2011;25(1):367–77.
stomach, small bowel, colon, bladder, or ureters 10. Evers L, Bouvy N, Branje D, Peeters A. Single- inci-
can present even up to 7–10 days after surgery sion laparoscopic cholecystectomy versus conven-
despite there being no visible mechanism during tional four-port laparoscopic cholecystectomy: a
the procedure. Notably, thermal burns from elec- systematic review and meta-analysis. Surg Endosc.
2016;31(9):3437–48.
trocautery, anastomotic leak, and ischemia fol- 11. Gupta P, Bhartia V. Hand-assisted laparoscopic surgery
lowing devascularization may present hours to using Gelport. J Minim Access Surg. 2005;1(3):110.
days following skin closure. Signs of tachycar- https://doi.org/10.4103/0972-9941.18994.
dia, anemia, or hypotension should prompt care- 12. Marcello PW, Fleshman JW, Milsom JW, et al. Hand-
assisted laparoscopic vs. laparoscopic colorectal sur-
takers to pursuit further workup. As previously gery: a multicenter, prospective randomized trial. Dis
reviewed, vascular injuries such as those to the Colon Rectum. 2008;51(6):818–26.
epigastric or mesenteric vessels can present post- 13. Holzheimer RG. Laparoscopic procedures as a risk
operatively as anything from an abdominal wall factor of deep venous thrombosis, superficial ascend-
ing thrombophlebitis and pulmonary embolism—a
hematoma to hemodynamic instability with pro- case report and review of the literature. Eur J Med
found anemia. Lastly, nerve injuries are best Res. 2004;9(9):417–22.
treated with prevention. This is accomplished 14. SAGES. Guidelines for diagnosis, treatment and use
with vigilant attention to detail such as appropri- of laparoscopy for surgical problems during preg-
nancy. Surg Endosc. 2007;5(11):3479–92.
ate patient positioning with judicious use of 15. Glasgow R, Visser B, Harris H, Patti M, Kilpatrick
cushioning, avoidance of excessive division and S, Mulvihill S. Changing management of gall-
traction, and awareness of anatomic structures stone disease during pregnancy. Surg Endosc.
when placing sutures, tacks, and staples. 1998;12(3):241–6.
16. O’rourke N, Kodali B-S. Laparoscopic surgery

during pregnancy. Curr Opin Anaesthesiol. 2006;
19(3):254–9.
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Physicians, American Academy of Family Physicians
1. Spaner SJ, Warnock GL. A brief history of endos- Panel on Deep Venous Thrombosis/Pulmonary
copy, laparoscopy, and laparoscopic surgery. J Embolism, et al. Management of venous thrombo-
Laparoendosc Adv Surg Tech A. 1997;7(6):369–73. embolism: a clinical practice guideline from the
American College of Physicians and the American 19. Chesney T, Acuna SA. Do elderly patients have the
Academy of Family Physicians. Ann Intern Med. most to gain from laparoscopic surgery? Ann Med
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18. Sharma A, Dahiya D, Kaman L, Saini V, Behera
20. Donatsky AM, Bjerrum F, Gögenur I. Surgical tech-
A. Effect of various pneumoperitoneum pressures on niques to minimize shoulder pain after laparoscopic
femoral vein hemodynamics during laparoscopic cho- cholecystectomy. A systematic review. Surg Endosc.
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Fundamentals of Laparotomy
Closure 15
William W. Hope and Michael J. Rosen
15.1 Introduction infection rate by their choice of laparotomy clo-

sure technique. This should be an area of great
Although not often a highlighted part of abdomi- focus for surgeons operating on the abdominal
nal operations, secure laparotomy closure is wall and cavity.
essential to minimize the incidence of incisional
hernias and infection. Despite the move to mini-
mally invasive surgery in many common general 15.2 General Concepts
surgical operations, the use of laparotomy is still
common and has an estimated incisional hernia Many types of incisions for accessing the abdom-
risk ranging from 10 to 23% and up to 69% in inal cavity have been described, and each has its
high-risk patient groups with long-term follow- particular advantage and disadvantage. The mid-
up [1–3]. The burden of incisional hernias is a line laparotomy (or celiotomy) incision is one of
major health concern with expenditures in excess the most often used incisions for accessing the
of $3 billion per year [4, 5]. Many patient-related abdominal cavity. It is versatile, allows rapid
risk factors contribute to the incidence of inci- access to all parts of the abdominal cavity, and is
sional hernia and include obesity, male gender, used due to the relative ease of entering the abdo-
postoperative respiratory failure, previous wound men because of the lack of muscle and vascula-
infection, older age, reoperation, diabetes melli- ture in this area. Although midline laparotomy is
tus, malignancy, malnutrition, history of chemo- widely used, some have recommended the use of
therapy, jaundice, glucocorticosteroid use, off midline incisions when possible due to inci-
smoking, and patients with abdominal aortic sional hernia formation [15]. Despite these rec-
aneurysms [6–14]. While these are important fac- ommendations, the midline laparotomy incision
tors for the surgeon to consider, they are often remains a mainstay for surgeons and is the focus
non-modifiable. Surgeons, however, can greatly of this chapter.
affect the incisional hernia rate and possibly the When discussing laparotomy closure, it is
important to have a general knowledge of wound
W. W. Hope (*) healing and abdominal wall anatomy. Healing of
New Hanover Regional Medical Center, University of fascia and laparotomy incisions follow the same
North Carolina at Chapel Hill, Wilmington, NC, USA general principles of wound healing. This
e-mail: William.Hope@nhrmc.org includes an inflammatory, proliferative, and mat-
M. J. Rosen uration phase, although the aponeurosis can take
Cleveland Clinic, Cleveland, OH, USA longer than other tissues to heal [16].
e-mail: rosenm@ccf.org

208 W. W. Hope and M. J. Rosen
The abdominal wall includes layers of skin, The linea alba lies in the midline and is formed
subcutaneous tissue, superficial fascia, deep fas- by the fusion of the anterior and posterior rectus
cia, muscle, extraperitoneal fascia, and perito- sheath. It runs from the xiphoid process to the
neum (Figs. 15.1 and 15.2). Surgeons should symphysis pubis. The rectus muscles lie lateral to
understand the linea alba and its surrounding the linea alba, and when the laparotomy incision
structures as they relate to laparotomy closure. veers off midline, muscle is often exposed, which
can make closure more difficult (Fig. 15.3).
Certain aspects of the laparotomy closure
technique can potentially make this procedure
easier. The laparotomy incision should be made
in the midline and should be as long as needed to
provide adequate exposure. There is no clear con-
sensus on whether to make the skin and fascial
incision using a scalpel or using Bovie electro-
cautery. Some animal data support the use of
scalpel for skin and fascial incision and report
fewer wound complications and higher tensile
strength [17–20]; however, the benefits have not
proven clinically significant in humans, with no
apparent impact on incisional hernia formation
[20–25]. As previously stated, it is ideal to make
the laparotomy incision through the midline, and
veering off can cause bleeding and can disrupt
layers of the abdominal wall often making clo-
sure more challenging and time consuming.
Traditionally, a mass closure technique of sutur-
ing fascia and muscle was recommended; how-
ever, experimental and clinical studies have led to
the recommendation of closure of the aponeuro-
Fig. 15.1 Side view of a laparotomy incision showing sis only [15, 16].
the layers of the abdominal wall including skin, subcuta-
neous tissue, and fascia
Fig. 15.3 Incision of the posterior sheath showing the

Fig. 15.2 Layers of the abdominal wall elevated to show anatomic makeup of the linea alba. When the midline
abdominal cavity and skin, subcutaneous tissue, fascial laparotomy incision veers off midline, the rectus muscle
layers, and muscle can be exposed and complicate closure
15 Fundamentals of Laparotomy Closure 209
15.3 Technical/Practical moved to using smaller suture materials/needles

Considerations/Safety to facilitate a short bite technique (Fig. 15.5).
Precautions For example, a 2-0 PDS Plus II (Ethicon,
Somerville, NJ, USA) on a 31 mm needle was
Several technical considerations are pertinent used in a recent randomized controlled trial
when discussing laparotomy closure and include comparing outcomes [26].
the type of sutures used and techniques of Several important points regarding closure
closure. should be highlighted. It is imperative to use
The suture type used for laparotomy closure meticulous suturing technique by placing the
has long been a subject of debate. Multiple ran- needle at a 90° angle to the desired tissue/fascia
domized controlled trials and meta-analyses and gently follow the curve of the needle through
have evaluated the ideal suture for closure with the tissue to minimize tissue trauma (Fig. 15.6).
differing conclusions. In general, recommenda- The suture to wound length ratio is a key princi-
tions are to use a slowly absorbing suture in a ple in laparotomy closure. The ratio is calculated
continuous fashion, because this is the most after measuring the length of the wound and also
efficient technique to reduce infection and inci- measuring the amount of suture material used to
sional hernia formation [15]. However, there is close the wound (Figs. 15.7 and 15.8). Measuring
controversy on the details of the suture used. suture material used can be done in many ways. It
Many surgeons use a large slowly absorbing is usually determined by first measuring the
suture on a large needle that is double stranded amount of suture material available before begin-
(Fig. 15.4), while others prefer single stranded. ning laparotomy closure and subtracting this
No definitive research recommends one particu- amount from the suture remaining after closure.
lar type of stitch; however, many experts have
Fig. 15.5 Suture and needles. Traditionally large needles

Fig. 15.4 Laparotomy closure using a double-stranded on large suture have been used, but recently smaller nee-
slowly absorbing suture dles and smaller suture have been proposed
Fig. 15.6 When closing fascia, it is important to practice Fig. 15.8 Measuring of the remaining suture following
meticulous suturing techniques such as entering the tissue laparotomy closure. This amount will be subtracted from
at a 90° angle and following the curve of the needle the total amount of suture leaving the amount of suture
used to close the fascia. This number can then be used
along with the length of the fascia measurement to calcu-
late the suture to wound length ratio
Using these numbers, the ratio is calculated. A

large body of literature has long supported the
notion that achieving a greater than 4:1 suture to
wound length ratio decreases incisional hernia
formation [27, 28]. Therefore, during laparotomy
closure, the suture to wound length ratio should
be calculated, and closures should be redone
when they fail to meet the 4:1 target. Although
the 4:1 suture to wound length ratio is generally
agreed on, there are many ways to achieve this
ratio, and recommendations on this have recently
changed.
The traditional technique for closure involved
using approximately 1 cm bites of fascia and 1 cm
advances, and this was based on some experimen-
tal studies [29–31]. Recently, this technique has
been challenged as new evidence shows closure
with smaller bites (5–8 mm) and smaller advances
(5–8 mm) produces a significantly lower inci-
Fig. 15.7 Measuring of the laparotomy incision to calcu- sional hernia rate [26, 32] and possibly surgical
late the suture to wound length ratio
site infection rates [32] compared with the tradi- suture bite including all layers of the abdominal
tional closure (Figs. 15.9 and 15.10). wall except the skin, defining layered closure as
Recommendations vary regarding which struc- an incision closed with more than one separate
tures should be included in abdominal closure. layer of fascial closure, and defining single-layer
Traditionally, a mass closure technique of sutur- aponeurotic closure as suturing the abdominal
ing fascia and muscle was recommended; how- wall fascia in one layer [15]. Whether to close the
ever, some experimental and clinical studies peritoneal layer separately during laparotomy clo-
recommend closure of the aponeurosis only [16], sure is debated; however, no short- or long-term
although no firm conclusions can be drawn, since benefits from this technique have been reported
there has been no clear definition of closure meth- [33], so this has not been recommended [15].
ods. Due to this, the European Hernia Society
guidelines proposed defining mass closure as a
15.4 Current Controversies/
Future Directions
Current laparotomy closure controversies relate

to the lack of strong evidence for closure in
patient groups that have not been well studied in
current literature. While the evidence is convinc-
ing for the short stitch technique for laparotomy
closure, one major criticism is that the data are
from European studies, which include patients
with a lower body mass index (BMI) compared
with the United States population. Another
unknown is the ideal laparotomy closure meth-
ods for patients undergoing emergency surgery. It
Fig. 15.9 Fascial closure using the small bites technique is unknown whether the short stitch concept
of 5 mm fascial bites and 5 mm advances applies to the higher BMI patients or to patients
that undergo emergency surgery. However, if you
Short stitch Long stitch believe in the concepts related to this closure
5 mm method, it makes sense that this technique would
10 mm
apply, although further research is needed.
One major factor related to laparotomy clo-
sure that has not been well studied is fascial ten-
sion. The amount of tension placed on the fascia
5 mm during laparotomy closure may effect incisional
hernia formation and ischemia development. An
old adage related to the closure of fascia (or other
10 mm
suture closure techniques) is “approximate, don’t
strangulate.” While many surgeons subscribe to
this with regard to laparotomy closure, it is a dif-
ficult factor to measure and can be very subjec-
tive and surgeon dependent.
The future direction of laparotomy closure
Fig. 15.10 Schematic showing two different types of includes creating accurate predictive models of
laparotomy closure. Recent literature has supported the
short stitch technique using 5 mm fascial bites and 5 mm
risk factors for incisional hernia development.
advances compared with the traditional 1 cm fascial bites Undoubtedly, some patient groups are at risk
and 1 cm advances even when applying appropriate laparotomy
closure principles. For these patients (such as M, Venclauskas L, Berrevoet F, European Hernia
S. European Hernia Society guidelines on the closure
patients with abdominal aortic aneurysms), the of abdominal wall incisions. Hernia. 2015;19:1–24.
use of prophylactic mesh augmentation has https://doi.org/10.1007/s10029-014-1342-5.
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Fundamentals of Robotic Surgery
16
Tomoko Mizota, Victoria G. Dodge,
and Dimitrios Stefanidis
16.1 Introduction performed by robotic surgery has been constantly

increasing since its introduction. According to the
16.1.1 The Advent of annual report of Intuitive Surgical Inc. (Sunnyvale,
Robotic Surgery CA), which has developed the da Vinci® Surgical
System, approximately 563,000 procedures were
Advancements in technology have revolutionized performed across specialties in the USA in 2016
surgery, first with the introduction of laparoscopic [5] up from just under 300,000 procedures in 2011
surgery and more recently with the advent of robotic for an approximate 190% increase in case volume
surgery. The original idea of the current robotic over the past 5 years [5].
surgery system began with the concept of “tele-
presence” at the National Aeronautics and Space
Administration (NASA) [1]. NASA research- 16.2 Features of Robotic Surgery
ers created a virtual reality system that could be
remotely controlled to operate in space. This system 16.2.1 Advantages of Robotic
displayed a three-dimensional (3D) graphic image, Surgical Systems Over
which seemed to surround the viewer in an imagi- Laparoscopic Surgery
nary environment [2]. This idea was introduced to
surgery in the 1980s allowing surgery to be per- Several technological limitations in laparoscopic
formed remotely by an expert surgeon transferring surgery have made the learning curve long and
his/her skill techniques to the patient site. In 1997, difficult. A robotic surgical system has been
the first telepresence surgery cholecystectomy was developed to address constraints of laparoscopy
performed in Belgium [3]. After being approved in addition to enabling telepresence surgery
for clinical use in the USA in 2000, robotic surgery [6, 7]. Table 16.1 lists specific features of robotic
has been applied to diverse surgical procedures in surgery, which address limitations of laparoscopy
a variety of disciplines, such as urology, general and make difficult tasks easier, resulting in
surgery, gynecology, neurosurgery, orthopedics, improved operator workload.
and cardiac surgery [4]. The number of procedures
16.2.2 Three-Dimensional Imaging

T. Mizota · V. G. Dodge · D. Stefanidis (*)
Department of Surgery, Indiana University School
of Medicine, Indianapolis, IN, USA Traditional laparoscopes show surgeons the oper-
e-mail: dimstefa@iu.edu ating field in two-dimensional (2D) images on a

216 T. Mizota et al.
Table 16.1 Advantages of robotic surgical systems over Robotic systems have several levels of motion
laparoscopic surgery
scaling for both instruments and the visual field,
Laparoscopic so that surgeons can select a preferable scaling.
surgery Robotic surgery
For instance, when a 3:1 ratio scale is selected,
Image quality Two- Three-
dimensional dimensional the motion of the instrument tip is reduced by one
Movements Reversal/ Natural intuition third of the surgeon’s hand motion.
fulcrum effect In addition to motion scaling, a high-
Motion scaling Amplified Favorable performance computer eliminates the effect of
Tremor Amplified Eliminated tremors in a surgeon’s hands. It also enables more
Degrees of 5 DOF 7 DOF precise and delicate movement of the robotic
freedom (DOF)
instruments.
Camera Unstable, held Stable,
platform by assistant controlled by
operator
Ergonomics Restricted Improved 16.2.5 Increased Degrees of Freedom
Since laparoscopic instruments are straight, the

screen. Surgeons are required to recognize 3D degrees of freedom (DOF) are limited to five:
anatomy from 2D images, which makes laparo- pitch, jaw, rotation, insertion/extraction, and
scopic surgery challenging and highly demand- actuation of the instrument. The 5 DOF restricts
ing. In contrast, the camera system in robotic the mobility of a surgeon’s technical performance
surgery is stereoscopic, allowing surgeons to per- and makes laparoscopic procedures difficult. The
form procedures watching 3D images. The bin- robotic system has a joint at the end of the
ocular imaging system reduces surgeon workload end-effector, which moves like a human wrist
and improves depth perception and precision dur- (7 DOF) [7]. This then reflects a surgeon’s com-
ing surgery [8]. plex performance in the tips of the instruments.
16.2.3 Elimination of 16.2.6 Stable Camera Platform

Motion Reversal
During laparoscopic surgery, an assistant handles
Due to leverage around a trocar site (fulcrum), a camera and is required to manually adjust the
laparoscopic instrument tips move opposite of camera position and orientation frequently. Since
the surgeon’s hand motions. This juxtaposition an operating view of laparoscopic surgery com-
can interfere with a surgeon’s performance dur- pletely depends on images captured by a camera,
ing laparoscopy. Conversely, robotic instruments the assistant’s skill in camera handling and com-
translate surgeon’s hand motions into identical munication with the primary surgeon has a large
instrument tip movements. This simplifies oper- impact on procedure performance. On the other
ating tasks and improves surgeon’s performance hand, a robotic surgery camera system can be
by mimicking natural hand motions. handled by a primary surgeon, which aids in
tremor elimination. This enables operating view
stability and comfort for a surgeon.
16.2.4 Favorable Motion Scaling
and Tremor Elimination
16.2.7 Ergonomic Positioning
The fulcrum effect has another influence on
instrument handling. The motions of instrument Ergonomic equipment for surgeons is essential to
tips are amplified greater than surgeon’s hand maximize surgeon performance. Laparoscopy
motions, which complicates the learning curve of has been demonstrated to lead to surgeon fatigue
laparoscopic surgery. Robotic surgery overcomes and pain in the neck, back, shoulders, elbows and
this issue with motion amplification adjustments. hips, because surgeons are required to stand
16 Fundamentals of Robotic Surgery 217
throughout a laparoscopic procedure, sometimes needs to be calibrated appropriately prior to

in contorted positions [9]. To overcome these case start. Inappropriate calibration will cause
issues, the robotic system is equipped with an problems with visualization at the surgeon
adjustable console. Thus, a surgeon can adjust console; therefore, if problems are encoun-
his/her visualization system and padded forearm tered with the image quality, camera recalibra-
rest to the most favorable height. This may tion should be considered. Attention to system
facilitate improved surgeon performance in his/ maintenance is also required to keep the sys-
her most comfortable position [10]. tem working efficiently.
• The robotic arms should be draped before the
case starts.
16.2.8 Safety Mechanisms • Setting up the robotic room for best effi-
ciency (positioning of the patient and operat-
Equipment problems can cause critical injury ing table)
to patients. Unlike laparoscopic equipment, the • Utilizing gravity is essential not only in lapa-
robotic surgery system has multiple sensing mech- roscopic surgery, but in robotic surgery as
anisms to prevent patient injury. When the system well. To maximize its advantage, surgeons
senses an error during a procedure, the surgeon is should be familiar with how to use gravity
alerted in order to avoid a patient injury. In addi- while maintaining patient safety. A patient can
tion, when a malfunction occurs in one component, easily slide or move during the procedure if
other backup components work to maintain the he/she is poorly positioned. To prevent
operation safely. If the system still needs to be shut improper patient positioning, surgeons need to
down, it occurs stepwise, but not immediately. secure the patient well on the operating table,
and test table manipulations before draping
the patient to ensure that the patient does not
16.3 E
ffective and Safe Use slide or move. Additionally, surgeons need to
of the Robotic System make sure the operating table is locked to pre-
vent movement during the procedure. This is
This section describes a stepwise practical usage particularly important with the older genera-
guide of the robotic surgery system. Although tion of existing systems (da Vinci® Si) as
robotic systems have built-in safety mechanisms motion of the patient during the procedure can
for the automatic detection of errors, they intro- lead to injuries. The newer generation of
duce new challenges for the operating room (OR) robotic systems (da Vinci® Xi), however, has
team that need to be addressed. For example, the addressed this issue by allowing the robot to
remote position of the operating surgeon to the move with the operating table.
patient bed introduces team communication issues
that need to be addressed. In the following para-
graphs, we will provide some practical tips for 16.3.2 Intraoperative Phase
trainees new to robotic surgery that can help them
master this promising technique faster. • Trocar placement
• Trocar placement is one of the significant dif-
ferences between robotic and laparoscopic sys-
16.3.1 Preoperative Phase tems, primarily with regard to distance between
trocars and the target. Surgeons should be thor-
• Setting up the robotic system oughly knowledgeable and plan where to place
• While the robotic system is typically set up by trocars safely. A common error is to place tro-
OR personnel prior to case start, it is still cars too close to each other, thus allowing
important for surgeons to understand the basic robotic arms to collide during the procedure.
steps of its setup; this may prove valuable in Additionally, trocars should typically be placed
some occasions where personnel experience a bit further away from the target than is neces-
may be lacking. The camera, for example, sary for laparoscopy.
• A robotic trocar has a thick black line near the

tip (Fig. 16.1). This line should be positioned
at the internal surface level of the cavity (i.e.,
peritoneum, pleura, etc.). This minimizes fric-
tion between the trocars and the cavity wall
(i.e., abdomen, chest wall, etc.) during motion
of the arms.
• Docking of robot cart and arms
• The orientation of the surgical cart depends on
the type of procedure performed (Fig. 16.2,
16.3, and 16.4). Generally, the robotic cart is
positioned near the target side, so that its robotic
arms can more easily reach the target, i.e., at the
feet for pelvic procedures (Fig. 16.2) or over
the head for upper abdominal procedures
(Fig. 16.3). Robotic arm docking sequence var-
ies from case to case, but either starts from one
side and goes to the other or starts with the Fig. 16.1 Robotic trocars
Fig. 16.2 Pelvis—at the feet, between the legs, or side-docked (i.e., prostate, colon, and rectum)
Fig. 16.3 Upper abdomen—over the shoulder (i.e., foregut)
Fig. 16.4 Flanks—beside patient (i.e., kidney)

camera arm and continues to the rest of the • Importantly, during an instrument exchange
arms. Once all arms are docked, surgeons (i.e., after the instrument has been placed
should confirm that the arms can move without and used), the clutch button should not be
collisions. If not given proper attention, this depressed; the instrument should just be
may limit instrument motion during the proce- pulled out and the desired instrument inserted
dure. The newer generation da Vinci® Si has in its place. The arm light will turn green, and
automated this process as it aligns the arms the instrument can be safely reintroduced to
automatically in reference to the target tissue so its prior position by pushing the instrument
that collisions are minimized. in. This is a safety mechanism of the robotic
• Most novices find it very challenging to attach system, which allows efficient instrument
the robotic arms to the trocars (this is mostly exchange without the need for visual monitor-
true for the Si system and easier for the Xi). ing of the insertion process. If, however, the
To facilitate docking, align the axis of the tro- robotic arm is clutched during an instrument
car with the axis of the arm. Once the trocars exchange, this safety mechanism is canceled,
have been attached to the arms, the arm can be and instrument insertion needs to be visually
elevated to some degree using the clutch but- monitored.
ton, so that the abdominal wall can be pulled • Setting up the surgeon console
further away from the intra-abdominal organs. • The surgeon console can be adjusted to an
This may be particularly useful in cases where ergonomically comfortable position which will
working space is limited due to patient anat- minimize surgeon stress and fatigue during the
omy. This maneuver may enhance the ability procedure. A surgeon can adjust the height of
to dissect. the viewer, the level of the handrest, and the
• Instrument insertion position of foot controls.
• Upon the first instrument insertion, the clutch Next, the visual field should be set up. For
button needs to be depressed to slide the instru- safety, the instruments should always be kept
ment in and place it in the desired position. within the visual field as instrument move-
Clutch button depression should be quick and ments in the absence of visualization can
temporary. A common mistake made by unfa- lead to injuries. The placement of a surgeon’s
miliar users is to keep their finger on the clutch head inside the forehead rest of the console
button too long, which causes inadvertent repeat is required to activate the robotic instruments.
depression and locking of the arm, preventing The surgeon can control instruments when
further movement. Similar to laparoscopic sur- his/her fingers are placed in the controllers.
gery, any further instruments need to be visual- If too much pressure is applied on the con-
ized when inserted into a cavity to avoid trollers, the instrument will be temporarily
preventable injuries. Further, the camera should locked. In this case, the surgeon needs to
be set at a wide-angle view to improve visual- release the pressure and move the control-
ization of any structures in the cavity as well as lers gently again. If the surgeon takes his/
the instrument tip. Additionally, when an instru- her fingers off the controllers after activation,
ment is removed, the surgeon and the bedside uncontrollable movement may occur which
assistant should confirm that the instrument is can lead to injury and must be avoided. If this
not attached to tissue. Communication between occurs inadvertently, the best approach is for
the surgeon and the bedside assistant is there- the surgeon to immediately remove his/her
fore vital during this step. head from the viewer (which will immobilize
the instruments). If he/she attempts to rein- oped the Fundamentals of Laparoscopic Surgery
sert the fingers into the controllers, this may (FLS), a simulation-based curriculum for the
likely lead to further movement and additive acquisition of basic laparoscopic skills outside
risk since it is done blindly (as the surgeon the OR [12]. Training on FLS has been demon-
cannot directly visualize his/her fingers with strated to improve surgeon proficiency in lapa-
his/her head inside the viewer). roscopy [13], and currently FLS certification is
a requirement for residents to obtain board cer-
tification in general surgery.
16.3.3 Postoperative Phase Similar to the experience with laparoscopy,
robotic surgery has come under scrutiny due to a
• Undocking the robot number of reported adverse events resulting in
• After confirming that the instruments are not lawsuits against the manufacturer. One of the
attached to any organs of the patient, they can main plaintiffs’ allegations has been inadequate
be removed, the arms can be detached from training of surgeons [14–16]. Several authors
the trocars, and the robot can be safely have therefore recommended that standardized
undocked. After this process, the robotic curricula for the training and assessment of
patient-side cart should be moved away from robotic surgery skills should be developed
the patient. The surgeon should always pay [17–19]. Accordingly, surgeons should be
attention to both the patient and the robot so required to possess an appropriate skill level uti-
that no injury occurs. In emergency situations, lizing the robotic system prior to performing an
the arms can be removed quickly with the tro- operation on a patient.
cars attached. To address this need, the Fundamentals of
Robotic Surgery (FRS) [20] was developed as a
simulation-based curriculum to help surgeons
16.4 Robotic Skill Acquisition acquire basic knowledge and skills crucial to per-
forming robotic surgery.
16.4.1 Issues with Robotic Surgery
with Focus on Surgeon
Competency 16.4.2 Fundamentals of Robotic
Surgery (FRS)
While new technology has revolutionized patient
care in many instances, its introduction is often FRS is a proficiency-based progression curricu-
associated with poorer patient outcomes. This lum (course) of basic robotic surgery skills which
issue became evident during the introduction was developed using a full life-cycle curriculum
of laparoscopic techniques in surgery. Despite development method by over 80 robotic surgery
multiple benefits of laparoscopy over lapa- experts, behavioral psychologists, medical edu-
rotomy on patient outcomes, an increased inci- cators, statisticians, and psychometricians from
dence of technical complications was observed around the world. The Department of Defense
related to inadequate training of surgeons on and Intuitive Surgical, Inc. funded its develop-
this new technique [11]. To overcome this ment. The main aim was to develop a standard-
issue, the Society of American Gastrointestinal ized curriculum that would help ensure that
and Endoscopic Surgeons (SAGES) and the surgeons safely and efficiently perform robotic
American College of Surgeons (ACS) devel- surgery [21].
a b
Fig. 16.5 FRS physical model with dome (a) and torso box trainer (b)
Proficiency-based training is recognized as an to these training materials, the FRS includes

effective method in surgical education [22, 23]. assessment tools in each module to assess sur-
In contrast to traditional training, which arbi- geon technical and nontechnical competency,
trarily defines training duration and/or number of which ensures skills to perform safe and suc-
practice sessions, proficiency-based training sets cessful robotic surgery.
expert-derived performance goals for trainees to The development process of the FRS curricu-
achieve. Thus, it enables training to be tailored lum is available online at www.frsurgery.org.
to individual needs and ensures the acquisi-
tion of the desired level of performance upon
completion.
The FRS curriculum consists of an online Take-Home Points
curriculum that provides fundamental knowl- • Robotic surgery can enhance surgical
edge of robotic surgery and a dry lab training capabilities but requires a new skill set,
module for psychomotor skills with tasks spe- which needs to be mastered.
cific to robotic surgery (www.frs.casenetwork. • All trainees/surgeons who will be per-
com/lms/). The online curriculum includes basic forming robotic surgery need to become
instructions on the use of the robot from preop- familiar with the features and nuances
erative preparation to postoperative debriefing. It of currently available robotic surgery
also includes a team training component, which systems.
is a vital skill, especially in robotic surgery, to • Similar to other areas of surgical prac-
facilitate communication between surgeons and tice, engagement in deliberate practice
other medical professionals in the OR. The psy- is paramount to become proficient in
chomotor module contains basic tasks of robotic robotic surgery and to optimize patient
surgery on a physical model (Fig. 16.5) or virtual outcomes. Simulation-based skills cur-
reality simulators (Fig. 16.6), ring tower transfer ricula, such as the Fundamentals of
(Fig. 16.7a), knot tying (b), railroad track (c), Robotic Surgery, have been developed
fourth arm cutting (d), puzzle piece dissection to promote this goal.
(e), and vessel energy dissection (f). In addition
a b
Fig. 16.6 da Vinci Skills Simulator® (dVSS) (a) and virtual reality simulation of the FRS dome: dVSS dome (b+c)
with different skill testing units and RobotiX Mentor virtual reality simulation (d)
a b
d e
3rd cut
1st cut
2nd cut
Fig. 16.7 Simulation tasks on a physical model. Ring tower transfer (a), knot tying (b), railroad track (c), fourth arm
cutting (d), puzzle piece dissection (e), and vessel energy dissection (f)
2. Fisher S, McGreevy M, Humphries J, Robinett W.

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Fundamentals of Gastrointestinal
Anastomoses 17
Talar Tatarian, Andrew M. Brown, Michael J. Pucci,
and Francesco Palazzo
17.1 Introduction [1, 2]. It took until the late nineteenth century for
William Stewart Halsted to identify the submu-
The creation of a gastrointestinal anastomosis is a cosa as the strongest layer of the intestinal wall
fundamental skill essential to general surgery. As [1–3]. Through most of the twentieth century, it
surgical techniques have evolved over the centu- became standard practice to perform a two-layer,
ries, key concepts critical to the success of an anas- inverting anastomosis.
tomosis hold true. This chapter will detail the Controversy arose in the 1960s and 1970s
history of gastrointestinal anastomoses, will pro- when studies on canine models found everted
vide general principles for creation of a viable and anastomoses to have increased edema and tensile
successful anastomosis, and will review key tech- strength in the first 21 days after surgery [4]. This
nical considerations and current controversies. was quickly refuted by several animal studies
which strongly recommended against mucosal
eversion after finding inverted anastomoses to
17.2 Historical Perspective have superior strength and decreased adhesion
formation [5–7].
Writings on gastrointestinal wound healing date as Further debate arose in 1966 with the intro-
far back as the early nineteenth century. In 1812 duction of automatic stapling devices. Ravitch
Benjamin Travers affirmed, “the union of a divided et al. were the first to report on the benefits of the
bowel requires the contact of the cut extremities in “Ligating-Dividing-Stapling Instrument,” citing
their entire circumference…the species of suture versatility, dependability, and a decrease in bowel
employed is of secondary importance if it secures wall trauma [8]. Initial randomized controlled tri-
the contact” [1, 2]. A decade later, the French sur- als (RCTs) comparing stapled versus hand-sewn
geon Antoine Lembert further specified the impor- gastrointestinal anastomoses found no difference
tance of serosal apposition with mucosal inversion in the rate of anastomotic leak, morbidity, or
mortality [9]. Since these early RCTs, newer
studies have found there are differences depend-
T. Tatarian · A. M. Brown · M. J. Pucci ing on the specific situation and location within
F. Palazzo (*) the gastrointestinal tract.
In 1993, Choy et al. published a large RCT dem-
Philadelphia, PA, USA onstrating that stapled ileocolonic anastomoses
e-mail: Francesco.Palazzo@jefferson.edu after elective right hemicolectomy had decreased

228 T. Tatarian et al.
fecal contamination and a trend toward a decreased covered on its outer aspect by the mesothelial lin-
anastomotic leak rate [10]. This was later supported ing of the peritoneal cavity. Good serosal apposi-
by a 2011 Cochrane report comparing 441 stapled tion is necessary to minimize the risk of leakage
versus 684 hand-sewn anastomoses. Stapled ileoco- [4, 15, 20, 21] and is best achieved by using an
lonic anastomoses had a significantly lower rate of inverting type of suture technique. Extraperitoneal
anastomotic leak, particularly in patients with segments of the GI tract without a serosal cover-
malignancy [11]. Studies of trauma patients after ing lack this component of anastomotic protec-
penetrating bowel injury have found lower leak tion and are at a higher risk of complications, as
rates with hand-sewn anastomoses [12, 13]. seen in the esophagus and lower third of the rec-
Data regarding colorectal anastomoses has tum [15, 22].
been mixed [9]. A 2001 meta-analysis included The submucosa provides the GI tract with the
nine trials studying 1233 patients randomized to majority of its tensile strength and is responsible
a hand-sewn versus stapled colorectal anastomo- for anchoring the sutures that hold an anastomo-
sis [14]. The authors found a higher incidence of sis together [15, 23]. The submucosa is composed
anastomotic strictures in the stapled group; how- of loosely interwoven collagenous, elastic, and
ever, the overall, radiological, and clinical leak nerve fibers in addition to blood and lymphatic
rates were similar. As such, current guidelines vessels. This layer has a predominance of type I
recommend the surgeon use their clinical judg- collagen [15, 24].
ment in deciding which type of technique to use. Intestinal mucosa is repaired by migration and
hyperplasia of epithelial cells which cover the
granulation tissue of the wound and seal the
17.3 Physiology of Wound defect, creating a watertight barrier [15, 25]. This
Healing and Anatomy sealing can occur in as little as three days if the
of the Intestinal Wall layers of the bowel wall are directly apposed.
Any inversion or eversion of specifically the
In order to understand the basic principles guid- mucosa will delay this process [15, 26].
ing the construction of a gastrointestinal anasto-
mosis, it is important to understand the basic
physiology of gastrointestinal wound healing and 17.4 General Concepts
anatomy of the intestinal wall. and Considerations
Creation of an enterotomy leads to initial
hemostatic vasoconstriction followed by second- 17.4.1 Factors Determining
ary vasodilation and increased capillary permea- Anastomotic Healing
bility, mediated by kinins. This results in edema
and swelling at the tissue ends [15, 16]. The Both local and systemic factors impact anasto-
appearance of granulation tissue in the anastomo- motic wound healing. These are highlighted in
sis commences the proliferative phase of healing Table 17.1.
during which collagen undergoes lysis and syn- The key local factors encouraging healing
thesis [15, 17, 18]. Studies in rabbits have shown include adequate intrinsic blood supply and the
that between days three and five of healing, there avoidance of undue tension on the anastomosis
is an abundance of undifferentiated mesenchymal [15, 27, 28]. These affect oxygen delivery to the
cells in the healing muscle layers along with cap- tissue which is required for the hydroxylation of
illary invasion. These cells transform into smooth lysine and proline during collagen synthesis [15,
muscle cells and phagocytic histiocytes. This 27, 29, 30]. During the explorative, resective, and
transformation is thought to be responsible for the reconstructive steps of any procedure, the sur-
establishment of smooth muscle tissue [15, 19]. geon must employ meticulous technique in order
The serosa consists of a thin layer of connec- to avoid excessive or rough handling of tissues.
tive tissue covering the muscularis externa. It is Additionally, excessive effort aimed at mobiliz-
17 Fundamentals of Gastrointestinal Anastomoses 229
Table 17.1 Local and systemic factors affecting anastomotic healing [7, 10]
Local Systemic
Positive Adequate blood supply Adequate nutritional status
Healthy tissue edges Hemodynamic stability
Seromuscular apposition
Negative Tension on the anastomosis Anemia/blood transfusion
Presence of infected or necrotic tissue Liver/kidney failure
Hematoma formation Medications (immunosuppressant, NSAIDs, steroids)
Radiation to involved bowel distal obstruction Sepsis
ing the limbs to bring together can damage the 17.4.3 Choice of Suture Material
primary blood vessels and impact perfusion [15, or Stapling Device
31, 32]. Conversely, inadequate mobilization can
leave tension on the anastomosis, compromising The choice of suture material is generally
microperfusion leading to inflammatory cell dependent on the location within the GI tract
infiltrates [15, 33]. The effect of tension on the and the enteric layer being anastomosed [35].
microcirculation at the anastomotic site is least Sutures are typically 2-0 or 3-0 gauge in caliber
tolerated in the colon [15, 34]. and connected to a narrow, tapered needle of
Systemically, the presence of hypotension, similar size. Suture may be monofilament,
hypovolemia, or sepsis affects blood flow and braided, or barbed. When performing a two-
subsequent oxygen delivery. Patient factors such layer anastomosis, the inner layer traditionally
as malnutrition, immunosuppression, and the use utilizes an absorbable suture material (i.e., poly-
of certain medications (i.e., steroids, NSAIDs) glactin [Vicryl]). The outer seromuscular layer
can also impair wound healing. is composed of nonabsorbable suture such as
silk or polyester (Ethibond). For single-layer
intestinal anastomoses, a long-lasting absorb-
17.4.2 Anastomotic Configuration able suture (e.g., polydioxanone [PDS]) or a
nonabsorbable suture may be used. In creating a
Gastrointestinal anastomoses are classically bilioenteric anastomosis, an absorbable syn-
described by the alignment of lumens being thetic monofilament suture is preferred to pre-
anastomosed (end-to-end, end-to-side, side-to- vent infection or stone formation.
side) and the relative direction of peristalsis in If the surgeon opts for a stapled anastomo-
the two segments (isoperistaltic vs antiperistal- sis, important considerations include choice of
tic). In deciding which configuration to choose, stapling device and staple height. For a more
one must take into consideration the segments in-depth look at stapling devices, you may
of bowel being anastomosed, size discrepancy refer to Chapter 10. In general, linear cutting
between the two segments, and any tension that staplers are preferred for a side-to-side anas-
may exist across the anastomosis. Anastomosis tomosis, whereas circular staplers are useful
to the “side” of a segment is useful in situa- for end-to-side or end- to-
end anastomoses.
tions where there is a size discrepancy between Staplers are available in various lengths and
two loops, such as a gastroenteric or ileocolonic diameters depending on intestinal location and
anastomosis. A side-to-side configuration also use. Staple cartridges are color coded to cor-
creates a wider anastomosis, minimizing the respond to the height of the staples [36]. For
risk of narrowing or stricturing. An isoperistaltic intestinal anastomoses, a cartridge with an
anastomosis is thought to promote emptying and open/closed stapled height of 3.5/1.5 mm is
is generally preferred; however, an antiperistaltic commonly used. For thicker tissues (i.e., gas-
anastomosis may be considered if delayed emp- tric tissue) a 3.8/1.8 mm or 4.1/2.0 mm car-
tying is desired (i.e., short gut). tridge may be used.
17.5 Technical Considerations: assume the cut end is secured by a staple line.
Review of Specific Stay sutures are placed at the proximal and distal
Anastomoses ends of the anastomosis, 5 mm from the staple
line, incorporating a seromuscular bite using 3-0
Fundamental to the success of any intestinal silk. These sutures are left untied and are secured
anastomosis is the adherence to a few key prin- with a small clamp.
ciples, aimed to minimize the risk of leak or dis- The posterior outer layer is created first using
ruption [2]. First, the surgeon must employ good interrupted seromuscular (Lembert) stitches of
surgical technique, minimizing trauma to the tis- 3-0 silk (Fig. 17.1). On the jejunal side, bites
sues through gentle handling with atraumatic should be taken along the posterior wall, 5 mm
instruments. All sutures should incorporate the away from the antimesenteric border. On the gas-
submucosa, which is the strength layer of the tric side, bites should be taken on the posterior
small intestine. Care should be taken to approxi- wall, ending 5 mm away from the staple line.
mate the mucosa while preventing it from extrud- Stitches should be placed 3–4 mm apart. Care
ing from the suture line. Sutures should be placed should be taken to take good seromuscular bites,
2–3 mm apart in order to create a watertight, air- avoiding full thickness bites incorporating the
tight, leakproof closure. Finally, all segments of mucosa. Sutures can be tied sequentially or once
bowel being joined must have healthy blood sup- all stitches have been placed. All knots are then
ply with adequate hemostasis and avoidance of cut with the exception of the most proximal and
tension on the anastomosis. As it applies to any distal knots, which serve to maintain traction.
anastomosis, be it gastrointestinal or vascular, With the posterior outer layer complete, the
one key tenet is that no distal stricture or obstruc- gastric staple line is excised, and a jejunal enter-
tion should exist; otherwise, the anastomosis otomy is made to expose the mucosa. The poste-
healing and lifespan are doomed. rior inner layer is then created using 3-0
With these general concepts in mind, we will absorbable braided sutures in a running locking
highlight the technical aspects of creating a few fashion (Fig. 17.2). Two separate full thickness
common anastomoses. sutures are placed starting at the midpoint of the
anastomosis. Each suture is tied down and then
tied to the tail of the other. Full thickness running
17.5.1 Hand-Sewn locking bites should be taken, advancing 5 mm
Gastrojejunostomy with each bite while remaining 2–3 mm above
the posterior Lembert stitches. Once at the api-
This section will review a hand-sewn end-to-side ces, the same sutures are used to “turn the corner”
isoperistaltic gastrojejunostomy in both a double- as you transition to the anterior inner layer. A full
layer and single-layer fashion. It is important to thickness bite is taken from the gastric lumen
note that this technique can be adapted to con- toward the corner stitch on the gastric side (in to
struct an enteroenteric, ileocolonic, or colo- out). The next bite is then taken from the corner
colonic anastomosis. stitch on the jejunal side into the jejunal lumen
(out to in). Once back in the lumen, the next
17.5.1.1 Double-Layer Hand-Sewn stitch crosses over to the gastric side. This
Gastrojejunostomy continues around the corners, advancing only a
The cut end of each enteric segment is brought few millimeters until you reach the anterior layer.
together and aligned in an isoperistaltic orienta- The anterior inner layer is constructed using a
tion. The cut ends are secured by a staple line, “Connell” stitch, passing the suture from outside
non-crushing bowel clamp, or a series of Babcock in, then inside out on one side, then crossing
clamps. For the purposes of this chapter, we will directly across and passing from outside in to inside
out on the other side (Fig. 17.3). (Common saying together to complete the anterior inner layer. As
for the Connell Stitch: “Go into the bar, then out of this step is completed, it is important for the assis-
the bar, cross the street and go into the next bar, go tant to keep constant tension on this running suture.
out of the bar, cross the street, etc.”) The bites The anterior outer layer is constructed using
should incorporate a relatively larger bite of serosa 3-0 silk Lembert sutures traversing the length of
and smaller bites of mucosa to ensure good inver- the anastomosis. Seromuscular bites should be
sion of the mucosa and aposition of the serosa. taken 3–4 mm apart and then tied. Once the anas-
Once the two sutures meet at the midpoint of the tomosis is complete, it should be examined and
anterior wall of the anastomosis, they are tied palpated to ensure patency and integrity.
Fig. 17.1 Hand-sewn two-layer

Interrupted lembert
gastrojejunostomy: the posterior
row is composed of interrupted
Lembert sutures (inset) using 3-0
silk. Stitches should be placed
3–4 mm apart, taking good
seromuscular bites. Once all
knots have been tied, the gastric
staple line is excised, and a
jejunal enterotomy is made using
surgical energy
Posterior outer row
3 - 4 mm
Jejunal enterotomy
Running locking

gastrojejunostomy: the posterior
inner row is performed using 3-0
Vicryl in a running locking
fashion. Bites should remain Posterior inner row
2–3 mm above the posterior
Lembert suture while advancing
5 mm with each bite

gastrojejunostomy: the anterior
inner row is constructed using a
Connell stitch, passing the suture
from outside in and then inside
out on one side, then crossing 4 1
directly across, and passing from 3
6
outside in to inside out on the
other side (inset). The bites 2
5
should incorporate a larger bite
Connell
of serosa and smaller bite of
mucosa to ensure good inversion
of the mucosa, as well as
aposition of the serosa
Anterior inner row
17.5.1.2 Single-Layer Hand-Sewn cut ends are stapled off, a small enterotomy is
Gastrojejunostomy made proximally along the antimesenteric border
The single-layer anastomosis begins similar to the of each segment (Fig. 17.4). Alternatively, the
double-layer anastomosis by bringing both the cut corner of each staple line can be cut off at the
end of the jejunum to the cut end of the stomach. antimesenteric border. One fork of the automatic
While generally a slowly absorbable suture is uti- stapling device is placed through each enterot-
lized, the techniques that have been described for a omy. The two forks are then connected and the
single-layer anastomosis can employ multiple dif- intestinal lumens manipulated to ensure good
ferent knots: some of these advocate the use of run- antimesenteric to antimesenteric apposition
ning near full thickness sutures (avoiding mucosa), (Fig. 17.4). If creating an enterocolonic anasto-
some employ the use of interrupted vertical mattress mosis, the stapler should be aligned along the
inverting sutures (Gambee stitch), and others support tinea as opposed to the true antimesenteric bor-
the use of the Halstead stitch (editor’s note: some of der. The stapling device is then fired to create a
these basic stitches can be found in Chap. 3). single common channel. The staple line within
With any suturing technique utilized, the same the lumen should be inspected to ensure hemo-
general concepts apply: the cut ends are aligned stasis. The common enterotomy is brought
with interrupted sutures, and the posterior wall is together with clamps to create a temporary linear
the first one created (in a running or interrupted closure. Here it is important to adjust the staple
fashion); when using a running suture, generally lines within the intestinal lumen so they are not
three quarters of the anastomosis are sutured directly crossing. A second firing of the linear
together prior to switching to a series of inter- stapler directly below the clamps permanently
rupted sutures to complete the final millimeters closes the enterotomy. The staple line should be
of the anterior wall. inspected for bleeding.
While not necessary, some surgeons opt to fur-
ther reinforce the staple line along the common
17.5.2 Linearly Stapled enterotomy by “dunking” it with a series of
Enteroenterostomy Lembert sutures. The distal end of the interior sta-
ple line can also be reinforced with a single 3-0 silk
A linear stapler is commonly used to create a Lembert stitch. This step—advocated by many—
side-to-side, functional end-to-end enteroenter- has also been heavily criticized for its paradoxical
ostomy. To begin, the cut ends of the segments potential of weakening the staple line. Finally, the
being anastomosed are placed side by side. If the resulting mesenteric defect should be closed.
Fig. 17.4 Stapled
enteroenterostomy: the two
forks of the stapler are
placed through enterotomies
made along the respective
antimesenteric borders.
Before the stapling device is
closed, the intestinal lumens
should be manipulated to
ensure good antimesenteric
to antimesenteric apposition.
The common enterotomy is
approximated with clamps
before being closed with a
second firing of the stapler
(not shown)
17.5.3 Circular Stapled Colorectal wall. The anvil’s shaft is mated with the trocar
Anastomosis until it snaps into place (Fig. 17.5). At this point,
the surgeon should ensure that the colon and rec-
A colorectal anastomosis can be created in an end- tum are aligned without twisting of the mesentery.
to-end or end-to-side fashion using a circular end- The EEA stapler is closed by turning the knob in a
to-end anastomosis (EEA) stapler. This requires clockwise direction until the ends are perfectly
the patient to be positioned in lithotomy. Generally, apposed. A marker on the EEA device will guide
the proximal colonic margin and distal rectal mar- the surgeon to ensure the anastomosis isn’t too
gin are divided first with a linear stapler. tight or too loose. The stapler is then fired and
The proximal (colonic) end of the anastomosis removed by turning the knob counterclockwise for
is prepared first. The linear staple line is cut off, and three half-turns and then rotating the stapler itself
the lumen diameter is measured using a series of counterclockwise for a half-turn to then remove it
sequential dilators in order to select the appropri- from the anus. The stapler should be inspected on
ately sized stapling device. The anvil head is then the back table to ensure there are two intact
placed within the lumen of the bowel. A single “doughnuts,” confirming that the stapler fired cor-
purse-string suture using 3-0 silk or polypropylene rectly. The anastomosis is then interrogated by
is placed along the cut end of bowel either freehand instilling air in the rectum, while the pelvis is filled
or using an automatic purse-stringing device with saline, watching for air bubbles.
(Fig. 17.5). The suture is tied around the anvil
above the tying notch, securing the anvil in place.
The tails of this suture should be kept very short. 17.6 Current Controversies
The trans-anal portion of the anastomosis
begins with gentle dilation of the anus, first manu- 17.6.1 Closure of Mesenteric Defects
ally, then with sequential dilators. This is per-
formed by the assistant who is no longer within the It is well accepted that routine closure of mesen-
sterile field. The shaft of the EEA stapler is placed teric defects after Roux-en-Y gastric bypass sur-
through the anus and into the rectum. The surgeon gery reduces the rate of internal hernia formation.
helps to guide the EEA stapler to the very end of This has been supported by both retrospective
the rectal stump. When the face of the EEA stapler and prospective randomized controlled trials [37,
shaft is flush with the rectal staple line, the assis- 38]. To date, there is no consensus on the ideal
tant turns the knob of the stapler in a counterclock- method of primary closure. Surgeons use a vari-
wise fashion to extend the trocar through the rectal ety of techniques including stapled closure and
Fig. 17.5 Stapled end-to-end colorectal

anastomosis: the anvil head is secured
within the proximal colonic lumen using a
purse-string (inset). This is then mated
with the trocar, which is seen extending
out of the stapler shaft and through the
rectal wall
Anvil
Purse string
Stapler
interrupted versus running closure using nonab- 17.6.2 Use of Barbed Suture
sorbable or barbed suture [38, 39].
Routine closure of mesenteric defects during Unidirectional barbed suture has been used in
colon surgery is more controversial. In the era of general surgery for cruroplasty and for the clo-
laparoscopic surgery, routine closure has been sure of peritoneal defects created during gastro-
limited by technical difficulty given the small intestinal and hernia surgery [42, 43]. Barbed
surgical space, proximity to mesenteric blood suture provides the surgeon with the ability to
supply and underlying ureter, and the increase in anchor the filament in a knotless manner and
operative time [40]. On the other hand, leaving allows for tension to be evenly distributed across
the defect open poses a risk of internal hernia- a wound as the barbs serve as fixation points [44].
tion and subsequent small bowel obstruction or The surgeon is thus able to operate independently
strangulation. Unlike with laparoscopic Roux- with more technical ease.
en-Y gastric bypass, the incidence of symptom- Studies evaluating the use of barbed suture in
atic internal herniation after laparoscopic colon creating gastrointestinal anastomoses have been
resection is relatively low. A retrospective review more limited. Recent studies have compared the use
of 530 consecutive patients found a 0.8% inci- of barbed suture to traditional interrupted sutures in
dence of internal herniation, recommending creating or closing the gastrojejunostomy during
against routine closure of the mesenteric defect laparoscopic Roux-en-Y gastric bypass [44–46].
[41]. Larger, prospective randomized trials are All have found a significantly shorter suture time
needed. and decreased cost associated with barbed suture;
however, two of the studies reported a case of anas- • The success of the anastomosis is dependent
tomotic leak with barbed suture. Larger randomized upon healthy blood supply with adequate
trials are needed in both laparoscopic and open hemostasis and avoidance of tension.
cases before its use in gastrointestinal anastomoses • All sutures should incorporate the submucosa
can be more widely adopted. (strength layer of the small intestine) and
approximate the mucosa while preventing it
from extruding from the suture line.
17.6.3 Intraoperative Indocyanine • The choice of suture material or staple is
Fluorescence Green generally dependent on the location within
Angiography the GI tract and the enteric layer being
anastomosed.
Adequate blood supply is the most critical factor
impacting anastomotic healing. Several methods
for objectively measuring blood perfusion have
been proposed including pulse oximetry, Doppler Suggested Readings
ultrasound, spectrophotometry, and others [47, 48]. Shackelford RT, Zuidema GD, Bickham WS. Surgery of
In the last decade, there has been an emergence of the alimentary tract. 2d ed. Philadelphia: Saunders;
fluorescence angiography (FA) using indocyanine 1978.
green and near-infrared light to assess bowel perfu- Ravitch MM, Rivarola A. Enteroanastomosis with an
automatic instrument. Surgery. 1966;59(2):270–7.
sion. This tool has demonstrated accuracy in Choy PY, Bissett IP, Docherty JG, et al. Stapled ver-
assessing microperfusion and has been associated sus handsewn methods for ileocolic anastomoses.
with improved outcomes in hepatobiliary, foregut, Cochrane Database Syst Rev. 2011(9):CD004320.
transplant, and plastic surgery [49–55]. Thornton FJ, Barbul A. Healing in the gastrointestinal
tract. Surg Clin North Am. 1997;77(3):549–73.
Recent studies looking at anastomotic leaks in Stenberg E, Szabo E, Agren G, et al. Closure of mesen-
intestinal anastomoses have focused on colonic teric defects in laparoscopic gastric bypass: a multi-
surgery. The 2015 PILLAR II study was a pro- center, randomized, parallel, open-label trial. Lancet.
spective, multicenter study looking at 139 patients 2016;387(10026):1397–404.
who had a colonic anastomosis. The authors
found that FA changed the operative plans in 11
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Fundamentals of Vascular
Anastomosis 18
Selena G. Goss and Dawn M. Salvatore
18.1 Introduction and Historical The specific uses of each of these are discussed
Background throughout the chapter. Most of the instruments
listed will be very familiar to the general sur-
The history of vascular repair and anastomotic geon, as they are utilized in other areas of surgi-
creation is relatively recent in the surgical field. cal practice.
While vessel ligation and cauterization had been In this chapter, we will refer to the creation of
the mainstays of vascular control for centuries, a vascular anastomosis, where the term “vascular”
attempts at suture repair of blood vessels date can be applied to either venous or arterial vessels.
back only to the late eighteenth century. In fact, Furthermore, though we may refer to an “arteri-
the first successful end-to-end arterial anastomo- otomy,” it is important to note that the discussion
sis was performed by Dr. John Murphy of can often be applicable to the venous system as
Chicago in 1896. Only in the twentieth century well. Likewise, the term “anastomosis” can refer
did the field of vascular surgery experience a to the connection of any conduit, whether venous
series of leaps and bounds, transporting us to our or arterial. Finally, the term “conduit” can be con-
current methods of practice. sidered as describing any vessel (autologous,
While vascular surgeons can usually be called autogenous, or synthetic) or graft that is being
upon to aid in challenging vascular emergencies, anastomosed to any target vessel.
it is still imperative that every general surgeon
possesses among their armamentarium of skills
the ability to perform a vascular repair or anasto- 18.2 G
eneral Concepts in
mosis. In this chapter we present the equipment Vascular Surgery
required, the general principles of vascular pro-
cedures, and the fundamental techniques of per- 18.2.1 Exposure
forming vessel repair and vascular anastomoses.
The basic instruments needed for creation of The key to performing any vascular anastomosis
a vascular anastomosis are listed in Table 18.1. is adequate exposure of the vessels involved,
along with protection of adjacent structures.
Electrocautery is used to dissect away overlying
S. G. Goss · D. M. Salvatore (*) and surrounding soft tissues. Conversion to
College, Thomas Jefferson University, Philadelphia,
sharp dissection with Metzenbaum scissors is
PA, USA most appropriate once the vessel is in close prox-
e-mail: selena.goss@jefferson.edu imity. Knowledge of the anatomy is imperative.

240 S. G. Goss and D. M. Salvatore
Table 18.1 Basic instruments used for performing a using non- traumatic vascular forceps (i.e.,
vascular anastomosis (see Appendix)
DeBakey forceps) to grasp only the adventitia.
Forceps Whenever possible, grasping of the entire vessel
DeBakey forceps or the intima should be avoided. The exposure
Right angle forceps
should allow for sufficient distance to allow
Gerald forceps (or other atraumatic, vascular forceps)
clamp placement for proximal and distal control
Vascular clamps or alternatives
Large vessel clamps (DeBakey peripheral vascular, of the vessel as well as provide enough working
renal, profunda, etc.) room to fashion the anastomosis (Fig. 18.1).
Bulldog clamps
Yasargil clamps
Medi-Loops (vessel loops) 18.2.2 Proximal and Distal Vascular
Metal clips (small, medium, large) Control
11-blade scalpel
Scissors
Once the vessel has been sufficiently exposed,
Metzenbaum scissors
DeBakey-Potts scissors
vessel loops are placed proximal and distal to the
Potts scissors (“pinch” Potts) anticipated site of anastomosis. Vessel loops can
Vascular needle holders (fine-tipped needle holders) be placed on larger side branches as well. These
Castroviejo needle holder loops allow for control and manipulation of the
Ryder needle holder vessel for clamp placement. The loop can also be
Mayo-Hegar needle holder used for vascular control. There are a variety of
Sutures tools that can be used to gain vascular control
3-0, 4-0, 5-0, 6-0, 7-0 Prolene (Fig. 18.2).
4-0, 5-0, 6-0 PTFE suture
Most small arterial and venous branches can
Irrigation catheter
be ligated with clips or silk ties without clini-
DeBakey heparin injector (“olive tip”) catheter
Stoney heparin injector
cal sequelae. However in certain situations,
Patch/grafts (as required by clinical scenario) for example, in a limb with chronic vascular
Autologous vein patch/graft occlusion and extensive collaterals, preserva-
Allograft (CryoGraft, cadaveric graft) tion of even small branches should be priori-
Xenograft (bovine pericardial patch) tized. Small arterial branches (1–3 mm) can be
Synthetic patch/graft controlled with small- or medium-sized clips,
Polyester (Dacron) with clips removed once the anastomosis is
Polytetrafluoroethylene (PTFE, Gore-Tex) completed. Yasargil vascular clamps are often
Misc
used for temporary control of small vessels
Syringes
(Fig. 18.2). Healthy small- and medium-sized
Felt pledgets
Rubber shods vessels (3–6 mm) can be easily controlled with
Sklar Bakes or Garrett dilators vessel loops by a double-loop (Potts) technique.
For control of larger vessels, various sizes of
angled and curved clamps have been developed
Dissection down to the vessel is facilitated by to provide vascular control while minimizing
the fact that there are typically no (or very few) interference to the operative field.
anterior branches of almost all arterial and It is important to take note of the degree
venous vessels. Thus, once a vessel is identified, of atherosclerotic calcification of the ves-
sharp dissection along the anterior surface is per- sel wall being clamped, as this may alter the
formed with a fair amount of ease. It is important degree to which clamping is effective. A heav-
to clear all tissue away from the adventitia so ily calcified vessel is often coexistent with
that a clean, precise anastomosis can be con- an irregular and plaque-laden lumen and thus
structed. The vessel should be handled with care, may not occlude completely when clamped.
18 Fundamentals of Vascular Anastomosis 241
Fig. 18.1 Exposure of

the femoral vessels, to
allow for adequate
proximal and distal
control and subsequent
anastomosis creation.
Blue vessel loops are
placed around the CFA
(left), the SFA (right),
and a yellow vessel loop
is placed around the
PFA in Potts fashion
Fig. 18.2 A PTFE graft

being sutured onto the
distal common femoral
artery (CFA). A variety
of tools can be used to
gain vascular during
creation of an
anastomosis. A femoral
artery clamp is placed
on the CFA (left), while
a profunda artery clamp
has been placed on the
SFA (right). Blue
vessels loops lay loosely
open on the CFA (left)
and SFA (right). A
yellow vessel loop has
been placed in Potts
fashion around a PFA
branch
Furthermore, clamping such a vessel may cause Once the vessels are adequately exposed and
inadvertent damage, such as vessel wall tear vessel loops are in place, appropriate vascular
or luminal disruption, requiring more exten- clamps can be chosen for control of each involved
sive dissection, e ndarterectomy, or even exci- vessel. It is important to have the operative field
sion of the vessel and reconstruction (beyond and vessels involved prepared in such a way that
the scope of this chapter). In these instances, vascular control can be obtained at the appropri-
another option for proximal and distal control ate time, specifically after anticoagulation and
is balloon catheter occlusion. vessel and conduit preparation.
18.2.3 Anticoagulation An autologous vein graft is prepared by

sequentially flushing the vein, which is dilated
Once adequate proximal and distal control has against resistance in order to detect areas of leak-
been achieved, the patient is systemically antico- age or stenosis. This serial dilation is performed
agulated, most commonly by intravenous admin- by compressing the vein manually or with a soft
istration of heparin (heparin sodium 50–100 units/ vascular clamp, while it is actively flushed with
kg). Generally, 3–5 min of circulation time is heparinized saline. An autogenous or synthetic
allowed prior to vessel clamping. Anticoagulation graft is inherently without defects and can be uti-
is performed to prevent thrombosis, and accumu- lized immediately once available. Regardless of
lation of platelet aggregates in the involved ves- the type of conduit being used, it is important to
sels during their manipulation and exposure to ensure that the conduit lies without kinking or
surrounding, thrombotic tissues. A 1000 unit twisting.
bolus dose of heparin is then administered every
hour thereafter until the anastomosis is complete
and uninterrupted circulation is reestablished. 18.2.5 Arteriotomy/Venotomy
In certain situations, such as with a trauma
victim of polytrauma who suffers a major extrem- Once the graft is prepared and heparin has sys-
ity vessel transection and a concomitant intracra- temically circulated, the previously prepared vas-
nial hemorrhage, systemic anticoagulation may cular clamps and previously placed vessel loops
be contraindicated. Direct intravenous or intra- are applied, and a longitudinal arteriotomy (for
arterial heparin instillation is an acceptable alter-the purpose of this chapter, arteriotomy and
native method to provide anticoagulation. venotomy are used interchangeably) is created.
Once the anastomosis has been completed, the An 11-blade scalpel is ideal for creating a
effects of the anticoagulant are allowed to wear 2–3 mm longitudinal arteriotomy, with care taken
off or can be inhibited by administration of a to not violate the back wall of the vessel. The
reversal agent. Protamine sulfate, used to reverse arteriotomy is elongated proximally and distally
the effects of heparin, is given at a dose of 1 mg to the desired length using DeBakey-Potts or
per every 100 units of heparin administered dur- Potts scissors. In general, the size of the arteriot-
ing the previous few hours of surgery. As prot- omy can range from 8 to 20 mm depending on the
amine has been shown to have serious side clinical situations. In similarity to the sizing of a
effects, including hypotension and anaphylactoid bowel anastomosis, the appropriate sizing of a
reactions, it is administered slowly and is not to vascular anastomosis is dictated in some part by
exceed 50 mg in total. experience and gestalt; however, the ultimate
goal is to have a patent anastomosis that allows
for laminar flow into the target vessel.
18.2.4 Conduit and Target Vessel Inadequate vascular control is generally
Preparation apparent by continuous bleeding from the arteri-
otomy. In controlled and elective situations, it is
An anastomosis can be constructed by sewing a ideal to investigate ongoing bleeding promptly.
patch onto a target vessel, by primarily sewing Creating the anastomosis with ongoing bleeding,
vessels together in end-to-end fashion, or by though necessary in certain circumstances, is
insertion of a conduit onto a target vessel in end- cumbersome and can lead to an imperfect anasto-
to-side fashion. If a conduit is used, preparation mosis. The most common reasons for ongoing
is relatively straightforward. The surgeon must bleeding are incomplete vascular clamp applica-
ensure that there is proper orientation of the con- tion; inadequate control due to a missed, usually
duit without twisting, kinking, or redundancy, posterior, branch vessel; and non-compressible,
especially during tunneling the conduit in an ana- often calcified vessels that cannot be adequately
tomic or subcutaneous plane. controlled with clamping.
18.2.6 Anastomosis cal points. Furthermore, proper placement of the

suture at these two locations is most critical as
The conduit is brought into the field and posi- inadequate technique results in anastomotic leaks
tioned for anastomosis creation. In general, per- that can be difficult and awkward to repair once
manent, monofilament suture (i.e., Prolene) with the anastomosis is complete.
the size of the suture (3-0, 4-0, 5-0, 6-0, or 7-0) is During creation of the anastomosis, it is
chosen depending upon vessel caliber. For exam- important to verify patency of the inflow and out-
ple, a common femoral artery anastomosis will flow vessels. Sklar Bakes or Garrett dilators may
generally require a 5-0 Prolene suture, while a be passed proximally and distally to ensure that
tibial artery may require a 6-0 or 7-0 Prolene the inflow and outflow vessels are not compro-
suture. The anastomosis can be created in stan- mised by the anastomosis.
dard running fashion (most common) or inter-
rupted sutures placed in simple or horizontal
mattress fashion. 18.2.7 Completing the Anastomosis
Certain principles of anastomotic creation and Reperfusion
should be followed for proper construction to
prevent luminal narrowing and ensure hemosta- Just prior to completion of the anastomosis,
sis. First, the securing knots are tied down on the with one or two suture throws remaining, the
outside of the vessel, not within the lumen. anastomosis is flushed by sequentially releasing
Second, the securing knots should be placed at or and re-clamping the inflow and outflow vessels.
near the 9 o’clock or 3 o’clock position on the This allows any stagnant and potentially clotted
longitudinal axis of the arteriotomy (Fig. 18.3). blood and intraluminal debris to be purged from
Ensuring that the knots are not located at the the vessel. The arteriotomy is then forcefully,
“toe” or “heel” position of the anastomosis pre- but carefully, flushed with heparinized saline to
vents narrowing of the anastomosis at these criti- allow any remaining platelet aggregates, debris,
Securing knots tied outside

of vessel at 3 o’clock or 9 o’clock Heel
12
Conduit 9 x 3
6
Toe
Heel Toe
Target Vessel
Anastomosis being performed

with standard running suture
Fig. 18.3 The anatomy

of a vascular anastomosis.
Depicting face of a clock,
toe, heel, etc.
and air to be evacuated from the vessel lumen. topical hemostatic agents and a short period of
The anastomosis is then completed as the mono- gently applied pressure. Surgicel® (Ethicon Inc.,
filament suture is tied down and secured with Cincinnati, Ohio), Surgicel® Fibrillar™ (Ethicon
6–8 knots. Inc., Cincinnati, Ohio), and Floseal hemostatic
While completing the anastomosis, it is impor- matrix (Baxter International Inc., Deerfield, IL)
tant to carefully release the vascular clamps in a are some commonly used topical hemostatic
deliberate and sequential manner so as to allow agents. Removal, irrigation, and repeat use of
any potential debris to be carried into the least these agents can be performed as necessary, espe-
vital outflow vessel. Notably, it is often useful to cially during reversal (i.e., protamine administra-
leave the clamps released but in place, should tion) of systemic anticoagulation.
there be uncontrolled bleeding from the arteriot- A true defect in the anastomosis will result in
omy that requires re-clamping. This allows ease persistent, vigorous bleeding from the suture
of obtaining immediate vascular control again, in line. There are a number of maneuvers that can
order to inspect the anastomosis, with less con- be used to achieve hemostasis in these situations.
cern for injuring a vessel by having to reposition First, a simple figure-of-eight repair stitch using
and replace the vascular clamp. monofilament suture will often stanch the bleed-
This sequence involves unclamping then re- ing from a suture line defect. If the vessel wall is
clamping a distal vessel first to allow back- fragile, a pledgeted suture placed in horizontal
bleeding into the anastomosis and evacuation mattress fashion can help support the suture
of any debris or clot. Next, the proximal inflow repair. Although manufactured felt pledgets are
vessel (or vessels) is unclamped such that any often available and typically used, a pledget can
potential debris would flow forward out of the be formed from a piece of autologous muscle, an
circulatory system and through the unfinished excess piece of vein graft, or a spare piece of
anastomosis, while the outflow vessels remain prosthetic graft.
clamped. Once the anastomosis is completed,
the least vital outflow vessel, for example, a
branch vessel or a vessel which is not supply-
ing an end-
organ structure, is unclamped
allowing for any possible remaining debris to A Word on Shunting
be flushed downstream to a non-vital location. Occasionally, one encounters a situation
The inflow vessel is unclamped, and, finally, where vascular control is required; how-
the main outflow vessel is unclamped, and forever, simultaneous preservation of forward
ward flow is reestablished with all vessels now flow is essential. Such scenarios are most
unclamped. commonly encountered in traumatic injury
to the carotid, vena cava, or extremity ves-
sels. When ongoing distal perfusion is
18.2.8 Hemostasis and Suture Repair needed, flow through the severed vessel
can be maintained by the use of a shunt. A
Once the anastomosis is completed and vascular variety of vascular shunts exist (beyond the
control removed, the suture line is checked for scope of this chapter); however, any sterile
hemostasis. Reasons for continued bleeding from tubing can be fashioned to provide this
a freshly created anastomosis are the presence of function so long as the ends are securely
a defect in the suture line (i.e., poorly placed, anchored to the inflow and outflow vessels.
improperly spaced, or loose sutures), needle hole Anchoring can be accomplished with exter-
bleeding, and generalized oozing from systemic nally placed umbilical tape (i.e., Rommel
anticoagulation. clamps) or specifically designed, circular
Bleeding from suture needle holes is common (i.e., Javid) vessel clamps.
and can usually be controlled with placement of
18.3 Physiology of a Vascular the anastomosis (Fig. 18.4). The “floor” describes

Anastomosis the recipient vessel wall that lies opposite to the
opening of an end-to-side anastomosis. The “toe”
The ideal consequence of creating an anastomo- of the anastomosis denotes the distal most end of
sis is forward flow without unnecessary loss of the anastomosis, which sits furthest along the
energy as blood is propelled forward. The recipient vessel. The “heel” of the anastomosis
decision to create an end-to-end anastomosis ver- designates the most proximal end of the anasto-
sus an end-to-side (or side-to-end) anastomosis mosis, which sits closest along the recipient
has physiological consequences. Generally, an vessel.
end-to-end anastomosis will have less physio- These three areas, which are prone to fluctuat-
logic disturbance as blood is flowing forward ing or low shear stress, constitute the regions that
without a flow divider or significant change in are most conducive to development of intimal
angle in the direction of flow, namely, blood will hyperplasia and atherosclerosis. Unfortunately,
flow more or less to follow a straight path. the long term consequences of these structural
In creating an end-to-side anastomosis, how- changes are anastomotic compromise which can
ever, one must consider the angle between the lead to vessel stenosis or occlusion. Thus, precise
graft and the native vessel. The greater the angle and intentional fashioning of an anastomosis is of
between the graft and native vessel, the more paramount importance.
energy is lost in the transition at the anastomosis.
In general, one should aim to create a 45° (end-
to-side) anastomosis in order to minimize the 18.4 Technical and Practical
energy loss and thus decrease the pressure gradi- Considerations for Creating
ent across the connection (Fig. 18.4). Vascular Anastomoses
When an end-to-side fashion anastomosis is
created, there are inherent physiologic conse- 18.4.1 Primary and Patch Repair
quences, including flow disturbance, turbulence,
and areas of stagnation, that have implications for The principles of patch repair are similar to the
the involved vessel walls. The areas of the anas- creation of any vascular anastomosis. A patch can
tomotic connection that are impacted most heav- be composed of an autologous vessel (vein
ily include the “floor,” the “toe,” and the “heel” of patch), an autogenous vessel (cryopreserved
Graft Vessel
45º
Fig. 18.4 Physiology of Heel Toe

an end-to-side
anastomosis. Side view
of an anastomosis, Distal Proximal
depicting flow through,
angle, floor, toe,
heel, etc. Floor of Native Vessel
cadaveric vein), a xenographic vessel (bovine inside-out on the target vessel. The suture can be
pericardial patch), or synthetic material. If it is sewn in continuous running fashion from the
anticipated that a patch repair will be required, an knot (at 3 o’clock) to the opposite side, 180° from
astute surgeon will prepare and drape a patient’s the original knot (9 o’clock). Once halfway
groin in anticipation of greater saphenous vein around the anastomosis (9 o’clock), this initial
harvest as this vessel is readily identified and eas- suture , is protected with a shodded clamp, and
ily procured. The patch is fashioned to the appro- the previously protected suture is then run in sim-
priate size and shape of the target vessel defect. ilar fashion in the opposite direction. With both
Construction of the repair is most commonly sutures meeting at the 9 o’clock position, the
performed with either single running or four-
anastomosis can be flushed and completed.
quadrant suture repair (see below Sects. 18.4.2
and 18.4.3).
Oftentimes, a small iatrogenic or traumatic 18.4.3 Four-Quadrant Repair
defect in a vessel can be repaired with a mono- (Diamond-Shaped
filament suture in figure-of-eight or horizontal Arteriotomy)
mattress fashion, without compromising the
lumen. If, however, the defect encompasses a sig- Four-quadrant repair is another method for creat-
nificant portion of the vessel wall, patch repair ing an anastomosis that can be utilized when the
may be necessary to simultaneously repair the operator has easy access to the target vessel, such
injury and maintain adequate vessel lumen. as in a superficial extremity vessel. One arm of a
Likewise, a longitudinal arteriotomy, which may double-barreled monofilament suture is sewn
be performed for endarterectomy, thrombectomy, inside-out at the heel (12 o’clock) of the target
or vessel exploration, is generally repaired with a vessel, and the other arm is sewn inside-out on
patch to prevent luminal narrowing. the conduit. Each arm of the suture is made to be
of even length, and three knots are tied down, fas-
tening the conduit securely to the target vessel.
18.4.2 Single Running Suture One arm of the suture is protected with a shodded
clamp, and the other is run in continuous fashion,
An anastomosis can be fashioned with a single, beginning with an outside-in throw on the con-
continuous, monofilament suture, with extra care duit followed by an inside-out throw on the target
taken to ensure that the lumen is not narrowed. vessel and so on.
This anastomosis is useful for superficial surgical When initiating suture at the heel or the toe, it
fields, where the operator has ease of access to is important to remember that sutures should be
the target vessel. thrown radially outward, like the spokes of a
A double-barreled, monofilament suture is bicycle wheel, with a millimeter or two more
placed at either the 9 o’clock or 3 o’clock posi- progress made on the target vessel than on the
tion, with one needle traveling inside-out on the conduit. This will provide optimal apposition at
artery and the other needle traveling inside-out the suture line with less risk of anastomotic
on the conduit. With both sutures held at equiva- defects. The suture is continued until the 3
lent lengths, three knots are tied down to secure o’clock position and then protected with a shod-
the conduit down onto the artery. You will notice ded clamp. The other arm of the suture is then
that having traveled inside-out on both vessels, sewn in similar fashion to the 9 o’clock position
the knot will land, appropriately, on the outside and then protected once again with a shodded
of the vessel. One suture is then protected with a clamp.
shodded clamp, and the other suture becomes the Ensuring the conduit is sized and spatulated
working suture. Starting from the knot at the 3 appropriately to the arteriotomy (or target ves-
o’clock position, the first suture should be sel), a second double-barreled monofilament
threaded outside-in on the conduit and then suture is begun, in similar fashion to the first, but
Fig. 18.5 Parachute
technique for 12
anastomosis creation
9 3
6
Suture thrown 5 times Conduit
around heel
Heel Toe
Target Vessel
this time at the toe (6 o’clock) of the anastomosis. sewn inside-out on the target vessel, progres-
Suturing is performed in similar fashion such that sively toward the heel, without bringing the con-
each end of this second suture meets the shodded duit down onto the target vessel. Keeping the
sutures at the 3 o’clock and 9 o’clock positions. conduit a short distance from the target vessel
The sutures are tied down at the 3 o’clock and 9 while continuing to sew creates the appearance of
o’clock positions for anastomosis completion. so-called parachute strings between the conduit
and target vessel (Fig. 18.5). In general, the
suture is thrown a total of five times, effectively
18.4.4 Parachute Technique placing two sutures on one side of the heel, one
suture at the apex (12 o’clock) of the heel, and
It is not uncommon to be required to create an another two sutures on the opposite side of the
anastomosis in a deep wound or narrow surgical heel.
field. In order to facilitate creation of an anasto- Once these five throws have been completed
mosis in such a situation, the “parachute tech- at the heel, the operator and the assistant gently
nique” aids in ensuring proper placement of and simultaneously pull tension on both ends of
sutures in the toe and heel of the anastomosis in the suture bringing the conduit down onto the tar-
an “open” technique. As previously discussed, get vessel. From here, the remainder of the anas-
this is of distinct mention as the toe and heel are tomosis is generally more straightforward and
the two areas of the anastomosis most likely to be can be performed by single running suture tech-
disadvantaged by suture defects or anastomotic nique or with a second running suture, as in the
narrowing. These are coincidentally the most dif- four-quadrant repair technique as discussed ear-
ficult areas to properly repair once creation of the lier in this chapter.
anastomosis is underway.
The parachute technique is begun with the
conduit a short distance from the target vessel. 18.5 Complications of Vascular
The operator sews a double-barreled, monofila- Anastomosis
ment suture outside-in on the conduit a few mil-
limeters away from the heel, bringing just over Early complications of vascular anastomosis cre-
half of the suture through; the other half of the ation include surgical bleeding and conduit
suture if protected to the edge of the surgical thrombosis, which may due to technical defi-
wound with a shodded clamp. The suture is then ciency at the anastomosis or inadequacy of the
conduit, the latter of which is beyond the scope of imaging, in order to identify any flow limita-
this chapter. Generally, when a problem occurs tion or anastomotic site complication that may
within the first 7 days after intervention, a techni- require intervention to maintain vessel or conduit
cal error must be assumed. The most common patency.
reasons for failure are undue tension on the con-
duit, poor lie of the conduit with kinking or twist-
ing, and improper construction of the anastomosis 18.5.1 Emergency Maneuvers for
with luminal narrowing. Obtaining Vascular Control
Postoperative bleeding can be mild, moder-
ate, or severe, with the latter usually requiring Occasionally, a traumatic or iatrogenic vascular
take-back and exploration to control bleeding. injury proves uncontrollable despite attempts at
Some degree of oozing from a fresh anastomo- repair. In these situations, there are emergency
sis can be attributed to bleeding from needle maneuvers that can be performed to allow for
holes, though this is usually self-limited and control of life-threatening hemorrhage. The sim-
readily controlled with topical hemostatic ple act of applying direct, manual pressure at the
agents or reversal of anticoagulation, as previ- site of hemorrhage, without the application of
ously discussed. gauze or other packing material, will be sufficient
When bleeding is more significant and the to halt profuse bleeding. Likewise, vascular
aforementioned maneuvers are ineffective, all clamp application is the preferred maneuver.
aspects of the anastomosis should be carefully In deep surgical wounds, such as in the pelvis
inspected. Any obvious defects between the target or retroperitoneum, where visualization and
vessel and the graft can readily be repaired with a access may be difficult, ongoing hemorrhage can
single 5-0 Prolene horizontal mattress or figure- preclude any real attempt at suture repair. In these
of-eight suture. Occasionally, a pledgeted suture events, it is safest to use direct pressure with a
can be used to reinforce a suture repair, especially sponge stick, proximal and distal to the defect
if the target vessel wall is thin or weakened. than to attempt a blind repair, where surrounding
One of the most feared early complications structures could inadvertently become injured
of creating a vascular anastomosis is thrombosis thus worsening the situation. If an extremity ves-
of the conduit or target vessel. Unfortunately, sel is injured and vascular control cannot be
vessel thrombosis is sometimes not discov- obtained, application of a tourniquet to the proxi-
ered until post-assessment, on clinical exam, mal extremity can provide temporary control.
and then confirmed with noninvasive studies. Ongoing distal extremity bleeding is generally
Expedient reoperation is necessary to investi- less severe and can be controlled with direct man-
gate the anastomosis and all vessels involved, as ual pressure.
a technical error must be ruled out as the culprit. When vessels are exposed and vascular control
In the absence of finding a technical problem at or direct repair is not feasible, the use of Fogarty
reoperation, one must consider a coagulopathy balloon occlusion catheters can be employed.
or other hematologic issues as a possible cause These catheters are available in multiple sizes and
for thrombosis. lengths and can be advanced into a vessel through
Anastomotic narrowing is a complication the defect with balloon inflation providing cessa-
that can develop months or years after surgery. tion of flow. For example, 5–8 mm caliber vessels
Luminal compromise can result from intimal can generally be controlled with #4, #5, or #6
hyperplasia. This thickening of the intimal layer Fogarty balloon catheters.
is a natural response to violation of the vessel The use of any of these aforementioned maneu-
wall and surgical manipulation. Bypass grafts vers is of course temporary, and they should pro-
and major vessels that have undergone repair vide partial, if not complete, control of hemorrhage.
or reconstruction are thus followed with serial The patient can then undergo active resuscitation,
allowing time to call for the assistance of a vascu- • Having adequate inflow, an appropriate con-
lar surgeon. duit, and adequate outflow are the key compo-
nents of a successful vascular anastomosis or
repair.
18.6 Current Controversies • Understanding the physiology of a vascular
and Future Directions anastomosis can aid in its creation.
• Vascular anastomoses can be created using a
The techniques for creating a vascular anastomo- multitude of techniques.
sis have not changed significantly in the recent • Obtaining hemostasis at a vascular anasto-
decades, though emerging technology has devel- mosis can be challenging but is usually
oped exploring the creation of a sutureless anas- achievable with diligent anastomotic creation
tomosis. A Hybrid Vascular Graft (W. L. Gore & and the aid of topical hemostatic agents.
Associates, Newark, DE) has been developed • If vascular control is not achievable by direct
that merges endovascular and open surgical tech- means of repair, a number of maneuvers can
niques, allowing for a hybrid approach to creat- be used to prevent catastrophic bleeding,
ing a vascular anastomosis. allowing for time to call in the assistance of a
The hybrid graft is composed of standard vascular surgeon.
expanded polytetrafluoroethylene (ePTFE), com-
monly used in vascular surgery, attached to a
short segment of ePTFE that is reinforced with Appendix
nitinol. This latter segment, which compacted to
allow for ease of intraluminal insertion, com- Below is a compilation of photos demonstrat-
prises the so-called sutureless anastomosis of the ing basic instruments used in vascular surgery
graft. The compacted section of graft is manually for creating an anastomosis. This is by no
inserted into the inflow portion of the anastomo- means an exhaustive list but rather serves as a
sis, and a trigger wire is released, allowing for general overview of instruments that can be
deployment of the compacted section of the graft utilized.
and apposition to the inflow vessel wall. The A variety of vascular clamps are used to gain
radial force of the graft against the inflow vessel vascular control on peripheral blood vessels.
wall precludes the need for suturing the graft to A variety of instruments are used to obtain
the inflow vessel. The remainder of the graft is vascular control on small and delicate vessels.
then available for traditional anastomosis cre- Bulldogs clamps (top row) of different sizes are
ation to the outflow vessel. made in metal and plastic and can be useful in
The Hybrid Vascular Graft has found its niche controlling side branches of major vessels. Gold
in difficult to access vessels, where extensive dis- Yasargil clamps (bottom, right) are placed with a
section may not be feasible or safe. Studies are Yasargil applier (bottom row).
currently being conducted on the utility and Locking and non-locking Castroviejo needle
safety of using this graft in complicated carotid holders (top row) are generally used for suture
artery disease. 5-0 or smaller. Ryder needle holders can be used
Take-Home Points for more sturdy needles and suture.
Castroviejo needle holders are used to per-
• A basic understanding of the techniques form vascular suturing with small caliber needles
involved in creating a vascular anastomosis is and suture.
necessary for every general surgeon. An olive tip (top) or Stoney (bottom) heparin
• Adequate exposure of the vessels involved is injector can be used to flush blood vessels and
paramount to obtaining vascular control and anastomoses prior to repair or closure, to ensure
creating vascular anastomoses. evacuation of air and debris.
Friedman SG. A history of vascular surgery. 2nd ed.

Suggested Readings Hoboken: Wiley-Blackwell; 2005.
Gore® Hybrid Vascular Graft. 2017, August. Retrieved
Cronenwett JL, Johnston KW. Chapter 87: from http://www.goremedical.com/products/hybrid.
Technique: open surgical. In: Rutherford’s Stanley JC, Veith F, Wakefield TW. Current therapy
vascular surgery. 8th ed. Philadelphia: Saunders; in vascular and endovascular surgery. 5th ed.
2014. p. 1284–303. Philadelphia: Saunders; 2014.
Hoballah JJ. Chapters 1–11 in Vascular reconstructions. Valenti D, et al. Carotid bypass using the gore hybrid
Anatomy, exposures, and technique. New York: Springer; vascular graft as a rescue technique for on-table failed
2000. carotid endarterectomy. J Vasc Surg. 2016;64:229–32.
Fundamentals of Exploratory
Laparotomy for Trauma 19
Chia-jung K. Lu and Joshua A. Marks
19.1 Introduction 1. An abbreviated index operation focused on

the rapid surgical control of hemorrhage and
19.1.1 Historical Background contamination followed by intra-abdominal
packing and temporary closure
The exploratory laparotomy for trauma focuses 2. Intensive care unit (ICU) resuscitation to cor-
on efficient surgical techniques to control hem- rect hypothermia, coagulopathy, and acidosis
orrhage and contamination prior to the onset of 3. Re-exploration with definitive surgical repair
the deadly triad: hypothermia, coagulopathy, and reconstruction of all injuries once hemo-
and acidosis. Stone et al. first introduced the dynamic stability is achieved [2]
concept of intra-abdominal pack tamponade in
1983. In their study, trauma laparotomies were The continued application of damage control
aborted at the first sign of coagulopathy, intra- principles in treating severely injured trauma
abdominal packs were placed to achieve tam- patients has led to improved survival with pene-
ponade, and patients returned to the operating trating abdominal trauma and has been utilized in
room for definitive surgery after the correction other fields including emergency general, tho-
of coagulopathy [1]. racic, urologic, and vascular surgery [3].
Rotondo et al. refined the techniques and
introduced the concept of damage control lapa-
rotomy in their landmark paper published in 19.1.2 Indications and Goals
1993. The damage control laparotomy is divided
into three phases: Trauma patients presenting to the emergency
department are evaluated using the Advanced
Trauma Life Support (ATLS) protocol.
C.-j. K. Lu Regardless of a patient’s physiology or mecha-
Department of Surgery, Division of Acute Care nism of injury, the ABCDEs of trauma resuscita-
Surgery, Sidney Kimmel Medical College at Thomas tion are always applied. Primary survey including
Jefferson University, Philadelphia, PA, USA
assessment of airway, breathing, circulation, dis-
J. A. Marks (*) ability, and exposure followed by secondary sur-
College, Thomas Jefferson University, Philadelphia,
vey and adjuncts to the survey, such as plain film
PA, USA radiographs and bedside ultrasound, helps iden-
e-mail: Joshua.Marks@jefferson.edu tify patients who require emergent laparotomy

254 C.-j. K. Lu and J. A. Marks
and provides clues for the necessity of damage surgeon at any level of training can confidently
control surgery. execute the steps of an exploratory laparotomy
Indications for trauma laparotomy include for trauma.
patients with hemodynamic instability, peritoni-
tis, and trajectory suggesting abdominal injury
such as transabdominal penetrating wounds or 19.2 General Concepts
abdominal wounds that violate the anterior rectus
fascia. There may be a role for nonoperative man- Successful exploratory laparotomy in trauma
agement of certain penetrating wounds; however, begins with preoperative setup and ends with
such discussion is beyond the scope of this chap- transportation to the surgical ICU for continued
ter. In general, trajectory determination yields resuscitation. This section highlights the general
injury identification and frequently requires concepts and key steps to the trauma laparotomy.
exploration. The unstable trauma patient belongs The details of specific exposures and maneuvers
in the operating room, and the abdomen is often for the retroperitoneal vessels and individual
the source. organ systems are discussed in the Technical
Once the trauma laparotomy is under way, one Approaches section.
of the most challenging aspects is knowing when
to employ damage control techniques. This is a
difficult decision even in the hands of the most 19.2.1 Preoperative Essentials
experienced trauma surgeon. Waiting for the
deadly triad to set in is too late. The surgeon must The team must minimize the “door to cut” time.
identify early cues including bowel edema, dusky The initial resuscitation should follow a fast
serosal surfaces, tissues cold to touch, noncom- orderly tempo that must continue through to the
pliant swollen abdominal wall, and diffuse ooz- OR and beyond until surgical control of injury
ing. The three main indications for damage and physiologic capture has been obtained.
control surgery include: Multiple tasks need to happen simultaneously as
the patient is being transported to the OR. The
1. Exsanguinating, hypothermic, and coagulo-
blood bank should be alerted of a potential activa-
pathic patient dying on the operating table tion of the massive transfusion protocol. The OR
2. Inability to control hemorrhage with direct staff is notified to adjust the room temperature to
hemostasis (large liver laceration, ruptured 75–80 °F and to ensure the availability of a rapid
retroperitoneal hematomas) transfuser (delivers large volume warm fluid and
3. Inability to close the abdomen (tension due to blood products to the patient) and a cell saver in
visceral edema, noncompliant abdominal the room. Although cell savers are extremely use-
wall) [4] ful in the setting of hemorrhage, intra-abdominal
contamination is a contraindication for their use.
The goals of damage control laparotomy are
to stop potential life-threatening bleeding, to
identify the injuries, to control contamination, 19.2.2 Positioning and Prepping
and to provide temporary abdominal closure [4]. (Fig. 19.1)
Regardless of the mechanism and extent of injury,
adhering to these basic principles will allow the Do not delay positioning and prep once the
surgeon to maneuver through a damage control patient is on the OR table. Remember, minimize
surgery in a calm and systematic fashion. This the “door to cut” time! Work concurrently with
chapter focuses on key maneuvers of damage anesthesiologists as they secure the airway and
control laparotomy for trauma, potential pitfalls begin preparations for resuscitation. Position the
associated with each maneuver, and available patient supine with both arms out. This allows
bailout techniques. The objective is to simplify anesthesia access to bilateral upper extremities
each maneuver to its bare essentials so that a for intravenous lines and monitoring purposes
19 Fundamentals of Exploratory Laparotomy for Trauma 255
Fig. 19.1 Patient
positioning and prepping
(supine, arms out, and
areas to prep)
and the surgeon access to the chest. Place a Foley –– The first stroke of the scalpel divides the
catheter to monitor urine output as well as to tri- skin and dermis to expose the subcutane-
age the genitourinary system. Prep the patient ous fat.
from the chin to knees and down to the operating –– The second stroke of the scalpel divides the
table bilaterally. This permits the surgeon access subcutaneous fat to expose the linea alba of
to the abdomen for laparotomy, to the chest for the midline fascia.
potential sternotomy or thoracotomy, to the groin –– The third stroke of the scalpel divides the
for additional central lines, and to the lower fascia and opens the peritoneum.
extremities for saphenous vein graft harvest as Be ready to encounter a gush of blood as
vascular conduit. A groin towel is placed to the abdominal tamponade is released.
ensure sterility. Do not forget to communicate with the
anesthesiologists prior to releasing the
abdominal tamponade so that they can pre-
19.2.3 Incision pare their resuscitation.
The trauma laparotomy incision is midline from 19.2.3.2 Potential Pitfalls

the xiphoid to the pubis. A trauma patient with multiple previous abdomi-
nal procedures presents as a challenge due to a
19.2.3.1 Key Maneuvers potentially hostile abdomen. Midline incisions in
• Make a single incision with a #10 scalpel from these circumstances may not permit the rapid
the xiphoid to the pubic symphysis. access needed and may cause additional damage
• The peritoneal cavity should be entered after to underlying structures due to dense adhesions.
three decisive strokes of the scalpel: An alternative approach is the bilateral subcostal
incision through which most of the abdomen still

can be explored.
19.2.4 Hemorrhage Control:

Packing the Four Quadrants
of the Abdomen
Once the abdomen is entered, the next move is

eviscerating the small bowel and packing the
abdomen to help control hemorrhage.
19.2.4.1 Key Maneuvers

• Pack the four quadrants of the abdomen with Fig. 19.3 Packing of the LUQ—spleen packing
folded, radiopaque laparotomy pads in a
clockwise fashion starting in the right upper –– The liver is now compressed anteriorly and
quadrant. posteriorly to achieve hemostasis.
• Packing the right upper quadrant and liver • Packing the left upper quadrant and spleen
(Fig. 19.2): (Fig. 19.3):
–– Divide the falciform ligament between two –– Surgical assistant retracts the left abdomi-
Kelly clamps and ligate with 0-silk sutures. nal wall outward away from the spleen.
–– Surgical assistant retracts the abdominal –– Position your non-dominant hand over the
wall upward and away from the liver. spleen to protect and elevate it toward the
–– Position your non-dominant hand over the midline.
liver to protect and retract it inferiorly. –– Use your dominant hand to position dry
–– Use your dominant hand to position dry packs posterior to the spleen.
packs above the liver. –– Release the spleen and place dry packs
–– Reposition your non-dominant hand under anterior to the organ.
the liver to retract it superiorly, and posi- • Packing the left lower quadrant and pelvis:
tion packs below the liver. –– Surgical assistant retracts the abdominal
wall laterally and away from the colon.
–– Sweep the small bowel and left colon
superomedially.
–– Pack the left paracolic gutter and pelvis
with dry packs.
• Packing the right lower quadrant and pelvis:
Falciform –– Surgical assistant retracts the abdominal
lig.
wall laterally and away from the colon.
–– Sweep the small bowel and right colon
superomedially.
–– Pack the right paracolic gutter and pelvis
with dry packs.
• Once the four quadrants are packed and hem-
orrhage is temporarily controlled, inform
the anesthesiologist and allow adequate resus-
citation before proceeding.
• Abdominal retractors such as Bookwalter,
Thompson, or Balfour should be set up at this
Fig. 19.2 Packing of the RUQ—liver packing time to assist in abdominal wall retraction.
19.2.4.2 Potential Pitfalls Table 19.1 Exploration of retroperitoneal hematomas

In terms of packing, quality is more important Penetrating
than quantity! Under-packing results in contin- Zone injury Blunt injury
ued hemorrhage, while over-packing can com- 1 (central) Explore Explore
2 (perinephric) Explore Observe if not
press the inferior vena cava (IVC), cause decrease
pulsatile/expanding
in venous return, and result in hypotension. 3 (pelvic) Explore Observe if not
pulsatile/expanding
19.2.5 Hemorrhage Control:

Identifying Retroperitoneal • Zone 2 encompasses the lateral regions of the
Hematomas (Fig. 19.4) retroperitoneum and contains the renal hilum
vasculature, kidney, adrenal gland, ureter, and
The retroperitoneum is divided into three zones, colon.
each containing vital structures that may require • Zone 3 is the pelvic retroperitoneum contain-
exploration during a trauma laparotomy: ing the iliac vessels and portions of the colon
and rectum.
• Zone 1 encompasses the central region of the
retroperitoneum and extends from the dia- Indications for exploration vary with each
phragm to the aortic bifurcation. It contains zone and the mechanism of injury (Table 19.1).
the abdominal aorta, celiac axis, superior mes- In general, all penetrating, pulsatile, and expand-
enteric artery (SMA), IVC, proximal renal ing hematomas require exploration. All zone 1
vasculatures, pancreas, and portions of the retroperitoneal hematomas are explored regard-
duodenum. less of mechanism of injury. The vascular surgery
tenet of obtaining proximal and distal control
remains true during exposure and exploration of
retroperitoneal hematomas.
1
2 2
19.2.6 Injury Identification
19.2.6.1 Key Maneuvers

• Remove packs one quadrant at a time, starting
from t.ctive bleeding, retroperitoneal hemato-
mas, bile staining, succus leakage, and dia-
phragmatic injuries.
• Running the small bowel:
3
–– Identify the ligament of Treitz by lifting up
the transverse colon and following the
transverse mesocolon to its base.
–– Flip the small bowel back and forth
between your hands to evaluate the bowel
wall and its mesentery.
–– Examine the entire small bowel from the
ligament of Treitz to the terminal ileum.
• Assessing the colon:
–– Identify the cecum and examine the ascend-
ing, transverse, descending, and sigmoid
colon for bowel wall and mesocolon
Fig. 19.4 Retroperitoneal hematoma zones 1, 2, and 3 injuries.
–– Follow the sigmoid colon to the rectosig- 19.2.7 Contamination Control

moid junction and evaluate the intraperito-
neal rectum. The goal is to limit the amount of intra-abdominal
–– A digital rectal exam and rigid proctosig- contamination as quickly as possible and plan
moidoscopy should be performed in all for definitive repair at a later time. Bowel inju-
patients with high index of suspicion for ries can be controlled and contained via several
rectal injury (pelvic fractures, truncal gun- techniques:
shot and stab wounds, penetrating wounds
of the lower abdomen, buttocks, or • Grasp and close opposing bowel walls with
perineum). Babcock or Allis clamps.
• Diaphragmatic injuries are difficult to diag- • Suture closure (interrupted or running) the
nose and must be repaired once identified: bowel injury with any suture on a non-cutting
–– Reduce any abdominal contents from the needle.
intrathoracic cavity. • Skin staples to reapproximate the bowel edges.
–– Surgical assistant retracts the liver or spleen • Tie off the proximal and distal ends of the
inferiorly to provide diaphragmatic injured bowel with umbilical tape (effectively
exposure. isolating the area of injury).
–– Reapproximate the diaphragmatic defect • Resect the injured bowel segment with a gas-
with hemostats. trointestinal anastomosis (GIA) stapler, and
–– Primarily repair the diaphragm with run- leave the bowel in discontinuity.
ning or interrupted nonabsorbable sutures
over a red rubber catheter inserted into the
pleural space. 19.2.8 Temporary Abdominal
–– Place the catheter to suction to evacuate the Closure
pneumothorax.
–– The assistant removes the catheter as the At this point of the operation, ongoing hemor-
surgeon ties down the suture repair. rhages are halted, major injuries are identified, and
–– Insert chest tube on injured side. intra-abdominal contaminations are controlled. It
is time to determine whether the patient is stable
19.2.6.2 Pitfalls for definitive repair or unstable and requires dam-
Do not forget to evaluate the gastroesophageal age control procedures. Contraindications to
junction, the anterior and posterior aspects of immediate reconstruction include hemodynamic
the stomach, and the pancreas via the lesser sac. instability; physiologic derangements including
Expose the gastroesophageal junction by divid- hypothermia, acidosis, and coagulopathy (be vigi-
ing the left triangular ligament of the liver and lant during the operation and look for these signs
retracting the left lobe of the liver laterally. To before they actually appear); and multisystem
enter the lesser sac, first retract the stomach injuries. Competing priorities such as concomitant
superiorly and the greater omentum inferiorly. head injury may require an abbreviated damage
Make a transverse incision in the thin portion of control operation. In addition, visceral edema,
the omentum with Bovie cautery just inferior abdominal noncompliance, and the need for a sec-
and parallel to the greater curvature of the stom- ond-look laparotomy preclude definitive abdomi-
ach. The posterior aspect of the stomach is nal closure in trauma patients.
assessed through the lesser sac. The anterior A few common techniques for temporary
surface of the body and tail of the pancreas can abdominal closure are listed below, and a more
be visualized and palpated through the lesser detailed analysis of such techniques is offered in
sac as well. Chap. 20:
• Rapid skin closure with towel clamps sequen- trolled setting, ensure the availability of an ICU
tially applied to skin edges 1–2 cm apart [4] bed, monitoring devices, Ambu bag, blood
• Negative pressure/vacuum-assisted closure products, and vasopressor medications. A thor-
(such as the ABThera system, KCI Medical) ough sign-out from the surgeon and anesthesi-
• Bogota bag or mesh closure ologist and a clear understanding of the patient’s
condition are keys to a successful ICU
19.2.8.1 Potential Pitfalls resuscitation.
Abdominal compartment syndrome (ACS) can
occur in the setting of an open abdomen! ACS
is defined as intra-abdominal pressure 19.3 Technical Approaches
≥20 mmHg with organ dysfunction [5]. Signs
include elevated peak airway pressure, hypo- 19.3.1 Exposing the IVC
tension, oliguria, and bowel ischemia. Treat
ACS by removing the temporary abdominal 19.3.1.1 Key Maneuver: Cattell-
closure device and releasing the pressure via a Braasch Maneuver (Fig. 19.5)
laparotomy. In some instances, tight or exces- • Right-sided visceral medial rotation with the
sive intra-abdominal packings may also need surgeon positioned on the patient’s left side.
to be removed. • Retract the right colon medially with your left
hand to expose the white line of Toldt.
• Holding the cecum in your left hand, bluntly
19.2.9 Transport from the OR dissect the white line of Toldt with your left
to the SICU index finger, and travel superiorly from the
cecum to the hepatic flexure (the correct plane
This is a crucial yet often overlooked and consists of loose areolar tissue that should eas-
underrated step of trauma laparotomy [4]. The ily divide).
transportation process should be a well-orches- • Continue mobilization of the right colon
trated event with constant communication medially and superiorly to the transverse
between the surgeon, anesthesiologist, OR colon until the IVC, right kidney, and iliac
staff, and SICU team. Prior to leaving the con- vessels are visualized.
Kocher Maneuver
Extended
Kocher
Maneuver
Cattell-Brasch
Maneuver
White line
of Toldt
Fig. 19.5 Cattell-
Braasch maneuver
19.3.1.2 Potential Pitfalls • The maneuver is complete when the aorta is

The correct plane of dissection can be more dif- visualized.
ficult to identify in the presence of a retroperito-
neal hematoma. However, hematomas often
create a dissection plane and may help guide your 19.3.2 Exposing the Abdominal
maneuver. Dissecting in a plane deep to the white Aorta
line of Toldt will result in elevation of the right
kidney. Identify and protect the duodenum as it is 19.3.2.1 Key Maneuver: Mattox
exposed with the mobilization of the hepatic flex- Maneuver (Fig. 19.6)
ure of the colon. • Left-sided visceral medial rotation with the
surgeon positioned on the patient’s right side.
19.3.1.3 Key Maneuver: Kocher • Retract the left colon medially with your left
Maneuver hand to expose the white line of Toldt.
• Medial visceral rotation of the duodenum to • Bluntly dissect the white line of Toldt with
expose the posterior aspect of the pancreatic your right index finger and travel superiorly
head. from the sigmoid colon to the splenic
• The c-loop of the duodenum is exposed after flexure.
the hepatic flexure is mobilized. • Identify the spleen, retract the spleen medially
• Gently retract the duodenum medially with in your left hand, and divide the peritoneal
your left hand. attachments to the spleen with your right
• Using a combination of blunt and sharp dis- hand.
section, divide the peritoneal attachments to • Rotate the left colon, spleen, tail of the pan-
the lateral wall of the duodenum with your creas, and stomach medially and superiorly to
right hand from the first portion, and move expose the abdominal aorta and the iliac
inferiorly to the third/fourth portion. vessels.
White line
Maddox Maneuver
of Toldt
Fig. 19.6 Mattox
maneuver
19.3.2.2 Potential Pitfalls between the right lateral surface of the liver
The Mattox maneuver may be too time-consuming and the abdominal sidewall.
for patients who require immediate supraceliac • Posterior hepatic packing:
aortic control in the setting of an expanding ret- –– Retract the liver superiorly with one hand,
roperitoneal hematoma. To expose the aorta above and place packs under the retracting hand
the celiac axis, retract the stomach laterally, and between the posterior surface of the liver
sharply divide the gastrohepatic ligament ver- and the infra-hepatic structures.
tically. Retract the distal esophagus/proximal • If bleeding stops after packing, leave the packs
stomach laterally and the left hepatic lobe to the in place! Premature removal of the packing
right (the left triangular ligament may need to be may result in further bleeding from peeling
divided) to expose the left crus of the diaphragm. the packs off the injured parenchyma.
Use your dominant index finger to bluntly dissect • To remove the packing, slowly irrigate with
the loose tissue around the aorta superiorly and water to loosen the packs.
inferiorly until an aortic clamp can be placed along • Localize and control residual areas of
the aorta. An orogastric tube placed by the anes- bleeding.
thesiologist will help differentiate the esophagus
from the potentially flaccid, empty aorta. 19.3.3.2 Potential Pitfalls
Excessive packing can compress the IVC and
jeopardize venous return. Too much packing can
19.3.3 Liver Injuries also limit diaphragmatic movement and cause
increase peak airway pressure and hypoventila-
Hepatic injuries range from small parenchymal tion. Full mobilization of the liver by dividing the
lacerations that are easily treated with pressure and triangular and coronary ligaments may improve
hemostatic agents to large avulsions or retrohepatic exposure of the injury and allow more effective
vena cava hemorrhage that require full liver mobi- packing. However, if a retrohepatic injury is sus-
lization and vascular control. Regardless of the pected, mobilization of the right liver lobe may
extent of the injury (and you likely will not know unroof the tamponade and cause severe
the full extent initially), the first step is to pack the hemorrhage.
liver. Hemorrhage not well controlled by packing
will require further mobilization and exploration. 19.3.3.3 Key Maneuver: Pringle
Three commonly utilized techniques for treating Maneuver
liver injuries/bleeding are discussed below. Several • Retract the anterior edge of the liver superi-
additional techniques are listed, but detailed orly and to the right.
descriptions are beyond the scope of this chapter. • Insert the left index finger into the foramen of
Winslow.
19.3.3.1 Key Maneuver: Hepatic • Pinch the thumb on top of the index finger to
Packing control the portal triad (hepatic artery, portal
• Recreate the anatomy by packing above and vein, common bile duct).
below the liver. • A vascular clamp can replace the fingers for
• Anterior hepatic packing: long-term control.
–– Divide the falciform ligament as previously • Release the clamp intermittently to limit total
described. ischemia time.
–– Retract the liver inferiorly with one hand,
and place packs over the retracting hand 19.3.3.4 Potential Pitfalls
between the anterior surface of the liver The Pringle maneuver is ineffective in patients
and the diaphragm. with a replaced left hepatic artery (most com-
• Lateral hepatic packing: monly off the left gastric artery) or injuries to the
–– Retract the liver medially one hand, and hepatic veins and retrohepatic IVC. A replaced
place packs over the retracting hand right hepatic artery (off the SMA) commonly
travels posterior to the portal vein. Feel for a pul- (and also rarely successful) and beyond the
satile structure posterior to the portal vein to help scope of this chapter.
identify this vessel. Be careful not to injure the
artery when placing a vascular clamp during the
Pringle maneuver. 19.3.4 Splenic Injuries
19.3.3.5 Key Maneuver: Suture Repair Indications for splenectomy in a trauma patient
• Reapproximate the liver parenchymal lacera- include active bleeding, hemodynamic instabil-
tions with sutures (0-chromic) on a large blunt ity, and concurrent moderate to severe brain
needle. injury that can exacerbate with ongoing hypoten-
• Take large bites incorporating the uninjured sive episodes. Due to its posterior location, the
liver parenchyma and capsule. spleen must be mobilized to the midline to allow
• Place figure-of-eight or horizontal mattress better exposure and control. Splenorrhaphy is
sutures. rarely performed during a trauma laparotomy.
When in doubt, the spleen should come out!
19.3.3.6 Potential Pitfalls
Taking too small of a bite of the liver parenchyma 19.3.4.1 Key Maneuver: Splenectomy
can cause the suture to tear through and result in • Surgeon is positioned on the patient’s right
more bleeding. When tying down the sutures, side.
apply just enough tension to reapproximate the • Place the left hand posterior to the spleen and
lacerated edges. Excessive tension during knot retract the spleen medially and anteriorly.
tying will further avulse the liver and exacerbate • Medial retraction of the spleen exposes the
the injury. retroperitoneal splenic attachments.
• Dissect and divide (blunt, sharp, or cautery)
19.3.3.7 Additional Hemostatic Agents the superior lienophrenic, lateral lienocolic,
and Techniques and posterior lienorenal attachments with the
Learn the available topical hemostatic agents right hand.
available at your institution. Commonly utilized • Lift the spleen off the right kidney and toward
topical agents include thrombin Gelfoam, the abdominal midline.
Surgicel, Combat Gauze, and fibrin glue. Argon • Place laparotomy pads posteriorly in the
beam coagulator can be used for hemostasis by splenic fossa to prevent the spleen from falling
creating an eschar on the bleeding liver surface. back into its original position.
Omental packing is useful in deep liver lacera- • Divide the short gastric vessels (suture liga-
tions and needs to be secured with sutures. tion, stapler, energy device) to expose the
Through-and-through liver injuries can be con- splenic hilum.
trolled via balloon tamponade by using a • Ligate and divide the hilar vessels:
Blakemore tube or a homemade balloon con- –– Individually dissect out the splenic artery and
structed from a Penrose drain over a hollow rub- vein, place two hemostats on each vessel,
ber catheter. A hepatotomy can be performed divide between the hemostats with scissors,
after adequate vascular inflow control with the and suture ligate the two ends with 2-0 silk ties.
Pringle maneuver. Using the finger fracture –– An alternative is to divide the artery and
technique, parenchymal defects are opened to vein with a vascular stapling device.
expose the injured vessels/ducts. Bleeding ves-
sels are then controlled with direct suture liga- 19.3.4.2 Potential Pitfalls
tion, clips, or electrocautery. Atrial caval shunts Excessive retraction during mobilization can tear
and hepatic venovenous bypass are rarely used the splenic capsule and cause more bleeding.
Identify and protect the tail of the pancreas to • Exposing the posterior surface:
prevent pancreatic leak and fistulas. Protect the –– A Kocher maneuver exposes the posterior
stomach during division of the short gastric ves- aspect of the head and neck of the pancreas.
sels. Care must be taken to ensure that all of the –– Medial mobilization of the spleen by divid-
short gastric vessels are adequately ligated to pre- ing the lienocolic and lienorenal ligaments
vent postoperative bleeding. exposes the posterior aspect of the body
and tail of the pancreas.
19.3.5 Pancreatic and Duodenal

Injuries 19.3.6 Kidney Injuries
The pancreas and duodenum are surrounded by Renal injuries are most commonly identified on
numerous vital structures. Adequate assessment CT scan during a trauma work-up. Indications for
of these two organs requires multiple maneuvers, exploration include active bleeding, hemody-
and detection of any pancreatic and duodenal namic instability, expanding or pulsatile hema-
injuries should raise suspicion for associated toma, and injury to the ureters or bladder. Renal
injuries to adjacent structures. salvage is rarely indicated if the patient has a nor-
mal contralateral kidney.
19.3.5.1 Key Maneuver: Exposure
of the Duodenum 19.3.6.1 Key Maneuver
• The first portion is inspected by following the • Exposure of the right kidney:
distal stomach to the pylorus and continuing –– Perform a right-sided medial visceral rota-
distally. tion to mobilize the right colon.
• The second and third portions are exposed –– Perform a Kocher maneuver to mobilize
with the Kocher maneuver, which also allows the duodenum.
examination of the posterior aspect of the • Exposure of the left kidney:
c-loop. –– Perform a left-sided medial visceral rota-
• The fourth portion is exposed by dividing the tion to mobilize the left colon, spleen, and
ligament of Treitz. distal pancreas.
• The third and fourth portion of the duodenum • Vascular control:
can be further mobilized with a Cattell- –– Obtain proximal renal vascular control
Braasch maneuver by carrying the dissection prior to entering Gerota’s fascia.
to the root of the small bowel mesentery. –– Lift the transverse colon and follow the
mesocolon to its base.
19.3.5.2 Key Maneuver: Exposure –– Sharply open and enter the retroperitoneum
of the Pancreas at this level.
• Expose the superior border of the pancreas by –– Extend the opening from the ligament of
dividing the gastrohepatic ligament. Treitz to the aortic bifurcation to allow full
• Exposing the anterior surface: exposure of the renal vessels.
–– Open the lesser sac and retract the stomach –– Identify the right renal vein as it enters the
superiorly. right lateral edge of the IVC, and isolate it
–– Sharply incise and divide the peritoneal with a vessel loop.
covering of the pancreas to examine its –– Retract the right renal vein superiorly to
anterior surface. expose the underlying right renal artery,
–– Continue the dissection to the right of the and isolate the artery with a vessel loop.
patient to expose the entire anterior aspect –– Identify the left renal vein as it crosses the
of the pancreas from the tail to the head. aorta laterally and enters the left lateral
edge of the IVC, and isolate it with a vessel artery conduit. The SMV and portal vein can be
loop. ligated; however, a second-look laparotomy to
–– Retract the left renal vein superiorly to evaluate bowel edema and viability is appropri-
expose the underlying right renal artery, ate. The IMA and IMV can be ligated.
and isolate the artery with a vessel loop.
• Nephrectomy: Take-Home Points
–– Once vascular control is obtained, open
Gerota’s fascia sharply at the lateral edge • Once the decision is made to take a trauma
of the kidney. patient to the OR, notify the anesthesiologist,
–– Right nephrectomy: place the left hand blood bank, and OR staff, and move quickly.
posterior to the kidney, mobilize it medi- Minimize the “door to cut” time.
ally and anteriorly into the midline abdo- • Communicate with the anesthesiologist before
men, and ligate and divide the renal releasing the abdominal tamponade.
vessels. • Be vigilant with abdominal packing; under-
–– Left nephrectomy: place the left hand pos- packing results in continued hemorrhage,
terior to the kidney, mobilize it medially while over-packing can compress the IVC and
and anteriorly into the midline abdomen, decrease venous return.
and ligate and divide the renal vessels. • Run the entire length of the bowel and quickly
control any contamination. Reserve definitive
19.3.6.2 Potential Pitfalls repair for a later time.
When isolating and dividing the renal veins, • Constantly evaluate the patient for physiologi-
remember that the right adrenal vein drains cal derangements including hypothermia,
directly into the IVC, while the left adrenal vein coagulopathy, and acidosis.
drains into the left renal vein. Prior to performing • Decision for damage control surgery should
a nephrectomy, always confirm the presence of a be made prior to the onset of the lethal triad.
contralateral kidney! If prior imaging is unavail- • Abdominal compartment syndrome can occur
able, an intraoperative on-table IV pyelogram in patients with an open abdomen.
can be performed to assess the contralateral
kidney.
References
19.3.7 Vascular Injuries: What Can
and Cannot Be Ligated! 1. Stone H, Strom P, Mullins R. Management of the
major coagulopathy with onset during laparotomy.
Ann Surg. 1983;197(5):532–5.
The abdominal aorta cannot be ligated! Suprarenal 2. Rotondo M, Schwab C, McGonigal M, Phillips G,
aortic injuries may need repair with a graft, even Fruchterman T, Kauder D, Latenser B, Angood P.
in the face of contamination. Injuries to the aortic ‘Damage control’: an approach for improved survival
bifurcation can be repaired with extra-anatom- in exsanguinating penetrating abdominal injury. J
Trauma. 1993;35(3):375–82.
ical bypasses. All infrarenal IVC injuries can 3. Johnson J, Gracias V, Schwab C, Reilly P, Kauder
be ligated if necessary. Suprarenal IVC injuries D, Shapiro M, Dabrowski G, Rotondo M. Evolution
cannot be ligated and may require shunting and in damage control for exsanguinating penetrating
repair with greater saphenous vein patch. The abdominal injury. J Trauma. 2001;51(2):261–71.
4. Hirshberg A, Walden R. Damage control for abdomi-
celiac trunk can be ligated due to extensive col- nal trauma. Surg Clin N Am. 1997;77(4):813–20.
laterals. The SMA cannot be ligated and should 5. Jacobs L, Luk S. Advanced trauma operative manage-
be repaired with a saphenous vein or internal iliac ment. Woodbury: Cine-Med; 2010.
Fundamentals of Temporary
Abdominal Wall Closure 20
Shelby Resnick and Niels D. Martin
20.1 Introduction Temporary abdominal wall closure was first

widely described in the latter part of the twenti-
In contemporary surgical practice, a fair amount eth century by vascular surgeons whose patients
of surgical jargon surrounds temporary abdomi- developed abdominal compartment syndrome
nal wall closure. To clarify, a “temporarily closed” following major abdominal aortic aneurysm
abdominal wall is often described as an abdomi- surgery [2]. These patients underwent massive
nal wall that has been “left open.” In fact, in the volume resuscitation, and only by leaving the
surgical literature, management of a temporary abdomen open, with a temporary dressing,
abdominal wall closure is synonymous with man- could the lethality of compartment syndrome be
agement of the “open abdomen” or often termed a overcome.
“damage control closure” (to be described below), In the early 1990s, this technique was com-
understanding the various nomenclatures will bined with the surgical “temporization” of other
alleviate future confusion. intra-abdominal injuries in the trauma literature;
There are many clinical scenarios that can together, it was called “damage control.” The
lead to a temporary abdominal wall closure [1]. term originated with the US Navy and describes
While ultimately the techniques of temporary the process of temporizing damage to a ship, just
closure are similar, it is important to understand enough to maintain sea and battle worthiness,
the underlying pathophysiology of each patient until the vessel could return safely for full repairs.
to optimize care. In fact, the underlying pathol- Surgically, damage control temporizes traumatic
ogy often drives the decision-making for abdomi- abdominal injuries to allow for a stabilization of
nal wall closure. patient physiology and hemodynamics [3]. Only
the most immediately life-threatening issues are
addressed at the index operation. The final step of
the damage control index operation is creation of
a temporary abdominal closure.
The temporary abdominal wall closure in
damage control allows for shunting of vascular
S. Resnick • N. D. Martin (*) injuries, packing of solid organ injuries, and con-
Trauma and Surgical Critical Care,
trolling contamination that may result in bowel
University of Pennsylvania, Philadelphia, PA, USA
e-mail: shelby.resnick@uphs.upenn.edu; discontinuity. The ultimate destination of the
niels.martin@uphs.upenn.edu damage control patient is the intensive care unit,

266 S. Resnick and N. D. Martin
where hemodynamic and physiologic stabiliza- Beyond providing a “dressing” to the abdominal
tion occurs prior to definitive surgical treatment. wall defect, the technique has several other goals.
Therefore, the temporary abdominal closure is This includes protecting the abdominal viscera
primarily managed outside of the operating room. from desiccation and infection while allowing for
Beyond vascular and trauma surgery, temporary fluid control. Abdominal fluids should optimally
abdominal closures may be necessary following be prevented from pooling in the recesses of the
any abdominal surgery where the patient suffers a peritoneum and also be adequately quantified
significant base deficit, low pH, hypothermia, large upon removal. Peritoneal fluid often contains
blood loss or requirement for blood transfusion, cytotoxic inflammatory mediators and endotox-
hypotension, high lactate, coagulopathy, or high ins, including IL-6, IL-10, TNF-alpha, TNF-beta,
degree of contamination [4]. The etiologies of these and CRP, which have been thought to play a con-
patients include intra-abdominal sepsis, abdominal tributing role in the development of multiple
compartment syndrome, pending abdominal com- organ dysfunction syndrome. Animal studies have
partment syndrome, hemorrhagic pancreatitis, and suggested that reducing the concentration of these
ruptured abdominal aortic aneurysms. Temporary mediators can help prevent inflammatory progres-
abdominal wall closure also facilitates “second- sion; however this mechanism has not been defin-
look” surgery for reexamination in the setting of itively shown in clinical studies [7, 8].
mesenteric ischemia. Finally, occasionally the An ideal temporary abdominal wall closure
abdomen is either opened or left open to treat extra- system would also facilitate eventual formal fas-
abdominal pathology such as refractory elevated cial closure and minimize the chances of long-
intracranial pressure [5]. In this setting, the open term ventral hernia formation. This is generally
abdomen lowers central venous pressure and achieved by preserving fascial integrity, prevent-
allows for improved venous outflow from the brain. ing fascial retraction (without creating pathologic
In total, these general surgery indications for tem- tension), and decreasing the risk of adhesion and
porary abdominal wall closure occur at a higher fistula formation. Additionally, the technique
frequency than trauma. A 2017 multicenter study should be easy to use by practitioners in the oper-
ordered the indication from most to least frequent ating room and at the bedside in the intensive
as peritonitis, trauma, vascular emergencies, isch- care unit. It should allow for rapid removal and
emia, pancreatitis, and abdominal compartment placement and be valuably priced.
syndrome [6]. The most frequently employed temporary
Regardless of indication, the methods and abdominal wall closure methods include patch
techniques of temporary abdominal closure are techniques and/or negative pressure therapy sys-
similar, based on the concept that the fascial tems. Older methods which include simple skin
edges and skin are not approximated leaving the closure or silo methods are mentioned here for
intra-abdominal viscera exposed. This temporary thoroughness; however, for the above optimiza-
anatomy requires unique technical and medical tion reasons, both the skin only and silo tech-
management knowledge and skills. Understanding niques are generally avoided if possible.
the various options and their specific advantages
and disadvantages and recognizing potential
complications are now a necessary component of 20.2.1 Skin Only
surgical training.
Skin-only closures utilize penetrating towel
clamps or staples to close the skin. This tech-
20.2 General Concepts nique provides few of the advantages achieved
with more sophisticated temporary closure tech-
Techniques for temporary abdominal wall closure niques and leaves the patient at a much higher
have evolved in the past three decades to optimize risk for development of abdominal compartment
the function and safety of the temporary closure. syndrome.
20 Fundamentals of Temporary Abdominal Wall Closure 267
20.2.2 Silo Techniques

(“Bogota Bag”)
The silo technique is commonly known as the

“Bogota bag” named after the Colombian sur-
geon who introduced it in the 1980s. It refers to
the use of any translucent, nonadherent, sterile
bag used to cover the abdominal cavity.
Commonly, an IV, dialysate, or irrigation bag is
used for this technique and is sewn to the skin
edge, circumferentially around the wound. The
silo technique does allow for visual inspection of
the abdominal viscera at the bedside. It is also
inexpensive and requires few materials, making it
a reasonable option in resource-poor environ-
ments. However, it lacks the capabilities of more
advanced temporary closure systems in terms of
fluid control and the ability to accommodate for
increasing intra-abdominal pressures.
20.2.3 Patch Techniques

Fig. 20.1 Patch technique. A Wittmann Patch is sewn to
the fascia and then closed over the protective layer with a
Patch techniques involve the use of a prosthetic Velcro®-like closing technique
material sewn to the edges of the fascia effec-
tively “bridging” the defect. This allows for
easy reentry on subsequent explorations and in combined with negative pressure therapy to help
theory prevents fascial retraction. At each reop- control and quantify peritoneal effluent.
eration, the fascial edges can be more closely
approximated and the patch progressively
trimmed to allow for eventual primary closure 20.2.4 Negative Pressure
of the fascia, at which time the patch is com- Therapy Systems
pletely cut out of the fascia. A disadvantage of
using this method is that each time the fascia is The most common contemporary techniques
sutured to the patch, there is a potential to dam- in temporary abdominal wall closure involve
age the fascial layers which need to stay intact a negative pressure therapy system (NPTS).
for primary closure to be possible. The poten- Most applications are commercial in nature
tial for fascial damage is further accentuated in and are highly utilized, in part, due to ease of
hypotensive, critically ill, and/or malnourished use. Additionally, there is increasing litera-
patients where the puncturing of suture holes ture supporting a higher primary fascial clo-
through the fascia can lead to fascial ischemia sure rate, even after long-term applications.
and necrosis, especially when repeated tight- NPTS allow for control of the abdominal
ening of the patch is performed. Patch options fluid effluent and its quantification. The dress-
include synthetic materials such as polytetra- ings themselves are relatively compliant, thus
fluoroethylene and Vicryl mesh. There are patch minimizing (but not negating) progression of
techniques that minimize fascial manipulation increased abdominal hypertension to frank
during serial explorations, such as the Wittmann abdominal compartment syndrome. There are
Patch [9] (Fig. 20.1). Patch techniques can be two main types of NPTS, towel-based and
sponge-based. NPTS employs the use of a 20.3.2 Towel-Based NPTS

nonadherent protective layer opposing the (Barker VAC)
bowel that is perforated to allow for fluid efflu-
ent, combined with an overlying sponge, gauze, The Barker VAC is a towel-based NPTS. A three-
or other porous materials in the subcutaneous layered occlusive dressing is used to apply nega-
space, and an outer, occlusive dressing. Once tive pressure and can be formed quickly and
sealed, controlled suction can be placed on the inexpensively with materials found in most oper-
porous layer to create the negative pressure and ating rooms. In one of the original papers by
draw off accumulating fluids and toxic metab- Barker, the technique was estimated to cost $126,
olites. Noncommercial methods can be per- though likely higher now due to inflation [10]
formed with products commonly found in most (Table 20.1).
operating rooms. The Barker Drain System provides to some
degree the same advantages as the commercial
negative therapy systems. It is generally much
20.3 Technical Considerations less expensive than commercial products and can
be created with simple materials. However, it
20.3.1 Patch Technique does not remove fluids as efficiently as the com-
mercially available products [11].
The commercially available Wittmann Patch™
is comprised of two sheets of biocompatible Table 20.1 Materials and steps for placement of the
material which attach to each other using a Barker VAC
Velcro®-like closing technique, one with micro Materials Placement steps
hooks and the other with loops. Each sheet is • Polyethylene drape: 1. Obtain a
sutured to the abdominal fascia. The abdomi- Barker initially described polyethylene drape
the use of the 3 M™ 2. Cut 1 cm slits in a
nal wound can then be easily opened and Steri-Drape™ large towel polyethylene sheet
closed by pulling them apart or pressing them drape 1010; however, in a to allow for
together, respectively. The entire patch is then pinch, a sterile X-ray drainage of the
covered with a hypobaric wound shield (HWS) cassette cover will also peritoneal fluid
suffice 3. Place the sheet
to help prevent contamination and promote • Surgical towels between the viscera
removal of fluid. The classically described • Two 10 mm flat silicone and anterior
HWS is similar to the towel-based NPTS, the drains with bulb abdominal wall
Barker VAC (see below), where a sterile gauze • Y adapter (Fig. 20.2)
• Adhesive drape (Ioban) 4. Place moist surgical
is used to cover the wound and the patch. A • Skin adhesive (Mastisol® towels over the
drain is then placed across the gauze and or tincture of benzoin) drape in the
placed to wall suction. Finally, the entire subcutaneous space
wound site is covered with a plastic adhesive 5. Lay the two flat
drains over the
drape to seal it. In lieu of a hypobaric wound towels
shield as described above, some surgeons opt 6. The skin is dried
to use a commercial negative pressure wound and prepped with an
system for more robust fluid management and adhesive
7. An adhesive sheet is
measurement. placed across the
In a similar manner to the Wittmann Patch™, wound and adhered
polytetrafluorethylene (PTFE) patches can be to the skin
used to accomplish the same goals. Sewn to the (Fig. 20.3)
8. The drains are
edges of the abdominal fascia, the patch is then connected via the
sewn together down the center, cut to reopen y-connecting
and resewn at each subsequent closing of the adapter and placed
abdomen. to wall suction
Fig. 20.2 Visceral protection. All contemporary forms of Fig. 20.3 Towel-based negative pressure therapy system
temporary abdominal closure involve the placement of a (Barker VAC). Using materials found in most operating
nonadherent sterile covering to protect the abdominal vis- rooms, the Barker VAC creates an inexpensive, three-layered
cera and prevent adhesion formation occlusive dressing to which negative pressure is then applied
Table 20.2 Placement steps for the commercial negative 20.3.3 Sponge-Based NPTS
pressure therapy system (ABThera™) (ABThera™)
1. Place the protective layer over the abdominal
contents. The layer may need to be trimmed to fit In contrast to the Barker VAC, commercially
the abdomen. If this is the case, it is important to
not leave any exposed foam sponge so as to prevent available, sponge-based abdominal NPTS are
any direct exposure of the sponge to the bowel designed to more evenly distribute the negative
which may cause injury pressure and to better drain the recesses and
2. The football-shaped foam piece is then sized to the dependent portions of the abdomen [11]. Some
dimensions of the subcutaneous space. It should be
in contact with all wound edges but not overlapping
studies have indicated that use of an instillation
the skin, which will help to apply medial tension feature available on some commercial NPTS can
3. Prep the skin with an adhesive, i.e., Mastisol® or decrease the number of intestinal adhesions, help
tincture of benzoin, to promote adhesion, especially prevent dehydration, and facilitate re-exploration
in areas of skin overlap or high moisture, like groin [4] (Table 20.2).
creases
4. The adhesive drape is then placed to cover the foam
If a NPTS is used in the setting of significant
and surrounding skin. The importance of this step bleeding and/or coagulopathy, the suction should
cannot be underestimated. For people with a large be placed at a lower level (~75 mmHg) for the
body habitus, an assistant to help hold back the first 48 h to avoid persistent hemorrhage and
skin, so a good seal with no gaps can be achieved, is
paramount. Any gaps will create subsequent
allow clotting of blood vessels. The output canis-
challenges for the device and care team. Cutting the ter should be closely monitored for signs of
large adhesive sheet into smaller more manageable ongoing bleeding. Suction should also not be in
sheets can help in more heavily creased areas. direct contact with bowel. Any anastomosis cre-
Additionally, shaving off excessive body hair will
be appreciated by the patient at the time of removal
ated during surgery should be placed in the abdo-
and can help with achieving a better seal men away for the NPTS.
5. A 2.5 cm hole is cut in the adhesive and foam where
the interface suction pad will be placed. Choose a
location that will be most effective for flow and the
position of the tube; this is generally centrally on 20.4 Practical/Safety Precautions
the device. Adhere the suction pad over the cut hole
(Fig. 20.4)
6. Connect the NPT machine and canister. Initial
Damage control laparotomy has decreased mortal-
settings should be set based on the physiology of ity rates in emergency surgery, but morbidity follow-
the patient. The usual set pressure is 125 mmHg ing the technique is still significant. Complications
continuous following an open abdomen are divided into early
Patients with temporary abdominal closure

are also at high risk for malnutrition for multiple
reasons including critical illness, lack of enteral
feeding secondary to intestinal injury or held for
procedures, and high-volume protein loss from
the peritoneal cavity fluid effluent. Peritoneal
fluid is estimated to contain 3 g/dL of protein,
with net daily losses frequently quantified in
liters, placing patients at an extremely high risk
for protein-calorie malnutrition [12]. This addi-
tional protein loss should be taken into account
when calculating caloric needs for repletion in a
patient with an open abdomen.
Fig. 20.4 Commercial negative pressure therapy system
(ABThera™). A suction pad is placed in a location that
will be most effective for flow and the position of the tube.
An open abdomen is not a contraindication to enteral 20.4.2 Postoperative Care
feeding, and temporary abdominal closures can be used in
conjunction with feeding tubes
Patients with a temporary abdominal wall closure
should be monitored in the intensive care unit.
and late complications. Prevention and early
Optimal care of the underlying pathology in
recognition of complications can be facilitated with
combination with management targeted at the
a high level of suspicion, comprehensive postoper-
open abdomen, including controlled volume
ative critical care, and optimal nutritional support.
resuscitation and appropriate ratios of blood
products, has been associated with a survival
advantage [13].
20.4.1 Early Complications Hypertonic saline has been suggested in the
literature to help facilitate earlier abdominal wall
Patients requiring temporary abdominal clo- closure. While the exact mechanism in humans
sure often require massive volume resuscitation has not been well described, the concept is that
and intra-abdominal packing or have continued the higher concentration of saline functions to
hemorrhage making them an at-risk population decrease overall fluid administered and addition-
for the development of abdominal compartment ally may shift fluid into the vascular system and
syndrome. Even with an open abdomen, patients decrease the capillary leak that occurs, thus pre-
can develop intra-abdominal hypertension and venting visceral edema. In a study of 23 patients
compartment syndrome and should therefore be who received 3% sodium chloride at 30 mL/h
monitored closely. Monitoring options include immediately after damage control surgery
bladder pressure transduction as well as physi- through postoperative day 3 or fascial closure
ologic assessments of urine output, airway (whichever occurred sooner), there was a 100%
pressures, and blood pressure. Development abdominal wall closure rate by day 7 [14].
of abdominal compartment syndrome with a Enteral nutrition is encouraged in all critically
temporary abdominal closure in place requires ill patients, especially those with an open abdom-
immediate attention. The temporary abdomi- inal wall. Studies have demonstrated that the use
nal closure should be immediately released or of enteral feeds in patients with an open abdomen
removed. Every attempt should be made to keep is associated with decreased morbidity and mor-
the abdominal viscera covered to prevent further tality and increased rates of fascial closure [15].
damage or desiccation of the bowel, often a new Additionally, patients with a temporary abdomi-
dressing can be fashioned to the dimensions of nal closure do not require paralysis or deep seda-
the larger wound. tion. Standard sedation goals are acceptable in
this population. In fact, if the patient meets the age. This results in a ventral hernia that can be
usual pulmonary criteria, extubation is also repaired 6–12 months later.
acceptable with an open abdominal wall.
20.4.4 Enterocutaneous Fistula (ECF)

20.4.3 Late Complications
Enterocutaneous fistulas are a dreaded complica-
While the abdomen should not be closed if the tion after an open abdomen, the incidence of
patient remains at a significantly high risk for which can run from 5 to 15% [11]. Not only do
development of abdominal compartment syn- ECFs create a significant reduction in quality of
drome, once the required surgical procedures have life, but they also carry a significant mortality
been completed, every attempt should be made to risk given the increased incidence of sepsis, mal-
close the abdomen in a timely fashion. The sooner nutrition, dehydration, and electrolyte imbal-
the abdomen is closed after the initial operation, ances. A correlation exists between the number
the lower the likelihood of c omplications, includ- of days of temporary closure and ECF develop-
ing fistula formation and loss of domain leading to ment [6, 18]. Other risk factors for fistula forma-
hernia formation. tion include bowel injuries and anastomoses,
While the ideal timeline for return to the oper- colon resections, large volume resuscitation,
ating room has not been fully described, it is intra-abdominal sepsis, increased number of
well agreed upon that delays in returning to the repeat explorations, and use of a permanent mesh
operating room are associated with a decrease directly in contact with the bowel [18]. NPTS can
in the ability to achieve primary fascial closure. be used to control ECF effluent and prevent
Pommerening et al. found that for each additional breakdown and further contamination of sur-
hour beyond 24 that a patient was delayed return- rounding tissues. Additionally, skin grafting
ing to the operating room was associated with a around the fistula can allow for ultimate place-
1.1% decrease in the likelihood of primary fascial ment of a wound manager device. ECFs often
closure [16]. This same study found that complica- create complex wounds, and whenever possible,
tion rates were increased in patients who returned a skilled wound therapist should be involved in
beyond 48 h. Additionally, functional outcomes, planning and creating the appropriate wound
including quality of life, pain, and return to work, managing systems.
are improved in a patient who undergoes abdomi-
nal wall closure within the first 7 days [17].
Primary closure of the abdominal fascial 20.5 Future Directions/
edges is usually possible when the fascial edges Current Controversies
are 3–7 cm apart. Separations any greater than
this require more complex surgical techniques to Temporary abdominal wall closure along with the
achieve definitive closure. Some cases may associated care models such as damage control has
require component separation with myofascial become lifesaving tools for the acute care surgeon.
flaps if adequate skin coverage is unavailable. In As the indications for leaving an abdominal wall
cases of severe contamination or in abdomens open have expanded beyond the trauma patient,
unable to be closed beyond 8 days, consideration there is increasing concern that this valuable tech-
of a planned ventral hernia is necessary. To create nique is being over utilized, leading to unnecessar-
a planned ventral hernia, a synthetic absorbable ily high rates of complications. Patients are now
mesh, frequently Vicryl, is sewn to the fascial surviving their initial insult, and many will face
edges to encourage granulation tissue formation complications and repeat surgeries stemming from
over the bowel while preventing further loss of the temporary closure. For some, the mortality ben-
domain. Once granulation has occurred, a split- efit has been traded in for long-term morbidity. In a
thickness skin graft is placed for ultimate cover- single-center retrospective study of a Houston
trauma center, the authors found that 20% of tion, and ventral hernias.
patients who underwent a damage control laparot- • Temporary abdominal closure alone does not
omy did not meet traditional indications [19]. The necessitate paralysis or deep sedation nor prevent
same group subsequently instituted a quality liberation from mechanical ventilation or enteric
improvement project which decreased the number feeding from occurring. These elements of care
of traumatic open abdomens by 16% without should be evaluated on a case-by-case basis.
changing mortality rates [20]. Future efforts will
likely continue to redefine the appropriate indica-
tions for temporarily closing the abdominal wall in
Suggested Readings
both trauma and emergency surgery populations.
Rotondo MF, Schwab CW, McGonigal MD, et al.
Take-Home Points ‘Damage control’: an approach for improved survival
in exsanguinating penetrating abdominal injury. J
• Temporary abdominal closure is a frequently Trauma. 1993;35:375–82; discussion 382–3.
employed technique in trauma and other Kron IL, Harman PK, Nolan SP. The measurement of
intra-abdominal pressure as a criterion for abdominal
aspects of emergency surgery that require a re-exploration. Ann Surg. 1984;199(1):28–30.
“damage control” approach. Wittmann DH, Aprahamian C, Bergstein JM, Edmiston
• Temporary abdominal closure techniques CE, Frantzides CT, Quebbeman EJ, Condon RE. A
should control fluid losses and minimize loss burr-like device to facilitate temporary abdominal
closure in planned multiple laparotomies. Eur J Surg.
of domain, in addition to providing coverage/ 1993;159(2):75.
protection of the bowel and intra-abdominal Chiara O, Cimbanassi S, Biffl W, et al. International
contents. consensus conference on open abdomen in trauma. J
• There are many options available to the sur- Trauma. 2016;80:173–83.
Kirkpatrick AW, Roberts DJ, Faris PD, et al. Active nega-
geon for temporary abdominal closure, which tive pressure peritoneal therapy after abbreviated
include silo techniques, patch techniques, and laparotomy: the intraperitoneal vacuum randomized
negative pressure therapy systems. Each has controlled trial. Ann Surg. 2015;262(1):38–46.
advantages and disadvantages associated with
them.
• A patient with a temporary abdominal closure References
can still develop an abdominal compartment
syndrome and should be closely monitored. 1. Weber DG, Bendinelli C, Balogh ZJ. Damage con-
• When using NPTS, low suction should be trol surgery for abdominal emergencies. Br J Surg.
2014;101(1):e109–18.
used for the coagulopathic patient. The canis- 2. Kron IL, Harman PK, Nolan SP. The measurement of
ter should be carefully monitored for signs of intra-abdominal pressure as a criterion for abdominal
ongoing surgical bleeding. re-exploration. Ann Surg. 1984;199(1):28–30.
• When using temporary abdominal closure 3. Rotondo MF, Schwab CW, McGonigal MD, et al.
‘Damage control’: an approach for improved survival
devices, care must be taken to avoid injury to in exsanguinating penetrating abdominal injury. J
the bowel. If a negative pressure system is Trauma. 1993;35(3):375–82; discussion 382-3.
used, a barrier to protect the bowel from direct 4. Chiara O, Cimbanassi S, Biffl W, et al. International
suction should be employed. consensus conference on open abdomen in trauma. J
Trauma. 2016;80:173–83.
• All attempts to decrease the amount of time 5. Joseph DK, Dutton RP, Aarabi B, Scalea TM.
the patient has an open abdomen should be Decompressive laparotomy to treat intractable intra-
made. Patients should return for initial attempt cranial hypertension after traumatic brain injury. J
at closure within 48 h, if possible. Trauma. 2004;57(4):687–93.
6. Coccolini F, Montori G, Ceresoli M, et al. IROA:
• Delay in closure increases complications International Register of Open Abdomen, preliminary
including fluid loss, protein loss, fistula forma- results. World J Emerg Surg. 2017;12:10.
7. Kubiak BD, Albert SP, Gatto LA, et al. Peritoneal Trauma. 2013;74(2):426–30; discussion 431-2.
negative pressure therapy prevents multiple organ 15. Burlew CC, Moore EE, Cuschieri J, et al. Who

injury in a chronic porcine sepsis and ischemia/reper- should we feed? Western Trauma Association multi-
fusion model. Shock. 2010;34(5):525–34. institutional study of enteral nutrition in the open
8. Kirkpatrick AW, Roberts DJ, Faris PD, et al. Active abdomen after injury. J Trauma. 2012;73(6):1380–7;
negative pressure peritoneal therapy after abbreviated discussion 1387-8.
laparotomy: the intraperitoneal vacuum randomized 16. Pommerening MJ, DuBose JJ, Zielinski MD, et al.
controlled trial. Ann Surg. 2015;262(1):38–46. Time to first take-back operation predicts success-
9. Wittmann DH, Aprahamian C, Bergstein JM, et al. ful primary fascial closure in patients undergoing
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closure in planned multiple laparotomies. Eur J Surg. 431–8.
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Clin Pract. 2010;25(5):510–6. 19. Hatch QM, Osterhout LM, Podbielski J, et al. Impact
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Fundamentals of Exploratory
Thoracotomy for Trauma 21
Deepika Koganti and Alec C. Beekley
21.1 Introduction these patients. In contrast, the last two categories

of patients are often stable enough that advanced
Thoracotomy for trauma can be classified into imaging, consultation with specialists, and careful
four categories: operative planning can occur before going to the
operating room. In addition, minimally invasive,
1. Thoracotomy for resuscitative maneuvers
image-guided radiologic therapies and endovascu-
only lar techniques are increasingly utilized in the set-
2. Thoracotomy for both identification and treat- ting of stable trauma patients with injuries that
ment of thoracic injuries and resuscitative require surgical intervention. The distinction
maneuvers between the third and second categories of patients
3. Thoracotomy for treatment of identified inju- is not as clear, in that some trauma patients with
ries in stabilized patients thoracic injuries may be stable on presentation but
4. Delayed thoracotomy for treatment of sequelae deteriorate rapidly and require more prompt inter-
of traumatic injuries vention. For the purpose of this chapter, the focus
will be primarily on the first two categories of tho-
The distinction is important since the first two racotomy listed above. Although the treatment of
categories involve operations on unstable patients. specific injuries will be touched upon, a complete
Time for extensive preoperative work-up, discus- discussion of the treatment of cardiac, pulmonary,
sion on approaches, and recruitment of specialists esophageal, and thoracic great vessel injury is
is not available. Simplicity, speed, flexibility, and beyond the scope of this chapter.
boldness are required for a successful outcome in The exploratory thoracotomy for trauma is his-
torically one of the most controversial surgical
procedures performed. The first reported success-
D. Koganti ful prehospital thoracotomy was done on a kitchen
College, Thomas Jefferson University, table in Montgomery, Alabama, in 1902 [1].
Philadelphia, PA, USA While the execution of the procedure has certainly
e-mail: deepika.koganti@jefferson.edu evolved since the early 1900s, the quoted survival
A. C. Beekley (*) rates of emergency thoracotomy in the literature
Department of Surgery, Division of Acute are extremely variable, contributing to the contro-
Care Surgery, Division of Bariatric Surgery, versy over the topic. Rates have been reported
Sidney Kimmel Medical College at
Thomas Jefferson University, Philadelphia, PA, USA from 0% to 70%. This large variation is largely
e-mail: alec.beekley@jefferson.edu due to the fact that different traumatic mecha-

276 D. Koganti and A. C. Beekley
nisms have different outcomes. For penetrating extensive amount of information on potential life-
chest trauma, the survival rates are approximately threatening injuries including presence of tension
18–33%. For stab wounds causing cardiac tam- pneumothorax, hemothorax, bony injury, and
ponade only, survival rates reach 70%. However, mediastinal injury such as widened mediastinum
for blunt trauma, survival rates are 0–2.5%. Yet, and pneumomediastinum. Another valuable and
some blunt trauma patients have a higher chance quick study is the Focused Assessment with
of survival based on presence or absence of vital Sonography for Trauma (FAST). The FAST
signs [2]. The likelihood of survival is the leading includes evaluation of the pericardial and perito-
factor in determining the indications for an emer- neal cavities. The eFAST, or extended FAST, has
gency thoracotomy. Due to varying practices for been established to further evaluate the pleural
performance of emergency department thoracot- spaces using ultrasonography. This study can pick
omy (EDT), the Eastern Association for the up hemothoraces and pneumothoraces requiring
Surgery of Trauma (EAST) published evidence- chest tube placement [4]. As stated in the guide-
based guidelines in 2015. A strong recommenda- lines above, if a chest tube is placed and 1500 cc of
tion was made for EDT for a pulseless patient blood is immediately drained or 200 cc/h over 4 h,
after a penetrating injury with signs of life. EDT an emergency thoracotomy is indicated.
was conditionally recommended for patients who
present pulseless with no signs of life after pene-
trating thoracic or extra- thoracic injury, for 21.3 Technique for Emergency
patients who present pulseless with signs of life Thoracotomy
after penetrating extra-thoracic injury, and for
patients who present pulseless with signs of life Since an emergency thoracotomy is never a
after blunt injury. A recommendation was made planned procedure, all equipment should be read-
against EDT for patients who present pulseless ily available and easily accessible. Most impor-
with no signs of life after blunt injury [3]. tantly, all providers should know where these
The goal of the EDT is to obtain access to the instruments are located in the trauma bay or oper-
chest to achieve direct hemorrhage control, release ating room prior to an emergency. The following
cardiac tamponade, control air embolism, perform is a list of equipment to successfully perform an
internal cardiac massage, and optimize flow to the emergency thoracotomy [5, 6]:
brain and heart to keep the patient alive for further
definitive management in the operating room. 1. Personal protective equipment: gloves, sterile
gloves, gown, scrub cap, face mask, and shoe
covers
21.2 R
esuscitative vs. Exploratory 2. Prepping the chest: povidone-iodine and ster-
Thoracotomy ile drapes
3. Access to the chest: scalpel with no. 10 blade,
The above criteria outline indications for or against curved Mayo scissors, rib spreader, Lebsche
immediate thoracotomy. However, patients who knife, Gigli saw, and/or trauma shears
arrive in more stable condition after thoracic 4. Control of hemorrhage and injury repair:

trauma may not need an immediate thoracotomy Metzenbaum scissors, DeBakey vascular for-
and have time to undergo further evaluation. As ceps, DeBakey aortic clamp, Satinsky vascular
always, the algorithm of airway, breathing, and clamps, artery clips, long and short needle
circulation should be followed for each trauma holders, high-volume suction, 3-0 nonabsorb-
patient, and interventions such as intubation, able suture (nylon, polypropylene) on round-
placement of chest tubes, and insertion of large bodied needle, 2-0 absorbable ties, laparotomy
bore IVs should be done as appropriate. A chest packs, Teflon pledgets, suture scissors, Foley
x-ray should be obtained once the patient is stabi- catheter 20F with 30 cc balloon, chest tube 30F,
lized. This simple and quick study provides an internal defibrillator, and ACLS medications
21 Fundamentals of Exploratory Thoracotomy for Trauma 277
Once the decision to proceed with emergency ning on the right lateral edge of the sternum, as
or resuscitative thoracotomy has been made, time this maneuver may save time for additional skin
is of the essence. There is no time for placement opening if division across the sternum is required
of a double-lumen endotracheal tube or bronchial (as it frequently is). In nonobese males, the inci-
blocker. Furthermore, establishment of large bore sion may track along the inferior border of the left
intravenous lines, while ultimately necessary for nipple/areola complex and then follow a gentle
success, can be performed by other providers in superior curve toward (but not into) the axilla. This
parallel to surgical opening of the chest. Optimal incision placement mimics the natural anatomic
positioning of the patient is supine with the arms contour of the ribs and may make pleural entry
out to the sides. This position allows access to easier.
both chest cavities but can allow additional pro- The incision is performed boldly with a no. 10
viders access to the upper extremities for antecu- blade scalpel (Fig. 21.1). The skin, subcutaneous
bital intravenous line placement by either tissue, and chest wall musculature are frequently
percutaneous techniques or direct cutdown. If the divided, and the chest wall is exposed on the ini-
equipment is immediately available, a rolled tial swipe of the blade. Intercostal incision may
towel or blanket can be stuffed behind the chest continue with the scalpel, although some sur-
to slightly elevate the operative (usually left) side geons prefer a curved Mayo scissors to open the
(~20°). This positioning can allow better poste- intercostal musculature and pleura above the rib.
rior extension of the thoracotomy incision and One side of the scissors is inserted into the pleu-
increased exposure to the posterior aspect of the ral cavity and one side left out; with respirations
hemithorax, without compromising access to temporarily held by anesthesia, the scissors can
other body cavities. The entire chest from the be pushed along the rib medially and then later-
chin to at least midway between xiphoid process ally to open the intercostal muscles and pleura. It
and umbilicus and laterally from bed to bed is frequently better to err a little high on the inci-
should be prepped. If the surgeon’s setting is a sion and intercostal space rather than err too low.
trauma operating room, a complete prep from the The intercostal incision should be opened as
chin to knees may be continued, while initial widely as possible to allow both of the surgeon’s
access to the chest is gained. Since emergency or hands access to the chest. For petite individuals
resuscitative thoracotomy is frequently initiated with relatively small thoracic cages, the surgeon
with a left anterolateral approach, the left side of should not hesitate to open the intercostal inci-
the chest is prepped first, so the primary surgeon sion all the way medially to the sternum and
can begin the thoracotomy incision as soon as divide the sternum for better exposure. Sternal
possible.
The goal is entry into the pleural cavity
through the fourth or fifth intercostal space.
Counting of the ribs is generally not recom-
mended, and many providers use the inferior
edge of the nipple/areola complex as a landmark
in nonobese males. Surgeons should realize that
the nipple may not be a reliable anatomic land-
mark in obese patients or females. In this instance,
the inframammary crease and/or xiphoid process
may serve to provide surgeons with a better idea
of where to place the initial incision in such
patients. Superior retraction of the breast should
be performed prior to incision in these instances.
Fig. 21.1 Initial incision for the left anterolateral (resusci-
The incision may begin at the left lateral edge tative) thoracotomy. Note simultaneous performance of
of the sternum. Some surgeons recommend begin- right tube thoracostomy and right femoral venous cutdown
Fig. 21.3 Left anterolateral thoracotomy with Finochietto

retractor cross bar on the lateral side and hand crank supe-
Fig. 21.2 Left anterolateral thoracotomy with Finochietto rior and lateral. Note extension to a clamshell incision
retractor cross bar on the medial side and hand crank infe- would be unobstructed but hand crank is sitting in axilla.
rior and medial. Note that the cross bar would interfere Note cross clamp is in place but almost sitting on
with clamshell extension and hand crank would be in the retractor
way of superior aspect of laparotomy incision. Note cross
clamp is in place and well away from retractor
division can be done with a Lebsche knife, trauma of the trauma team to empirically place a chest
shears, bandage scissors, or Gigli saw. tube in the right chest. This can provide some
A rib spreader (Finocchietto retractor) is information on pathology in the right chest and
now placed in the intercostal incision to pro- guide secondary steps.
vide retraction. This device is a rack-and-pinion Upon entry into the pleural cavity, several pos-
retractor. The “rack” side, or crossbar, can be sible scenarios may be encountered:
placed medially, which has the advantage of
easy access to the hand crank on the inferior 1. A large rush of air under pressure is released.
and medial side of the field and clearer access The patient may or may not have return or
to the posterior portions of the pleural cav- improvement in vital signs. The lung injury
ity for maneuvers like aortic cross clamping or that was the source of the tension pneumotho-
treatment of lung injuries. The disadvantage of rax may be large or small, but it should be
this placement is that the hand crank and cross sought out for evaluation, as some may require
bar can obstruct access to the heart, right side surgical treatment. In patients who have clini-
of the chest, or superior aspect of the abdomen cally improved, with release of tension pneu-
if midline laparotomy is performed (Fig. 21.2). mothorax, methodical exploration of the chest
Placement of the rack laterally has the advantage may be performed once other body cavities
of an unobstructed view of the heart and unim- have been evaluated for injuries. In patients
peded access to the sternum and right chest for who do not improve, surgeons should evaluate
“clamshell” extension of the thoracotomy inci- for another problem, such as tamponade or
sion. With lateral rack placement, the hand crank hemorrhage in another body cavity.
resides superiorly and laterally (Fig. 21.3); sur- 2. A massive rush of blood under pressure is
geons should be aware that this positioning can released. This frequently represents a diffi-
result in the hand crank catching clothing, blan- cult challenge as it can indicate a great ves-
kets, or the patient’s shoulder skin and tissues as sel, proximal lung hilum, or cardiac injury.
the crank is turned. Treatment of these various injuries will be
Access to and exposure of the pleural and peri- discussed below.
cardial cavities should generally take less than 3. Neither blood nor air is released. This may
2 min. While surgical access to the left chest is indicate a contained pericardial tamponade or
initiated, the surgeon should direct other members a hemorrhage source in another body cavity.
If opening the pericardium reveals no injury In settings where the heart is empty and the
but an empty or near-empty heart, resuscita- suspected hemorrhage source is below the dia-
tive measures (such as application of aortic phragm, application of an aortic cross clamp as
cross clamp) should be instituted, and a rapid described below should probably occur before
search for hemorrhage sources in other cavi- prolonged open cardiac massage or delivery of
ties must begin. intracardiac medications and/or electric shocks.
In settings where a cardiac injury is present, the
injury should be repaired or temporized before
21.4 Pericardiotomy attempting to restore cardiac activity. Surgeons
should realize that successful restoration of per-
After the chest is opened, exposure obtained, and fusing cardiac activity will not occur in the set-
obvious intrathoracic hemorrhage sources con- ting of an empty heart, profound acidosis, or
trolled or temporized, the pericardium should be profound hypothermia.
opened. This generally should be done relatively There is no accepted algorithm for delivery of
early in the steps of resuscitative thoracotomy. intracardiac medications. Surgeons have tried epi-
This is typically done with a longitudinal inci- nephrine, atropine, calcium chloride, sodium bicar-
sion along the left lateral aspect of pericardium, bonate, vasopressin, and likely a host of other
usually anterior and parallel to the left phrenic vasoactive medications in attempts to restart the
nerve. A tense pericardium can be difficult heart, with varying degrees of success. Surgeons
to grasp or lift with forceps. In this instance, should be wary of the typical vasoactive medica-
a scalpel blade can be used to make a small tion ampules such as epinephrine or atropine. The
(5–10 mm) nick in the pericardium to then allow needles associated with these ampules are typically
Metzenbaum scissors to be inserted to open the large and can actually result in a cardiac injury that
pericardiotomy widely. Obviously, care must be will continue to bleed in a coagulopathic patient.
taken such that the scalpel does not injure the Successful salvage after resuscitative thoracotomy
underlying heart. In the absence of blood or fluid has more to do with the reversibility of the underly-
in the pericardium sac, the pericardium may be ing insult rather than the technique or medications
loose enough to grasp and elevate with forceps to employed. At the conclusion of a successful resus-
simply make the initial cut with the Metzenbaum citative procedure, it is rare that the pericardium
scissor tips. can be closed due to cardiac congestion from resus-
The pericardium should be opened for the citation and treatment.
majority of its longitudinal dimension (thoracic Critical to the success of the procedure is the
inlet to the diaphragm). The heart can then be teamwork of all involved. The surgeon can per-
delivered and inspected for injury. Treatment of form the fastest and smoothest resuscitative tho-
cardiac injuries is briefly addressed below. In racotomy, but without concomitant establishment
the absence of organized cardiac activity, open of large bore intravenous lines, initiation of dam-
cardiac compression should be initiated. The age control resuscitation strategies, and in-
technique for open cardiac massage is to place parallel triage of other body cavities for injury
the bases of the surgeon’s palms together at the and/or treatment of other hemorrhage sources,
inferior apex of the heart. The left hand is typi- success will not be possible.
cally positioned right and anterolateral and the
right hand left and posterolateral. The flat aspects
of the palms are then closed together around the 21.4.1 Application of Aortic
heart from the base of the palm toward the fin- Cross Clamp
gertips. One-handed compressions or angling
of the fingertips into the myocardium should be Before rushing to cross clamp the descending
avoided, as direct perforation of the heart can aorta, the surgeon should consider what he is
occur with this technique. trying to accomplish by the maneuver. If there
is known or suspected uncontrolled hemorrhage placed, the surgeon can often use its presence to
above the diaphragm, aortic cross clamping help distinguish the flaccid aorta from the esopha-
makes no sense and may actually worsen bleed- gus. If it can be visualized, the parietal pleura
ing. The settings where application of an aortic overlying the aorta should be spread with a scis-
cross clamp may help are as follows: sors or clamp and the aorta partially encircled with
the surgeon’s nondominant thumb and index fin-
1. The patient is in extremis with multiple inju- ger. A pitfall with this step is that complete encir-
ries. The bleeding source or sources have not clement of the aorta can result in avulsion of an
been clearly identified. The initial thoracot- intercostal artery (which behaves like a hole in the
omy has not demonstrated a source, and the aorta and can result in substantial bleeding). With
goal is to restore perfusion at least to the heart, gentle traction of the aorta, the surgeon can apply
lungs, and brain until hemorrhage sources can the cross clamp (Figs. 21.2 and 21.3). Failure to
be identified and controlled. open the parietal pleura overlying the aorta often
2. The patient is in extremis with a cardiac or results in the clamp slipping off the aorta or incom-
intrathoracic injury which has been repaired or pletely occluding it.
controlled. The goal is to restore perfusion at Once the clamp is in place, if possible the sur-
least to the heart, lungs, and brain to allow time geon should request a timer be started and callouts
for continued blood product resuscitation. at 10 min intervals instituted. The surgeon should
3. The patient is in extremis with a known or sus- not release the cross clamp until in a position to
pected injury below the diaphragm. Application control hemorrhage and when some hemodynamic
of the cross clamp is a temporizing measure to stability is restored. Patients requiring cross clamp
allow resuscitation to begin and allow the sur- for more than 30 min almost uniformly develop
gical team time to find and control the hemor- fatal physiology. Therefore, if normo- or hyperten-
rhage source. sive blood pressures are achieved and hemorrhage
is controlled, the surgeon should consider removal
In all instances, the cross clamp is a temporiz- of the clamp in a slow, controlled fashion and be
ing measure, and the surgeon should realize that willing to tolerate some permissive hypotension.
once applied, the clock is ticking. After about Furthermore, if a hemorrhage source below the
30 min (or less), the patient will become “cross diaphragm is identified and controlled or the clamp
clamp dependent,” and successful salvage can be moved to a more distal location proximal to
becomes highly unlikely. an injury, this should be done as soon as possible.
The cross clamp should be applied to the Infrarenal aortic cross clamping may be tolerated
descending aorta as close to the diaphragm as pos- for a longer period of time than descending tho-
sible. Nevertheless, surgeons should not hesitate to racic cross clamping.
use the most accessible place on the descending
aorta to place their clamp based on their initial
incision and the patient’s habitus and anatomy. 21.4.2 Clamshell Thoracotomy
Division of the inferior pulmonary ligament can
assist with superior and anterior retraction of the The clamshell extension into the opposite pleural
lung, but this maneuver is not always necessary. cavity provides excellent exposure to the heart,
Once the lung is retracted anteriorly, the surgeon both pulmonary hilum and even (to some degree)
should slide her knuckles along the posterior the proximal great vessels. This maneuver should
aspect of the rib cage until she feels them curve be done anytime additional exposure is needed for
anteriorly to the articulation with the vertebral col- surgery on the heart, pulmonary hilum, or great
umn. Typically, the first tubular structure encoun- vessels. It is recommended that the incision exten-
tered will be the descending aorta. It is often sion from the left chest to the right chest be curved
flaccid in patients who have hemorrhaged to arrest gently superior, as the right hemidiaphragm is
or near-arrest. If an orogastric tube has been higher and the right pulmonary hilum may be
better exposed with this maneuver. The sternum 21.4.3 Median Sternotomy
can be divided with a heavy scissor, Lebsche
knife, or Gigli saw. This move severs the internal In certain instances, the median sternotomy may
mammary arteries. Once the patient is resusci- afford superior exposure and be the incision of
tated, these will bleed quite vigorously and will choice. Examples of trauma scenarios where
need to be controlled, which is fortunately rela- median sternotomy may be superior to thoracot-
tively easy to do. The use of a Finocchietto retrac- omy include isolated stab wounds within a few
tor can assist with maximal exposure to both centimeters of midline in the setting of obvious
thoracic cavities (Figs. 21.4 and 21.5). clinical tamponade (distended neck veins, hypo-
tension, and clear breath sounds bilaterally). In
these cases, the likelihood of anterior cardiac
injury and pericardial tamponade is so high and
the exposure via sternotomy so ideal that this
should be the incision of choice. Gunshot wounds
in the same area are more variable in terms of
trajectory and energy transfer, and hence thora-
cotomy may be better in those instances. The
median sternotomy affords exposure to the heart,
ascending aorta, proximal aortic arch and arch
vessels (except left subclavian artery), innomi-
nate vein, superior vena cava, and pulmonary
artery and hilum. The median sternotomy may
also be useful for injuries to the thoracic inlet, as
the incision may be easily extended up either side
of the neck or out above or below either clavicle.
With planning, practice, experience, and proper
Fig. 21.4 Diagram showing extension of anterolateral
equipment, the median sternotomy can also be
thoracotomy into clamshell extension with division of accomplished in minutes.
sternum and ligation of internal mammary arteries The median sternotomy incision is begun just
(Reprinted with permission from Chapter 13: Choice of above the jugular or suprasternal notch and taken
Thoracic Incision, from Front Line Surgery: A Practical
Approach Edited Martin M and Beekley A. Springer;
to just below the xiphoid process. Cautery can be
New York, 2011) used to divide the subcutaneous tissues and strap
musculature just above the jugular notch and the
subcutaneous tissues just below the xiphoid pro-
cess. With continued dissection, the surgeon can
carefully insert his index finger in the retrosternal
plane at these locations to create the initial dis-
section plane for either an electric sternal saw or
the Lebsche knife (Fig. 21.6). The sternum can be
opened fairly rapidly with either of these instru-
ments. Ventilation should be held during sternal
division. Care should be taken to stay as close to
the middle of the sternum as possible.
Bone wax, if available, can be used on bleed-
ing sternal edges, but the goal is to get after the
injury that is killing the patient. A rack-and-pinion
Fig. 21.5 Clamshell thoracotomy incision exposure. sternal retractor can then be placed; some cautery
Right pneumonectomy has been completed dissection of filmy retrosternal attachments may
Fig. 21.7 Pericardium being opened through median ster-

notomy incision (Photo courtesy of Dr. Peter G. Deveaux
and Dr. Garth Lecheminant)
Fig. 21.6 Median sternotomy being performed with

Lebsche knife (Photo courtesy of Dr. Peter G. Deveaux
and Dr. Garth Lecheminant)
Fig. 21.8 “Pericardial well” being created with heavy

be necessary to facilitate this retraction. Exposure
silk sutures secured to cut edges of the pericardium
to the superior mediastinum requires division of (Photos courtesy of Dr. Peter G. Deveaux and Dr. Garth
the thymus; care should be taken to avoid injury to Lecheminant)
the innominate vein with this maneuver. The peri-
cardium should then be opened longitudinally,
using techniques as described in the resuscitative
thoracotomy section. Once the pericardium is
incised enough to get a finger in, the remainder
can quickly and safely be dissected by dividing
the pericardium over the surgeon’s finger or suc-
tion tip (Fig. 21.7). Although techniques to create
a “pericardial well” are described, this is not
always necessary or helpful unless extensive work
on the heart is required. If there is difficult expo-
sure to a cardiac injury, multiple heavy silk
stitches can be placed on either side of the cut
edges of pericardium and draped over the retrac-
Fig. 21.9 Complete “pericardial well” created with
tor or actually affixed to the drapes with a clamp heavy silk sutures secured to cut edges of pericardium
under some tension (Figs. 21.8 and 21.9). This (Photos courtesy of Dr. Peter G. Deveaux and Dr. Garth
elevates the heart slightly into the field and helps Lecheminant)
keep the ventilating lungs from pushing into view. briefly disconnect the ventilator circuit, then
Patients with tamponade physiology will often compress the lung with laparotomy pads, and
have immediate correction of their hypotension, keep it compressed with lap pads and a lung
unless they are in full arrest already. The surgeon retractor, while mechanical ventilation is re-
should initially seek simple digital control of car- instituted. Use dry lap pads to soak up or blot up
diac injuries exposed. Treatment of these injuries any blood, and try to hone in on the bleeding
is briefly discussed below. source. Once the bleeding is controlled, system-
atically explore for other injuries.
21.4.4 “Trapdoor” Incision

21.4.6 Lung Injuries
The anterolateral thoracotomy incision and the
median sternotomy can be combined, although Lung injuries range from small lacerations to
doing so increases morbidity and makes closure destructive lesions requiring anatomic resection.
more challenging. The combination of these surgi- Small lacerations can be oversewn or stapled off;
cal approaches never occurs based on initial plans through-and-through penetrating wounds with
but arises out of necessity. One can anticipate a sce- hemorrhage can be exposed through the technique
nario where a patient in extremis with penetrating of stapled tractotomy, where an anvil of the linear
thoracic trauma or combined mediastinal and cervi- stapler is passed through the wounds and the other
cal trauma had an initial surgical approach with a half of the stapler is closed over it exteriorly.
left anterolateral thoracotomy but then had opera- Firing the stapler safely opens the superficial lung
tive findings (proximal great vessel, e.g., left subcla- above the injury to allow direct visualization and
vian) that could not be adequately exposed by the suture control of the hemorrhage or air leaks
anterolateral thoracotomy approach. Combination (Fig. 21.10). The majority of lung injuries can be
of the anterolateral thoracotomy, median sternot- managed with this technique or nonanatomic sta-
omy, and even an additional clavicular extension pled resection (Fig. 21.11). Major hemorrhage
into a “trapdoor” exposure allows access to the from the middle of the lung parenchyma or near
proximal great vessels including the left subclavian the hilum can be temporized with either a “hilar
artery and vein. This is obviously a more morbid twist” maneuver (Fig. 21.12), manual compres-
procedure, but surgeons should remember it is sion of the hilum in the surgeon’s hand, or vascu-
being done to save a life. lar clamping (Fig. 21.13). The goal in this setting
is speed and simplicity. Anatomic resections, such
as lobectomy, can be challenging even in elective
21.4.5 Initial Steps in the settings. In unstable trauma patients, they are even
Blood-Filled Chest more so. A thorough understanding of lobar anat-
omy and variations in segmental and subsegmen-
If upon opening the chest a significant amount of tal variability is necessary for safe resection.
blood is encountered, the first step is to ensure Pneumonectomy for trauma can be successfully
adequate exposure by maximizing length of inci- performed, but the need for it must be recognized
sion and self-retained retraction. Rather than go as early as possible, and close coordination with
directly to full packing of the thoracic cavity like anesthesia is required (Fig. 21.14).
in a trauma laparotomy, scoop or sweep the blood
out of the chest through the incision, and then use
dry lap pads and suction to try to rapidly clean up 21.4.7 Cardiac Injuries
the remaining blood and fluid. If the inflated lung
is continually in the way, a technique to deflate Small cardiac injuries can be oversewn with 3-0
the lung without using a double-lumen tube or to 5-0 monofilament suture. The heart can be par-
bronchial blocker is to have the anesthesia team tially stabilized by the surgeon’s nondominant
a b
Fig. 21.10 Stapled tractotomy technique for control of ing the tract and exposing the underlying injured lung tissue
bleeding from through-and-through pulmonary wounds. A for direct suture control (b) (Reprinted with permission
linear stapler is passed through the defect and fired (a) open- from Asensio J et al., J Am Coll Surg 1997;185:486–487)
Fig. 21.12 “Hilar twist” technique for rapid and tempo-

Fig. 21.11 Nonanatomic stapled lung resection for con- rary control of pulmonary hilar hemorrhage (Reprinted
trol of pulmonary injury (Photo courtesy of Dr. Adam with permission from Chapter 14: Lung Injuries in Combat,
Hamawy and Dr. Dennis Chambers) from Front Line Surgery: A Practical Approach Edited
Martin M and Beekley A. Springer; New York, 2011)
hand or an assistant. The use of pledgets is gener- 21.4.8 Esophageal Injury

ally recommended, and surgeons should be care-
ful that suture placement does not encircle or The proximal two-thirds of the esophagus are
injure coronary vessels (Fig. 21.15). The presence best accessed through the right chest and the dis-
of penetrating injury to the heart necessitates a tal esophagus through the left chest. If possible,
complete inspection of all surfaces of the heart. the devitalized tissue should be debrided and a
Through-and-through injuries are rarely surviv- primary repair in layers performed. More destruc-
able but, if present in a living patient, require clo- tive lesions may require esophagectomy and
sure of external holes with subsequent evaluation immediate or delayed reconstruction, depending
for septal or valvular injury. on patient status.
21.4.9 Great Vessel Injury

a
Due to the high lethality of these injuries, there are
few individual surgeons who have extensive expe-
rience with their treatment. Standard vascular prin-
ciples of adequate exposure, proximal and distal
control, debridement of devitalized vessel ends,
b
and tension-free reconstruction with interposition
generally apply. Subclavian vessels can frequently
Fig. 21.13 Control of pulmonary hilm, initially with the

surgeon’s hand (a) and then with a vascular clamp (b). Note
lateral retraction of the lung with opposite or assistant’s hand
(Reprinted with permission from Chapter 14: Lung Injuries
in Combat, from Front Line Surgery: A Practical Approach Fig. 21.14 Close-up of hilum remnant after control and
Edited Martin M and Beekley A. Springer; New York, 2011) division with TA 60 mm stapler for rapid pneumonectomy
Fig. 21.15 Suture repair of

cardiac wound utilizing
pledgets (Reprinted with
permission from Chapter
15: Diagnosis and
Management of Penetrating
Cardiac Injury, from Front
Line Surgery: A Practical
Approach Edited Martin M
and Beekley A. Springer;
New York, 2011)
be ligated, which will be well tolerated and can be 21.5 Complications and
bypassed or reconstructed when the patient is more Future Directions
stable. Vascular shunts can also be placed as a tem-
porizing damage control measure. Major venous The emergency thoracotomy, like any other pro-
structures such as the superior vena cava and supra- cedure, is not without complications. Injury to
hepatic inferior vena cava should have lateral repair other thoracic structures including lacerations
(not ligation) if possible. Although anterolateral of the heart, coronary arteries, aorta, phrenic
thoracotomy may be the utility incision for patients nerves, esophagus, and lungs can occur [7].
in extremis, surgeons should learn alternate inci- Ischemia to other organs distal to the aortic
sions or extensions which may provide optimal cross clamping, including the spinal cord and
exposure to various injuries (Table 21.1). brain, can occur as well [8, 9]. Of the patients
who survive EDT, a reported 15% are noted to
have severe neurological impairment. The most
Table 21.1 Six evidence-based recommendations for common postoperative complications include
EDT from the Eastern Association for the Surgery of atelectasis, pneumonia, recurrent bleeding, dif-
Trauma (J Trauma. 79(1):159–73, 2015)
fuse intravascular coagulation, empyema, infec-
Question Recommendation tions, and sternal dehiscence [10].
PICO #1 In patients who present pulseless to the
emergency department with signs of life
The risk to the healthcare team must also be
after penetrating thoracic injury, we taken into consideration. Trauma patients tend to
strongly recommend resuscitative have a higher rate of infectious diseases, placing
emergency department thoracotomy. trauma providers at high risk, especially in an
Strong recommendation
emergency setting. For example, one study found
emergency department without signs of a 7% incidence of either HIV or hepatitis B in an
life after penetrating thoracic injury, we urban trauma population [11, 12], while another
conditionally recommend resuscitative study found that 26% of acutely injured patients
emergency department thoracotomy. had evidence of exposure to HIV (4%), hepatitis
Conditional recommendation
B (20%), or hepatitis C virus (14%) [13], empha-
emergency department with signs of life sizing the importance of personal protection.
after penetrating extra-thoracic injury, While the emergency thoracotomy has had its
we conditionally recommend place in the surgical world for over a hundred
resuscitative emergency department
years, it continues to elicit controversy. However,
thoracotomy. Conditional
recommendation no other alternative procedure has challenged the
PICO #4 In patients who present pulseless to the EDT until recently. The resuscitative endovascu-
emergency department without signs of lar balloon occlusion of the aorta (REBOA) is a
life after penetrating extra-thoracic temporary endovascular catheter inserted via the
injury, we conditionally recommend
resuscitative emergency department common femoral artery into the aorta to provide
thoracotomy. Conditional aortic occlusion. Like aortic cross clamping dur-
recommendation ing a thoracotomy, the goal of the balloon is to
PICO #5 In patients who present pulseless to the stop the hemorrhage and perfuse the heart and
emergency department with signs of life
brain until definitive hemostasis can be obtained.
after blunt injury, we conditionally
recommend resuscitative emergency REBOA is seen as the preferred procedure by
department thoracotomy. Conditional some surgeons since it is much less invasive
recommendation and has been associated with fewer complica-
PICO #6 In patients who present pulseless to the tions [14, 15]. However, there is no published
emergency department without signs of
life after blunt injury, we conditionally consensus on the indications for REBOA use.
recommend against resuscitative It currently has mainly been utilized in blunt
emergency department thoracotomy. and penetrating abdominal or pelvic injuries
Conditional recommendation [16]. Despite the promising role of the REBOA,
its clinical benefit still remains unclear with Suggested Readings

some studies showing no clear reduction in
hemorrhage-related mortality, and it is not with- Front Line Surgery: A Practical Approach, Editors: Martin
M. and Beekley, A.
out complications [17]. However, Rhee et al. Top Knife: Art and Craft of Trauma Surgery by Hirschberg
found in an autopsy study that REBOA use and Mattox.
would have been potentially beneficial in 50.0% ASSET: Advanced Surgical Skills for Exposure in
of blunt thoracic and 33.3% of penetrating tho- Trauma by American College of Surgeons Committee
on Trauma.
racic trauma patients [18]. While new, innova- Advanced Trauma Operative Management (ATOM):
tive procedures such as REBOA continue to find Surgical Strategies for Penetrating Trauma, Editors:
their place in the trauma setting, the emergency Jacobs, L. and Luk, S.
thoracotomy continues to remain the “go to”
for surgeons.
References
Take-Home Points
1. Brohi K. trauma.org. 2006. Retrieved from http://
• Indications for an emergency thoracotomy www.trauma.org/index.php/main/article/361/.
2. Brohi K. trauma.org. 2001. Retrieved from http://www.
include patients who present pulseless and
trauma.org/archive/thoracic/EDTrationale.html.
have suffered penetrating trauma with or with- 3. Eastern Association for the Surgery of Trauma. An
out signs of life or have suffered blunt trauma evidence-based approach to patient selection for emer-
with signs of life within 5 min of arrival. gency department thoracotomy: a practice management
guideline from the Eastern Association for the
• Start with an anterolateral thoracotomy in an
Surgery of Trauma. J Trauma Acute Care Surg. 2015;
unstable or arrested patient. 79(1):159–73.
• Median sternotomy may be a better initial 4. Hammada S, et al. Integrating eFAST in the initial
choice if the patient has isolated clinical signs management of stable trauma patients: the end of plain
film radiography. Ann Intensive Care. 2016;6:62.
of cardiac tamponade from an anterior low-
5. Brohi K. trauma.org. 2001. Retrieved from http://www.
velocity wound. trauma.org/archive/thoracic/EDTindications.html.
• If the hemorrhage source is not obviously in 6. Feliciano D. Thoracotomy in the emergency depart-
the left pleural space, a pericardiotomy along ment. (A. C. Trauma, Producer). 2004. Retrieved from
https://www.facs.org/~/media/files/quality%20pro-
with exploration of other body cavities for
grams/trauma/publications/thoracotomy.ashx.
identifying hemorrhage should be done. 7. Cothren C, Moore E. Emergency department thoracot-
• Indications for cross clamp of the aorta include omy for the critically injured patient: objectives, indi-
hemodynamic instability with unidentified hem- cations, and outcomes. World J Emerg Surg. 2006;1:4.
8. Connery C, et al. Paraparesis following emergency
orrhage, hemodynamic instability after repair of
room thoracotomy: case report. J Trauma. 1990;
intrathoracic injury, or hemodynamic instability 30:362.
with known hemorrhage below the diaphragm. 9. Brohi K. trauma.org. 2001. Retrieved from http://
• The aortic cross clamp should be removed as www.trauma.org/archive/thoracic/EDToperative.
html.
soon as possible after hemorrhage control is
10. Dizon V, et al. Trauma reports. 2003. Retrieved

established; survival after 30 min of cross from https://www.ahcmedia.com/articles/25786-ed-
clamp time is rare. thoracotomy-revisited-a-complete-reassessment-of-
• If the chest is filled with blood, first maximize its-past-present-and-future.
11. Baker J, et al. Unsuspected human immunodeficiency
exposure and then evacuate the blood. Hold
virus in critically ill emergency patients. JAMA.
respirations briefly to pack, and ultimately 1987;257:2609.
retract the deflated lung. 12. Sloan EP, et al. Human immunodeficiency virus and
• The resuscitative endovascular balloon occlu- hepatitis B virus seroprevalence in an urban trauma
population. J Trauma. 1995;38:736.
sion of the aorta (REBOA) may be an alter-
13. Caplan E, et al. Seroprevalence of human immunode-
native to emergency thoracotomy done for ficiency virus, hepatitis B virus, hepatitis C virus, and
hemorrhage control and should be considered rapid plasma reagin in a trauma population. J Trauma.
in certain cases. 1995;39:533.
14. Moore L, et al. Resuscitative endovascular balloon gap analysis of trauma patients in England and Wales.
occlusion of the aorta for control of noncompressible Emerg Med J. 2015;32(12):926.
truncal hemorrhage in the abdomen and pelvis. Am J 17. Morrison J, et al. A systematic review of the use of
Surg. 2016;212:1222–30. resuscitative endovascular balloon occlusion of the
15. Brenner M. A clinical series of resuscitative endovas- aorta in the management of hemorrhagic shock. J
cular balloon occlusion of the aorta for hemorrhage Trauma Acute Care Surg. 2016;80:324–34.
control and resuscitation. J Trauma Acute Care Surg. 18. Joseph B, et al. Identifying potential utility of resus-
2013;75:506–11. citative endovascular balloon occlusion of the aorta:
16. Barnard E, et al. Resuscitative endovascular balloon an autopsy study. J Trauma Acute Care Surg. 2016;
occlusion of the aorta (REBOA): a population based 81:128–32.
Fundamentals of Becoming a Safe
and Independent Surgeon (From 22
First Assistant to Skilled Educator)
Nabeel R. Obeid and Konstantinos Spaniolas
22.1 Introduction intended to produce a single, well-trained surgeon

scientist [1]. However, it was Edward Churchill
Primum Non Nocere This Latin phrase is known of the Massachusetts General Hospital who intro-
to all in the medical profession and translates to duced the rectangular concept of a surgical resi-
“First, do no harm.” It is a guiding principle for dency program in 1938, where trainees would
physicians throughout the world and holds espe- learn from multiple expert surgical educators and
cially true in the practice of surgery. The surgeon would be given increasing levels of responsibility
must, at every level for every intervention, decide with demonstration of competence. This has
if the potential risks outweigh its proposed bene- stood the test of time and remains the basis for
fits. This thought process occurs on a daily basis surgical training today.
in clinical practice, when reviewing a surgical
consent with a patient or discussing an invasive
procedure with the family of a critically ill 22.2 General Concepts
patient.
This core principle is just one of the many ele- Surgical training in the United States is governed
ments that shape a surgeon, leading to safe and by the Accreditation Council for Graduate
independent care of the surgical patient. One Medical Education (ACGME). Their program
must obtain the proper set of skills and specialty requirements specifically outline competency-
training in order to be proficient with providing based goals and delineation of resident responsi-
such care. This education begins in medical bilities and highlight six core competencies
school with rigorous courses and clinical rota- including patient care and procedural skills [2].
tions and advances into specialty training with Despite the graded responsibility and structured
graduated responsibility in the form of residency nature of these programs, there have been con-
training. William Halsted is credited with estab- cerns regarding passive advancement of residents
lishing the first American surgical education pro- from year to year without demonstration of com-
gram at Johns Hopkins in 1889, which was an petence. Therefore, the ACGME and American
apprenticeship, pyramidal residency model Board of Surgery (ABS) jointly instituted the
General Surgery Milestone Project [3]. This pro-
N. R. Obeid • K. Spaniolas (*) gram was designed as a more effective way to
Department of Surgery, Stony Brook Medicine, evaluate residents in the core competencies and
Stony Brook, NY, USA to improve transparency for how the resident is
e-mail: Konstantinos.Spaniolas@
stonybrookmedicine.edu

290 N. R. Obeid and K. Spaniolas
evaluated, ultimately ensuring advancement dently, and almost one quarter of fellows were
based on these milestones of achievement. unable to recognize early signs of complications.
The ACGME, in collaboration with the ABS Additionally, lack of confidence by surgical resi-
and Association of Program Directors in Surgery dents has been shown to be a significant factor in
(APDS), has also released updated case mini- choosing to pursue a fellowship in the first place
mum requirements for each category, effective [7]. Another study evaluated the relationship
for the 2017–2018 academic year, which parallel between surgeon status and rate of complications
the changing patterns of surgical care [4]. These among newly trained ophthalmologists and found
include a higher case number for basic and com- that surgeons in their first year of practice were
plex laparoscopic procedures and reflect the nine times more likely to have high complication
emphasis on appropriate and relevant training for rates (defined as >2%) as compared to surgeons
today’s surgeon. In addition, there is now a in their tenth year in practice [8]. Each year of
requirement to log 25 cases, at a minimum, in the independent practice found a 10% drop in patient
role of teaching assistant as a chief resident. This risk of adverse event. Although these findings
is intended to help residents develop the skills seem intuitive, they are alarming nonetheless,
necessary to safely and effectively teach junior and the patient safety issues are evident.
residents, a skill that will be invaluable in their While concerning in many regards, this defi-
future practice. ciency appears to dissipate by the time the trainee
Another step taken to ensure competence and completes their respective fellowship (if pur-
promote safety is the intraoperative assessment sued), with one study reporting 95% of respon-
requirement of the ABS. The board now requires a dents being highly satisfied with operative
minimum of six operative and six clinical perfor- experience and feeling competent in completing
mance assessments to be eligible for certification 85% of procedures [9]. In fact, the methods of
[5]. These assessments consist of procedure- or assessment for procedural training in surgical fel-
encounter-specific evaluations by faculty of resi- lowships have been studied and appear to be suc-
dent performance, both intraoperatively and in the cessful from both the director and trainee
outpatient setting. The strict accreditation process perspectives [10]. Overall, it appears that the fel-
of the ACGME for surgical training programs and lowship year(s) may help to bridge the gap from
the arduous certification process administered by residency to enter independent practice as a com-
the ABS help to ensure that graduating residents petent and well-prepared surgeon.
attain the essential knowledge and skills necessary The transition from training to surgical prac-
to make the safe transition to surgical practice. tice is a difficult one. The challenges are many,
Despite the efforts to ensure resident compe- including independent patient care, operating
tency and readiness for practice, a recent report room autonomy, as well as less obvious issues
suggested a shortcoming in this regard for those such as practice management skills, which have
entering general surgery subspecialty fellowship been shown to be absent from most surgical train-
training [6]. This widely referenced and highly ing program curriculums [11]. For a new sur-
publicized study reported the results of a compre- geon, hospitals will review privilege requests
hensive survey administered by the Fellowship and, once approved, may require formal proctor-
Council, which was sent to program directors in ing or a focused professional practice evaluation
minimally invasive, bariatric, colorectal, hepato- during a provisional period. This involves the
biliary, and thoracic surgery fellowships. The newly hired surgeon to be evaluated by an expe-
results were surprising to many, including the rienced physician as a quality control measure,
fact that one in five new fellows was unprepared ensuring that the surgeon possesses the appropri-
for the operating room, 30% were unable to per- ate and expected technical skills to safely care for
form a laparoscopic cholecystectomy indepen- patients.
22 Fundamentals of Becoming a Safe and Independent Surgeon (From First Assistant to Skilled Educator) 291
22.3 Practical Considerations forums and social media outlets, like the
International Hernia Collaboration or Bariatric
Formal Programs The American College of Surgery Masters Facebook group, can facilitate
Surgeons (ACS) initiated a 1-year transition to interactions between a young surgeon and other
practice program in 2013, the goals of which are expert surgeons while overcoming geographic
to help surgeons establish autonomy in decision- limitations [14, 15].
making, both in and out of the operating room,
mentorship, and familiarity with practice man- Choose Wisely One of the basic principles that
agement [12]. This program has had initial suc- should be adhered to is to create an environment
cess and is expanding nationwide in diverse for success early on by modifying the variables
practice settings, serving as an excellent platform that are under one’s control in the practice set-
to provide a smooth transition for the young, ting. Surgical outcomes, both at the individual
independent surgeon. and department level, are increasingly being
used to measure quality and value. These can be
Mentorship Whether part of a formal program used for metrics as part of institutions’ quality
or not, one of the keys to success for newly estab- improvement programs but also help to make
lished surgeons is to find an effective mentor. sure individual surgeons are meeting the
This individual should serve as an advisor for expected benchmarks. In this light, for the young
such a transition, investing time and effort to help surgeon, it is important to “start smart.” Early in
guide and support the surgeon early in his career. one’s independent clinical practice, it is wise to
For many, this takes the form of a senior partner begin with low-complexity cases to maximize
or a division chief, but most importantly, this role the potential for favorable outcomes while still
should be filled by someone who expresses a refining on technical skills and familiarizing
dedication and commitment to ensuring the suc- with a new environment. Success is more likely
cess of the young surgeon. With time and experi- when choosing to perform routine operations
ence, the surgeon may take on more complex early on, those that the surgeon can perform with
cases, and having an effective mentor is invalu- comfort and confidence, rather than high-com-
able in this setting. plexity cases (e.g., revisional bariatric, hepato-
pancreatobiliary, or low rectal cancer cases).
Seeking Out Opinions In addition to finding a With increased case volume, the learning curve
quality mentor, it is important to develop collab- becomes less steep and outcomes tend to
orative relationships with other surgeons. This improve. This is well demonstrated for many
can be quite helpful when faced with a diagnostic surgical procedures, from hernia repair to com-
dilemma and unique patient presentation or, per- plex gastrointestinal or subspecialty surgery
haps most notably, for intraoperative consulta- [16–19]. Once experience is established, vigi-
tions [13]. In such times, seeking the opinion of lance and careful planning are paramount to ven-
others is vital to one’s success. Many times, these ture into more complex clinical cases, in order to
relationships are with former mentors or other avoid the pitfall of overconfidence. As care com-
faculty at teaching institutions. Participating in plexity increases, seeking out opinions, intraop-
mortality and morbidity conferences and other erative assistance, and detailed preoperative
hospital-wide venues will allow a new surgeon to planning can increase the chances of operative
promptly familiarize with a new practice envi- and long-term success. In re-operative surgery,
ronment and importantly identify surgeon- this includes getting all the required information
experts in different fields. In addition, (e.g., imaging, liberal use of endoscopy, previ-
unconventional but increasingly popular ous operative reports) prior to walking into the
approaches such as the ACS Communities online operating room.
Prepare for Success Patient complexity is also a Table 22.1 Common complications among varying sur-
significant factor, and the newly independent surgical subspecialties with associated risk factors
geon should likely avoid the medically complex Morbidity (procedure) Risk factor(s)
patient with multiple major comorbidities or risk General surgery
factors for complications (e.g., end-organ failure, Incisional hernia Laparotomy, COPD,
(abdominal procedure) increased BMIa
extremes of age) during the early stage of prac-
Surgical-site infection OR time ≥ 4 h, lack of
tice. One study comparing outcomes among sur- (ventral hernia repair) vacuum dressingb
geons in various stages of their careers found that Mortality (open ventral Functional status, liver
for cardiovascular procedures, early-stage sur- hernia repair) disease, malnutrition,
geons had higher morbidity and mortality rates age > 65 years,
ASA ≥ 4,
than later-stage surgeons, but the reverse was true contaminationc
for digestive procedures, possibly due to an Colorectal surgery
appropriate selection of less complex patients by Surgical-site infection Contaminated or dirty
the early-stage surgeons [20]. A list of common (elective colectomy) case, female gender,
surgical complications with associated risk fac- open surgeryd
tors is shown in Table 22.1, which may serve as a Anastomotic leak Male gender,
(laparoscopic low anterior BMI ≥ 25 kg/m2,
guide in selecting appropriate and low-risk surgi- resection) ASA > 2, tumor size
cal patients [21–32]. Risk factor optimization and >5 cm, preoperative
patient preparedness for surgery will also allow chemotherapy, longer
for better postoperative outcomes. OR time, number of
staple firings ≥3,
intraoperative blood
Look Around You The independent surgeon loss/transfusions,
should also be mindful of the environment in anastomosis within
5 cm of anal vergee
which they practice. Despite being well-trained
Incisional hernia Wound packing,
or experienced with high-risk procedures, one’s (sigmoidectomy) infection, previous
hospital infrastructure may not have the capacity herniaf
or resources for these procedures to be done in a Vascular
safe manner without jeopardizing patient out- Acute kidney injury Active smoker, HTN,
comes. If such operations or high-risk patients (elective abdominal aortic CKD, open repair,
aneurysm) arrhythmiasg
are to be taken on, a planned, measured approach
Groin wound infection Previous groin
should be used with careful review of the steps (lower extremity dissection, female
and details; assembly of a specialized, experi- revascularization) gender, increased BMI,
enced team; and even consideration for a practice ESRD, malnutrition,
urgent/emergent
run with a cadaver or animal laboratory.
procedureh
Finally, the newly trained surgeon entering Bariatric surgery
practice should adhere to safe practice patterns Venous thromboembolism Male gender, higher
and society guidelines. This will help the surgeon (bariatric) BMI, CHF, HTN,
establish a credible reputation of practicing age ≥ 60 years,
African-American race,
evidence-based medicine consistent with current
COPDi
standards of care, thereby delivering optimal care Leak (laparoscopic sleeve Male gender,
to the patient. Examples of popular society guide- gastrectomy) BMI ≥ 50 kg/m2, OR
lines include the clinical practice guidelines of time, conversion to
the American Society of Colon and Rectal open, intraoperative
complications, HTN,
Surgeons (ASCRS) or the practice management degenerative joint
guidelines of the Eastern Association for the diseasej
Table 22.1 (continued) available. For the new surgeon, proficiency-based

Morbidity (procedure) Risk factor(s) credentialing may be the way of the future, using
Surgical oncology both simulation and submission of intraoperative
Pancreatic leak Soft pancreatic texture, videos of individual performance for review.
(pancreaticoduodenectomy) intraoperative blood
transfusion ≥4 unitsk
Bile leak (hepatectomy) Bevacizumab use, Take-Home Points
major hepatectomy,
two-stage hepatectomy, • General surgery residency aims to graduate
selective clamping, R1 competent surgeons; despite this, evidence
or R2 resectionl
suggests that training may be inadequate for
COPD chronic obstructive pulmonary disease, BMI body
mass index, OR operating room, ASA American Society of
independent practice.
Anesthesiologists classification, HTN hypertension, CKD • Subspecialty fellowship training may be a
chronic kidney disease, ESRD end-stage renal disease, way to close the gap, producing surgeons who
CHF congestive heart failure are capable of practice in an environment of
a
Goodenough et al. [21]
b
Poruk et al. [22]
autonomy.
c
Basta et al. [23] • Formal transition to practice programs exists
d
Pedroso-Fernandez et al. [24] to aid new surgeons in settling into practice.
e
Qu et al. [25] • Finding an effective mentor who is committed
f
Connelly et al. [26]
g
Castagno et al. [27]
to the success of the surgeon is paramount.
h
Bennett et al. [28] • Developing a collaborative relationship with
i
Haskins et al. [29] peers, senior faculty or partners, or joining
j
Benedix et al. [30] online forums can help the surgeon in com-
k
Fathy et al. [31]
l
Guillaud et al. [32]
plex or challenging situations.
• “Start smart” by choosing low-complexity
cases in low-acuity patients to help maximize
Surgery of Trauma (EAST) [33, 34]. The surgeon early success and positive outcomes.
should also be familiar with society safety • Understanding practice environment and hos-
initiatives, like the Safe Cholecystectomy
pital capabilities/resources can guide the sur-
Program of the Society of American geon to select appropriate patients; it is critical
Gastrointestinal and Endoscopic Surgeons to prepare in advance and ensure an experi-
(SAGES) [35]. enced team is available for more complex
procedures.
• Familiarity with society guidelines will allow
22.4 Current Controversies/ the surgeon to practice the most up-to-date,
Future Directions evidence-based medicine and provide optimal
care to the surgical patient.
Training of the general surgeon continues to
evolve over time, as specific initiatives and adap-
tations occur frequently with the primary goal of
ensuring competent surgeons that are capable of Suggested Readings
providing optimal surgical care to the patient. It
is likely that future efforts will focus on ways to Mattar SG, Alseidi AA, Jones DB, Jeyarajah DR,
Swanstrom LL, Aye RW, et al. General surgery resi-
make the transition to independent practice more dency inadequately prepares trainees for fellowship:
seamless and may make these formalized transi- results of a survey of fellowship program directors.
tion programs more widespread and readily Ann Surg. 2013;258:440–9.
Cogbill TH, Shapiro SB. Transition from training to sur- in surgical subspecialty fellowships. J Surg Educ.
gical practice. Surg Clin North Am. 2016;96:25–33. 2012;69:521–8.
Klingensmith ME, Cogbill TH, Luchette F, Biester T, 11. Klingensmith ME, Cogbill TH, Samonte K, Jones
Samonte K, Jones A. Factors influencing the deci- A, Malangoni MA. Practice administration training
sion of surgery residency graduates to pursue gen- needs of recent general surgery graduates. Surgery.
eral surgery practice versus fellowship. Ann Surg. 2015;158:773–6.
2015;262:449–55. 12. Cogbill TH, Shapiro SB. Transition from train-

ing to surgical practice. Surg Clin North Am.
2016;96:25–33.
13. Novick RJ, Lingard L, Cristancho SM. The call,

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Fundamentals of Acceptable
Behavior in the Operating Room 23
(Etiquette)
Annie P. Ehlers and Andrew S. Wright
23.1 Introduction It is increasingly clear that a culture of safety

and respect in the operating room leads to
Nothing is less important than which fork you use. improved patient outcomes. This same culture of
Etiquette is the science of living. It embraces
everything. It is ethics. It is honor.
respect also improves team communication,
—Emily Post enhances professionalism, and allows for a better
educational experience for all. This chapter aims
As much as the culture and practice of surgery to be an introduction to the fundamentals of
have changed and evolved over the last several behavior and communication in the OR. This is
hundred years, it remains true that the operating often called “OR etiquette,” as etiquette is defined
room (OR) can be an intimating place for medical as a code of conduct among a group or profes-
students or junior residents. In the past, surgeons sionals that should dictate how we act and work
have often had the reputation of being arrogant or with others. This is related to but distinct from
demeaning, with frequent stories akin to hazing of manners—which are behaviors (good or bad)
junior residents in the OR, or of impulsive, dis- that reflect our attitude toward others. Etiquette,
ruptive behavior aimed at team members such as therefore, creates the structure within which
nursing staff, anesthesia team, and support per- manners exist.
sonnel. In fact, this type of “old-school” behavior We begin with a discussion of the evidence
is no longer acceptable, for many reasons. The behind the increased understanding of the impor-
OR is a special place, but it is still in the end a tance of behavior and communication in the
workplace, and workplace norms of mutual OR. We describe the key team members that are
respect and polite behavior must apply. In the encountered and then move forward with a dis-
modern era, it is clear that surgeons must work in cussion focused on communication, skills of
a respectful and collaborative fashion with all leadership and followership, methods of giving
members of the patient care team. It is incumbent and receiving feedback, and a discussion of avail-
on the surgeon to create an atmosphere of mutual able programs for improving team communica-
respect, trust, and communication. tion and culture. Finally, we will end with a few
pointers for how good manners in the operating
room can enhance the OR experience for all.
A. P. Ehlers • A. S. Wright (*)

Department of Surgery, University of Wisconsin,
Madison, WI, USA
e-mail: awright2@uw.edu

298 A. P. Ehlers and A. S. Wright
23.2 T
he Importance of Team patient safety and well-being are at the heart of all
Culture in the OR our efforts. It is especially important that all mem-
Environment bers of the team have a “shared mental model”—a
common understanding of the issues, both medical
Analysis of medical errors has shown that more and logistical, which might affect the course of an
than two-thirds involve issues of team communi- operation. This allows for improved efficiency,
cation [1], and these are contributed to by issues better situational awareness, and better ability to
of institutional and team culture. These errors can recognize and respond to issues. Here we describe
include missed communication, inaccurate com- the individuals commonly encountered in the
munication, or inability or unwillingness of team operating room.
members to speak up—all of which can be related
to the culture of a team or institution and which
are dramatically affected based on the tone and 23.3.1 The Surgeons
climate set by surgeon leaders, both in and out of
the operating room. Every surgical team will consist of an attending
Every team and institution have a “safety surgeon, usually accompanied by one or more
culture”—the attitudes, behaviors, and expecta- assistants. In the private practice setting or for
tions that affect patient outcomes for good or for particularly complex cases involving multiple
ill. There is increasing evidence that this safety organ systems, this assistant may be a second
culture directly affects both morbidity and mor- attending surgeon. Alternatively, surgeons in pri-
tality. For example, in a study of 31 hospitals in vate practice may operate with certified surgical
South Carolina, institutional safety culture was assistant (CSA) or physician assistant (PA), with
directly related to patient death [2]. For every various regulations regarding scope of practice
1-point change (on a 7-point scale) in the hospi- based on relevant state law.
tal-level scores for respect, clinical leadership, In the academic setting, the assistants may
and assertiveness, 30-day mortality after surgery include medical students, residents, or fellows.
decreased from 29% to 14%. In another example, Fellows are fully trained surgeons who have com-
measures of safety culture across 22 hospitals in pleted residency and who are doing 1–3 years of
Michigan directly predicted patient outcomes additional subspecialty training. They may be in an
after bariatric surgery [3]. In that study, when ACGME-accredited program, in which case they
nurses rated coordination of OR teams as accept- are usually not licensed to practice independently,
able, rather than excellent, serious complications or may be in a non-ACGME fellowship, in which
were 22% more likely. case they may be (but are not always) licensed and
credentialed to practice independently.
In the learning environment, it is important for
23.3 The Operating Room Team the surgeons to discuss roles and responsibilities
as well as educational goals for the case, which
The act of surgery is inherently team-based. Each may vary depending on the level of training and
operation requires the surgeon to work closely and experience of the team members. An important
effectively with their assistants, anesthesia provid- concept in surgical education is “progressive
ers, nursing staff, surgical technologists, and ancil- autonomy,” in which learners are allowed to take
lary staff members to make the OR function. Team on more and more responsibility in an operation
members frequently move in and out of the OR, based on their level of competency. A preopera-
with change of shift or for breaks, and additional tive discussion between the surgeon and the resi-
team members may be required for specialty or dent is critical to clear understanding of which
emergency care. The key is to remember that the parts of the operation the learner can be expected
patient is at the center of the team, thus the phrase to perform and when the attending might need to
“patient-centered care.” Always keep in mind that take control of the case.
23 Fundamentals of Acceptable Behavior in the Operating Room (Etiquette) 299
It is the responsibility of every member of the 23.3.3 The Circulator

surgeon’s team to review the patient’s case in
detail to understand their past medical and surgi- The circulator is typically a nurse by training
cal history, their current disease and how it has who is responsible for maintaining the flow of the
been managed to date, relevant medications, and OR, while the surgeons are sterilely gowned and
review of all diagnostic studies to anticipate diffi- gloved. It is important (especially for new resi-
culties that may be encountered during the opera- dents) to introduce yourself to the circulator to
tion. Secondarily, it is incumbent on each member open the flow of communication for the day and
to discuss the case with other members of the to give them a baseline understanding of your
team to ensure that all individuals have a shared skill level so that they can assist you as necessary.
mental model of the operative plan, the postopera- For example, the circulator may pay extra close
tive plan, and any anticipated difficulties. attention to the medical student as they don their
During the operation, the patient is the focus sterile gown and glove to ensure that they do not
of the team. Each individual is expected to do break the sterile field. Throughout the case, the
their part to advance the operation while helping circulator works to maintain the flow of the
other team members to do the same. Following OR. As such, the circulator is not always avail-
the operation, it is important to discuss postoper- able to assist in tasks not related to the direct care
ative care such as pain management, dietary of the patient.
restrictions, venous thromboembolism prophy-
laxis, and the need for new or existing prescrip- 23.3.3.1 The Anesthesia Team
tion medications. Without the anesthesia team, the surgeon cannot
operate. The anesthesia team consists of either an
attending anesthesiologist who is present for the
23.3.2 The Surgical Technologist or duration of the case or an anesthesia resident or
Scrub Nurse certified registered nurse anesthetist (CRNA)
who is supervised by an attending anesthesiolo-
Working closely with every surgical team is the gist who may be overseeing several operations at
surgical technologist or scrub nurse, often once. In some states, depending on state law, a
referred to as the “scrub.” This individual will CRNA can also practice independently. The
have various levels of training depending on their anesthesia provider is often helped by an anesthe-
background—he or she may be a certified surgi- sia technician, much like the surgeon is helped by
cal technician or a nurse with extra training. The a surgical technician.
scrub is an integral part of the team as they are The anesthesia team is responsible for provid-
responsible for ensuring that all necessary equip- ing pain control and sedation, managing the air-
ment is open or readily available prior to the case way, medical and fluid management throughout
starting, anticipating the needs of the surgeon to the case, and monitoring the patient for any phys-
maximize efficiency, and troubleshooting when iologic derangements that may or may not be
there are equipment problems or failures. related to the operation at hand. They should
Depending on the scope of practice as defined by meet the patient ahead of time to evaluate for any
state law and regulations, the scrub may or may risk factors such as underlying cardiovascular or
not be authorized to assist with limited surgical pulmonary disease.
tasks. It is the responsibility of the surgeon (or Communication with the anesthesia team is
surgical resident in their place) to meet with the critical for maintaining the safety and well-being
scrub ahead of time, confirm that all necessary of the patient. One of the most important tools to
equipment is available, and confirm this during promote this communication is the surgical pause
the surgical pause or “time-out.” Doing so will or “time-out,” which will be discussed in greater
foster a collegial environment while also helping detail later on in the chapter. Throughout the
the case run more smoothly. case, the surgical team must also alert the
anesthesia team if they anticipate significant should never be in the OR prior to or during anes-
hemodynamic changes for the patient. This can thesia induction or during positioning or prepping
range from events as common as insufflation of and draping in the operating room. They should not
pneumoperitoneum during a laparoscopic opera- directly interface with the patient or provide clini-
tion to more uncommon events such as unex- cal care, except as necessary for device interroga-
pected, significant hemorrhage. Conversely, it is tion or programming when needed.
imperative that the anesthesia team communi-
cates with the surgeon about any significant
changes in hemodynamic status or about other 23.4 Communication
issues that may impact patient care.
Finally, it is important to debrief with anesthe- One of the most important determinants of a suc-
sia at the end of the case, to ensure that all mem- cessful operation is ongoing effective communi-
bers of the team have the same situational cation between all members of the surgical team.
awareness and understanding of the patient’s The goal is for each member of the team to have a
intraoperative course and postoperative plan. common understanding about the patient, the pro-
This includes issues such as fluid and electrolyte posed operation, and the expected flow of the
management, expected or potential postoperative case—the “shared mental model.” One of the most
issues, and a plan for pain management. common communication tools used in this setting
is the surgical pause or “time-out.” While many
institutions use a time-out, many of these are
23.3.4 Additional Support Personnel unstructured and therefore miss an opportunity to
ingrain a culture of communication.
Depending on the case, there may be many other In order to combat this, we strongly recom-
support personnel in the operating room. This mend using a structured and formalized checklist
often includes perfusionists, pharmacists and as part of the surgical pause. The prototype for
pharmacy technicians, and IT support. Other spe- this type of structured process is the World Health
cialty physicians such as pathologists, gastroen- Organization Surgical Safety Checklist. The
terologists, or pulmonologists may come into the Surgical Safety Checklist, introduced in 2008, is
OR to analyze samples, assist or perform joint a 19-point checklist to be used at 3 time points—
procedures, or discuss unusual situations. The immediately when the patient enters the operat-
housekeeping personnel are often neglected and ing room (prior to induction of anesthesia), just
ignored but are critical for OR operations and before the skin incision and just before the patient
efficiency. As discussed in the “manners” section leaves the operating room [4, 5]. The checklist
below, a kind word and helping hand to house- was tested in eight cities throughout the world to
keeping can go a long way. test its impact on patient morbidity and mortality.
A special mention should be made of industry In a before-after study design, the investigators
representatives, who may often be present in the found that implementation of the checklist was
operating room during a case. A complete analysis associated with a significant reduction in mortal-
of the relationship between surgeons and industry ity rate (1.5% vs. 0.8%, p < 0.01) and inpatient
is beyond the scope of this chapter. In brief, the role complications (11.0% vs. 7.0%, p < 0.01) [4].
of an industry representative is to be an unobtrusive While the checklist has largely been heralded as
resource for the safe and effective implementation a success, some critics have asserted that it is not
of technology. They should respond to questions the checklist itself that reduces complications but
when asked and can give advice about the specific rather the fact that the checklist provides an
techniques for devices or implants. They should opportunity for the team to come together and
not provide clinical advice or guidance. Their pres- discuss critical elements that are not to be missed
ence should also be limited to only those portions [6]. It is our opinion that it does not matter how
of the case where their services are needed and the checklist works, only that it does.
Several additional studies have shown other who will accompany the patient to the postanes-
benefits to introduction of a formalized check- thesia or intensive care unit.
list, including reduced mortality, morbidity, and
hospital length of stay as demonstrated in a
recent randomized controlled study that showed 23.5 Leadership and Followership
reduction in complications from 19.9% to
11.5% with introduction of the checklist [7]. Although the OR may seem like a highly regi-
Despite this, some other studies of surgical mented environment, each member of the surgi-
checklists have shown no improvement in out- cal team will serve as both a “leader” and a
comes [8, 9]. This seems to be due to implemen- “follower” at different points during the opera-
tation issues, with wide variations in tion. This includes everyone from the most senior
implementation between institutions and even attending surgeon to the most junior medical
between different specialties within an institu- student.
tion, with suboptimal implementation being Within the OR, the surgical attending has ulti-
common [10, 11]. Institutions who adopt a mate responsibility for the patient. However, sur-
checklist in name only, but whose team mem- gical residents will often act as leaders to junior
bers ignore or minimize the process, are unlikely residents and medical students. In the setting of
to reap the benefits. On the other hand, institu- “progressive autonomy” for surgical trainees, the
tions that develop a strong culture of safety with attending surgeon may also formally or infor-
robust and mandatory implementation will see mally cede control of the case to the resident or
better results [12]. This speaks to the impor- fellow and may take a follower role him or her-
tance of the etiquette of the OR—the code of self. In fact, more often than not, the surgical
conduct that regulates our actions. attending will assist a senior resident through a
In order to derive the most benefit from the case, rather than perform the operation with the
surgical safety checklist, all team members must resident’s assistance.
be present and actively engaged in the process. In the OR, the team leader is responsible for
Music should be turned off, side conversations setting the tone. It is up to the leader to make sure
stopped, and all attention should be focused on that all team members have a shared understand-
the checklist items and how they relate to the ing of how the day will proceed as well as any
patient. Typically it is the role of the surgical potential problems that may arise. In many cases,
attending, fellow, or resident to lead the checklist. the surgical attending does not arrive to the OR
As the designated leader, it is important to review until the patient has arrived, been intubated, and
and discuss each individual item on the checklist. prepped and draped. In this case, it is up to the
This includes ensuring that every team member senior-most resident to lead the team. A resident
has introduced themselves and making it clear who arrives early, completes the surgical time-
that all individuals in the OR are empowered to out in a thorough but efficient manner, and moves
speak up if they become aware of a potentially the room forward is much more effective than
unsafe situation. one who arrives late or is not familiar with the
The checklist can be modified by individual patient or the case. While an extensive discussion
hospitals or services to include relevant items of successful leadership traits is outside of the
specific to their patient population. For example, realm of this chapter, in general a good leader is
if a specific surgical team has additional items one who outlines a clear vision of the work that
that must not be forgotten (e.g., processes regard- needs to be accomplished while also empowering
ing cardiopulmonary bypass in cardiac surgery), those around them to take ownership over their
this can be included. Many checklists also include individual work.
a debriefing section for use at the end of the case While leadership is a commonly discussed
including items such as specimen processing, topic, what is less commonly discussed is the
communication with the patient’s family, and importance of “followership.” While there are
several different descriptions of the various types setup, efficiency, technical maneuvers, and
of “followers” on any given team, many focus on communication.
a spectrum from passive to active and from Giving and receiving feedback are distinct
dependent, uncritical thinking to independent, skills that require both parties to be attentive and
critical thinking [13, 14]. Compared to the field open. To facilitate this process, several methods
of leadership, the study of followership is rela- have been described that turn feedback into an
tively new, but it is generally agreed that effective active process for both parties. Ideally, the men-
followers are those who are paying attention to tor and the trainee have a briefing prior to the
what is going on around them, taking an active case in order to set learning objectives and then
interest in the process, and questioning or chal- formally debrief after the case to discuss how
lenging leadership or the status quo when neces- well the learning objectives were met as well as
sary. This last point is especially critical. ways to improve this in the future. In the press of
In the OR, being a good follower is a crucial clinical concerns and the drive toward efficiency,
component to maintaining patient safety as it is the debrief session is often skipped or missed. It
incumbent upon the followers (including resi- is incumbent on the learner, therefore, to specifi-
dents, medical students, nursing staff, and all cally seek out and ask the attending surgeon for
other participants) to speak up if they notice that feedback and if necessary to schedule formal
something is going wrong or that the environ- meeting times. It is also important for feedback
ment has become unsafe. Especially for more to flow both ways, and the attending surgeon
junior members of the team, it can be intimidat- should ask for feedback from the residents as
ing to alert the attending that he or she may be well.
making a mistake or misjudging the situation. A good methodology for providing feedback
However, it is important to remember that such is to ask an open-ended question such as “How
actions, when carried out with tact and respect, did you think that operation went?” Which can be
are in the best interest of the patient and may followed with “What went well?” and “What
actually prevent serious harm from occurring. could have gone better?” This allows the person
providing feedback with a baseline to start from
and allow for self-reflection on the part of the
23.6 Giving and Receiving learner. This can be followed with specific feed-
Feedback back about one to two actionable items, prefera-
bly relating back to the goals stated during the
Feedback has gained an increasingly important initial briefing.
role in surgical education. Feedback may be sum-
mative and/or formative. Summative feedback is
often given at discrete time points such as the end 23.7 Improving Communication
of a rotation and is a culmination of observations Skills
of performance. Formative feedback involves an
ongoing assessment of skills or knowledge and While a number of high-quality tools exist to
may be given throughout an education augment the surgical education provided in a
experience. residency program, most focus on pathophysiol-
There is an often misunderstood distinction ogy of disease or surgical technique. A less com-
between teaching and feedback. As an example, monly discussed yet increasingly important
teaching is when the attending surgeon corrects component of surgical education is the
the resident’s needle angle during a bowel anas- nonoperative skills that are required for safe and
tomosis. Feedback is when the attending surgeon effective patient care. A common term for this is
and resident meet after the case and discuss per- “Nontechnical Skills for Surgeons” or
formance—either technical or nontechnical. For NOTSS. Developed in Europe by a team of sur-
example, a feedback session might discuss room geons, anesthesiologists, and psychologists, the
NOTSS curriculum aims to identify important 23.8 Manners in the Operating

nontechnical skills needed by surgeons for suc- Room
cessful practice. Each element or skill is catego-
rized as being related to situation awareness, If OR etiquette represents a code of conduct—
decision-making, leadership, or communication respect, communication, shared mental model,
and teamwork [15]. and teamwork—then manners represent the
There are four core categories within the behaviors that embody this code of behavior.
NOTSS curriculum. The first is situational aware- These seem like simple rules that should have
ness, which focuses on gathering information and been learned at an early age, but a few pointers
assimilating it for use in the current and future will go a long way toward integrating junior resi-
time. An example of this would be the surgeon dents and students into the OR team.
who learns that their patient has chronic pain
understands that this may lead to difficulty con- 1. Be polite.
trolling postoperative pain and subsequently 2. Be respectful.
works with the anesthesia team prior to the case to 3. Be humble.
formulate a plan. The second category is decision- 4. Learn everyone’s name.
making. This skill can build on “situation aware- 5. Offer help without being asked.
ness” as it requires the surgeon to take in all of the 6. Ask for help when needed.
available information to formulate their options 7. Thank your colleagues.
and then select the best option for the patient. 8. Keep the patient at the center of all you do.
Intrinsic in this is that the surgeon also communi-
cates the selected option, formulates a plan, and Rude, disruptive, or disrespectful behavior is
then later analyzes their choice. The third cate- not tolerated. Do not yell or make sarcastic com-
gory is leadership, which has been previously dis- ments. Do not make jokes with sexual or racial
cussed in this chapter. The fourth is communication themes. Do not gossip or denigrate others. Many
and teamwork. Surgeons who excel at this skill surgeons enjoy listening to music in the operating
actively engage their team to develop a shared room, but in choosing a playlist, be aware that
mental model that can then be used to mount a some music may have offensive lyrics that should
more coordinated effort [15]. Surgical safety not be played in the workplace. It is most polite
checklists are one way to improve communication to ask before playing music and to check in with
and teamwork, as discussed above. While NOTSS music preferences, as not everyone in the OR
is a relatively new concept, there is evidence to may appreciate loud death metal. Music should
suggest that these nontechnical skills can improve be turned off during critical times such as the ini-
surgeon performance overall [16]. tial time-out.
Another great resource for training and devel- Surgeons use social media like many others,
opment in leadership, followership, and team but the OR is not the place to check Facebook or
communication skills is the TEAM STEPPS pro- Instagram. When posting to social media, be pro-
gram developed by the Agency for Healthcare fessional—anything posted to the Internet can be
Quality and Research [17]. This includes basic screen captured and spread, no matter what pri-
skills such as establishing roles, communication vacy settings you may have turned on. A recent
techniques including cross-checks, checkbacks, study of publicly accessible Facebook posts
and callouts, as well as more advanced skills such showed 14.1% of surgery residents had posted
as team huddles, briefing and debriefing, and potentially unprofessional content, and 12.2%
strategies for managing conflicts or disagree- had clearly unprofessional content, with viola-
ments. Many institutions have adopted TEAM tions of patient privacy being one of the most
STEPPS training, and the course is available common problems, along with description of
online for individuals through the AHRQ binge drinking and racially or sexually offensive
website. material [18]. Specific to the OR, be aware that
social media postings with potentially identified References

patient information are absolutely forbidden.
This does not need to include a name of a patient 1. Institute of Medicine (IOM). To err is human: building
a safer health system. Washington, DC: The National
to be identifiable information—a few details of a Academies Press; 2000.
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ing can be enough to cause trouble. Z, Neville BA, et al. Perception of safety of surgi-
cal practice among operating room personnel from
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Conclusion
operative death rate in South Carolina. Ann Surg.
In this chapter, we have reviewed the funda- 2017;266(4):658–66.
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OR. While nothing can substitute the value of A, English WJ, Carlin A, et al. Safety culture and
complications after bariatric surgery. Ann Surg.
spending time in the OR learning these skills 2013;257(2):260–5.
firsthand, understanding these basic tenets is 4. Haynes AB, Weiser TG, Berry WR, Lipsitz SR,
an important first step for medical students and Breizat AH, Dellinger EP, et al. A surgical safety
residents beginning their surgical training. checklist to reduce morbidity and mortality in a global
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5. WHO surgical safety checklist and implementa-
Take-Home Points tion manual. Available from, http://www.who.int/
patientsafety/safesurgery/ss_checklist/en/.
• Effective communication improves patient 6. Pugel AE, Simianu VV, Flum DR, Patchen Dellinger
E. Use of the surgical safety checklist to improve
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• Identifying and understanding the roles of Public Health. 2015;8(3):219–25.
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tant starting point for new medical students Vonen B, Eide GE, et al. Effect of the World Health
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improve the safety culture by promoting a 8. Erestam S, Haglind E, Bock D, Andersson AE,
shared mental model. Angenete E. Changes in safety climate and team-
work in the operating room after implementation of
• All members of the surgical team should strive a revised WHO checklist: a prospective interventional
to act as effective leaders and followers while study. Patient Saf Surg. 2017;11:4.
participating in the operation. 9. Zingiryan A, Paruch JL, Osler TM, Hyman
• Teaching and feedback are two distinct enti- NH. Implementation of the surgical safety checklist
at a tertiary academic center: Impact on safety culture
ties that are important aspects in the develop- and patient outcomes. Am J Surg. 2016;214(2):193–7.
ment of a surgeon. 10. Biffl WL, Gallagher AW, Pieracci FM, Berumen

• Keep the patient at the center of all you do in C. Suboptimal compliance with surgical safety check-
the OR. lists in Colorado: a prospective observational study
reveals differences between surgical specialties.
Patient Saf Surg. 2015;9(1):5.
11. Russ S, Rout S, Caris J, Mansell J, Davies R, Mayer
E, et al. Measuring variation in use of the WHO sur-
Recommended Readings gical safety checklist in the operating room: a mul-
ticenter prospective cross-sectional study. J Am Coll
Gawande A. The checklist manifesto: how to get things Surg. 2015;220(1):1–11.e4.
right. New York: Metropolitan Books; 2010. 12. Gitelis ME, Kaczynski A, Shear T, Deshur M, Beig
Institute of Medicine (IOM). To err is human: building M, Sefa M, et al. Increasing compliance with the
a safer health system. Washington, DC: The National World Health Organization surgical safety checklist-
Academies Press; 2000. a regional health system’s experience. Am J Surg.
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“TeamSTEPPS.” Available at https://www.ahrq.gov/ ten part of doctors’ leadership. BMJ Careers.
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17. Team STEPPS. Available from, https://www.ahrq.

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skills. Surg Clin North Am. 2012;92(1):37–50. PJ. An assessment of unprofessional behavior among
16. Hull L, Arora S, Aggarwal R, Darzi A, Vincent C, surgical residents on Facebook: a warning of the dan-
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Fundamentals of the Daily Routine
as a Surgeon: Philosophy, Mentors, 24
Coaches, and Success
Charles J. Yeo
24.1 Introduction (you’ll never forget it) and training never stops.”
Certainly this is an important issue, focusing on
We are all stimulated, prompted, and pushed by oth- the importance of lifelong learning, and the
ers to achieve what we can in life. Many of us will change that accompanies surgical careers. At #9,
reflect back to the lessons from our parents, our sib- we have “job security,” which refers to the fact
lings, and our many teachers along life’s course, all that general surgeons are necessary and much
of whom have given us some measure of direction needed commodity and that on the national level,
and focus toward our careers. This chapter is there are many open positions for general sur-
designed to be a bit philosophical and a personal geons, often not in urban centers but in more
testimony to some of the things that I believe are rural areas. At #8 we have “the pay is not bad,”
important in creating a successful s urgical career. making reference to the fact that the compensa-
First, I would like to commence with a top ten tion of general surgeons is comfortable and well-
list, somewhat in the tradition of the David above societal averages. At #7 we have the entry
Letterman show “Daily Top Ten List.” This list “your mother will be proud of you.” I would add
however was composed by Dr. Richard that fathers, aunts, and many other family mem-
C. Thirlby, given as his presidential address to the bers are often proud and pleased with having a
Western Surgical Association in 2006, and pub- surgeon in the family. At #6, “surgeons have
lished in the Archives of Surgery in 2007 panache: the surgical personality and the culture
(Fig. 24.1). I have used this top ten list for many of surgery.” Very true—some of the TV and
years when talking about surgical careers to our movie stereotypes of surgeons are true. There is
medical students at the Thomas Jefferson doubtless a certain culture, ambiance, and feel of
University. Dr. Thirlby starts with #10 and counts a surgical group. At #5 we have “you will have
down to his #1 reason for going into general sur- heroes; you will be a hero.” I doubt there is any
gery. At #10, he commences with “training is fun surgeon who has trained and who does not have a
litany of stories about those that have influenced
them, driven them, motivated them, and done
amazing things with surgical patients.
C. J. Yeo Additionally, the assistance we render to patients
Professor and Chairman, Department of Surgery, often leads them to be thankful, grateful, and
Senior Vice President and Chair, Enterprise Surgery,
consider you a hero. At #4, “there is spirituality if
Jefferson Health, Jefferson University Hospital,
Philadelphia, PA, USA you want it.” There can be no doubt about this. At
e-mail: charles.yeo@jefferson.edu times, patients will miraculously recover from

308 C. J. Yeo
Fig. 24.1 The top ten list of Dr. Richard TOP TEN LIST
Thirlby. Arch Surg 2007; 142: 423–429 1. I love to cut
2. Patients will change your life
3. You will change patients’ lives
4. There’s spirituality if you want it
5. You will have “heroes”; you will be a hero
6. Surgeons have panache: the surgical personality and
the culture of surgery
7. Your mother will be proud of you
8. The pay is not bad
9. Job security
10. Training is fun (you’ll never forget it) and training never
stops
Fig. 24.2 The Ten Commandments from The Ten Commandments (Exodus 20:2-17 NKJV)
the New King James Version of the Holy 1. I am the Lord your God. You shall have no other gods
Bible before Me.
2. You shall not make for yourself a carved image or bow down
to it. For I am the Lord your God.
3. You shall not take the name of the Lord your God in vain.
4. Remember the Sabbath day, to keep it holy.
5. Honor your father and your mother.
6. You shall not murder.
7. You shall not commit adultery.
8. You shall not steal.
9. You shall not bear false witness against your neighbor.
10. You shall not covet your neighbor's house; you shall not
covet your neighbor's wife, nor anything that is your
neighbors.
major interventions or trauma, often inexplica- King James Version of the Holy Bible, these are
bly, and out of the bounds of statistical predic- referred to as the well-known Ten Commandments
tions. At #3, “you will change patients’ lives.” (Fig. 24.2). In my mind, these ten command-
Without a doubt this is one of the most personally ments, now several thousand years old, represent
satisfying end points for me. I still tingle when I important lessons regarding one’s higher power,
get a simple “thank you for saving my life 5 years the sanctity of the Sabbath day, respecting one’s
ago.” At #2, “patients will change your life,” an parents, and prohibiting actions such as murder,
important, almost daily occurrence and a truism. adultery, theft, lying, and coveting others’
We learn from our patients’ daily, exhibit non- belongings. Inarguably, these are appropriate ide-
judgmentalism and become better human beings als to live by.
due to our interactions with our many patients. Remaining on the theme of top ten lists or Ten
Lastly, at #1, “I love to cut,” reflecting the joy that Commandments, I have always had affection for a
comes from performing a procedure with perfec- list of ten items proposed by Dr. James D. Hardy,
tion, detail, and a minimum of motions, all for the MD, the longtime outstanding chair at the
good of the patient. How can you not love this top University of Mississippi in Jackson, Mississippi.
ten list! Thank you Dr. Thirlby. Perhaps I am partial to Dr. Hardy’s list because he
took the time to phone me back in 1986, as a
young faculty member at Johns Hopkins, having
24.2 Two Other Ten heard me speak at a meeting, to ask me to write a
Commandments book chapter for his famous text book Hardy’s
Textbook of Surgery, 2nd edition, published in
Not to be overly dramatic, but there is another list 1988. I worked hard on this chapter, as it was on
of ten items which I believe are equally important the topic of “The Pancreas,” quite a broad and
in the daily life of a surgeon. Taken from the New extensive topic in a clinical domain that ended up
24 Fundamentals of the Daily Routine as a Surgeon: Philosophy, Mentors, Coaches, and Success 309
Fig. 24.3 Hardy’s Ten Hardy’s Ten Commandments

Commandments 1. Honor thy Faculty and Administration
2. Always remember who you are and what you represent
3. Continue to improve work habits, efficiency and excellence
4. Educational and professional growth must be continued throughout
a career
5. Treasure and preserve your clinical integrity
6. Prepare for leadership
7. Admire and nourish professional relationships
8. On achieving immortality: Great teachers live on
9. Nurture your family: “plan for, and spend time alone with each child;
the greatest thing a parent can do for the children is to love the
spouse; take quiet time alone for creative thinking”
10. Enjoy your work: “There is nothing more sustaining through the
vicissitudes of life, than the daily pursuit of important work that you
truly enjoy”
being quite important to me in my career. Dr. 24.3 L

esson from a Coach: Part
Hardy presented his personal ten commandments One
at the University of Pennsylvania Medical School
commencement on May 24, 1992, as he was the While the training of a general surgeon is lengthy
invited speaker at what was the 50th anniversary (4 years of medical school, followed by at least
of his graduation from Penn Medical School. His 5 years of surgical residency), there are many
list was published in the Journal of the Mississippi fundamentals imbued within the training para-
State Medical Association, and it reflects a fasci- digm that become important on a day-to-day
nating combination of personal and cultural val- basis for those of us that practice the field of sur-
ues (Fig. 24.3). Dr. Hardy spoke of honoring the gery. Surgery itself requires knowledge, technical
faculty and the entire administration of the institu- skill, and stamina but, ultimately, teamwork. The
tion, remembering who you are and what you rep- surgeon does not function alone. Within the com-
resent, and constantly striving to improve work plex framework of the current healthcare delivery
habits, efficiency, and excellence. He goes on to system, the surgeon is one of many professionals
discuss the importance of educational and profes- who provides care to patients. Consider the
sional growth throughout a career and the impor- nurses, anesthesiologists, support staff, adminis-
tance of preserving one’s integrity. He speaks of trators, dietary staff, etc., all of whom must work
preparation for leadership and nourishing profes- in unison to provide safe and effective care. On a
sional relationships. He notes the importance of smaller scale, this is quite similar to the workings
teachers and how they live on in the lives of their of a team; let’s take, for example, a college bas-
learners. He then, for numbers nine and ten, takes ketball team.
a more personal tone, speaking about family and One of my heroes in life is Pete Carril, former
specifically stating in #9 “plan for, and spend time basketball coach at Princeton University, who, in
alone with each child; the greatest thing a parent his tenure there, won 514 games and 13 Ivy
can do for the children is to love the spouse; take League men’s basketball championships. For
quiet time alone for creative thinking.” Lastly 29 years Carril’s teams won because he knew how
(#10), he talks about enjoyment of one’s work and to teach basketball, perhaps better than others of
ends with “there is nothing more sustaining his era. He knew how to explain the sound funda-
through the vicissitudes of life, than the daily pur- mentals and basic strategies that make up the
suit of important work that you truly enjoy.” In my game to generations of young scholar athletes
mind, these remarkable ten items provide a very participating on the national stage. A short but
meaningful mixture of both organizational and wonderful book authored by Pete Carril and Dan
personal suggestions to achieve satisfaction in White and introduced by Bobby Knight is entitled
one’s personal and professional life. The Smart Take from the Strong (Fig. 24.4). In this
310 C. J. Yeo
Fig. 24.4 Pete Carril:

The Smart Take From
The Strong
book, Coach Carril lays bare his philosophy for #19, “anyone can be average”, and #23, “the way
basketball success. At the end of the book, he pro- you think affects what you see and do.” Yes I am a
vides a few pages entitled “25 little things to big fan of Coach Carril. Thankfully, to this day he
remember.” While these little things are quite rel- remains a common presence at Jadwin Gym, in
evant to basketball, they are also relevant to life Princeton, watching the new generation of Ivy
and surgery. For example #1, “every little thing League basketball players (both men and women)
counts. If not, why do it?” Or, #13, “you want to compete, strive to win, and mature both on and off
be good at those things that happen a lot.” Or, #17, the basketball court (the actual hardwood floor
“in trying to do a specific thing, the specific thing has been named “Carril Court” in his honor).
is what you must practice. There is little transfer Teamwork, vision, anticipation, and dedication to
of learning.” In addition to those three selected one’s personal effort are important not only in
ones, there are two others that I particularly enjoy, basketball but in surgery.
Fig. 24.5 Malcolm
Gladwell, Outliers: The
Story of Success
24.4 Malcolm Gladwell ers, b asketball players, fiction writers, ice skaters,
concert pianists, chess players, master criminals,
Keeping on those same topics of teamwork, repet- and what have you, this number comes up again
itive action, and success, Malcolm Gladwell, the and again.” That is, that 10,000 hours of practice
bestselling author of various books including The are required to achieve the level of mastery asso-
Tipping Point, Blink and others, provides a nice ciated with being a world-class expert in anything.
synopsis of these points in his book entitled Contrast this with the current 850 cases needed
Outliers: The Story of Success (Fig. 24.5). In this for a graduating surgical chief resident to docu-
book, Gladwell discusses the now well-known ment when submitting his or her credentials to the
theme supported by neurologist Daniel Levitin, American Board of Surgery. Let’s take this num-
that is, the 10,000 hours of practice dogma. ber—850 cases. Let’s make the assumption that
Gladwell writes “In study after study, of compos- the average case that a chief resident scrubs on is
312 C. J. Yeo
perhaps 2 hours in duration, noting that many 24.5 William Stewart Halsted
cases such as breast biopsies and endoscopies are
short, well less than 1 hour, and others certainly It is impossible for me to contribute a chapter
exceed 3–4 hours. However, 2 hours appears to be regarding the daily routine of a surgeon without
a reasonable guesstimate. If one multiplies mentioning arguably the most famous of all
850 hours times 2, the result is merely 1700 hours, American surgeons, Dr. William Stewart Halsted.
far short of the 10,000 hours of practice needed to A recent biography by Gerald Imber (Fig. 24.6)
achieve mastery. Also, some of that 1700 hours makes use of many past works and synthesizes
may not actually be spent in actual performance them nicely into a modern-day biography entitled
of the operation, such as suturing, dissecting, or Genius on the Edge: The Bizarre Double Life of
firing staplers, but rather may involve set up, clo- Dr. William Stewart Halsted. William Stewart
sure, or waiting for pathology results. Hence, we Halsted was born on September 23, 1852, in
have additional support for the premise of Coach New York City, educated at Andover and Yale,
Carril. Carril stresses teamwork, paying attention, and went to medical school at the College of
focus on the basics, and his #18, “whatever you Physicians and Surgeons in New York City, grad-
are doing is the most important thing that you are uating in 1878. He took his internship at Bellevue
doing while you are doing it.” In those 850 cases, Hospital and was the first “Professor of Surgery
residents need to focus on deliberate practice and in the Johns Hopkins Hospital” as stated on his
learning correct technique. grave stone. He died on September 7, 1922, at the
In Outliers, Gladwell goes on to stress the Johns Hopkins Hospital, a post-op death.
three qualities that employment or work needs to Halsted’s career highlights are numerous and
have if it is to be considered satisfying to the include his work with cocaine leading to its use
employee. Stated another way, these are the three as a topical anesthetic; his contributions to the
attributes that our profession must have in order “radical cure” of the inguinal hernia; his use of
to give satisfaction in the field of surgery: auton- Listerian principles to dramatically decrease
omy, complexity, and a connection between wound infections; his operations for gallbladder
effort and reward. In my mind, surgery offers all disease, thyroid disease, periampullary cancer,
three. There certainly is autonomy when it comes aneurysm, and breast cancer; and his embracing
to surgical decision-making, surgical skills, and the role of the surgeon as a clinician-scientist.
performance of surgical procedures. Complexity The Halsted residency program was renowned
is obvious, as even the most straightforward for its final product that of generating 17 chief
inguinal hernia repair, bowel resection, or endo- residents in a total of 33 years. Imber writes:
vascular intervention has elements that are com- “Halsted was a complex and isolated man, for-
plex and challenging. Lastly, the connection bidding and nurturing; rigid, proper, and secre-
between effort and reward can be seen at two lev- tive; compulsive and negligent; stimulating and
els: first, surgical effort in a difficult scenario reclusive; addicted and abstemious;… and always
may lead to the reward of a patient surviving a concerned with advancing the science of sur-
difficult disease. Second, a surgeon’s overall gery… if a single person can be considered the
effort (by this I mean operations performed, father of modern surgery, the only contender is
patients seen, or even work relative value units William Stewart Halsted.”
(wRVUs) achieved) is typically linked to per- Interestingly, much like the story that I dis-
sonal compensation and salary. While this may cussed earlier of Dr. Hardy returning to his medi-
not be true in surgical residency, it tends to be cal school graduation to deliver an address at the
true after completion of residency in both aca- 50th anniversary of his medical school g raduation,
demic practice and in private practice. Halsted was invited back to his undergraduate
Fig. 24.6 Gerald Imber,

Genius on the Edge: The
Bizarre Double Life of
Dr. William Stewart
Halsted
university, Yale, where on June 27, 1904, he era has dawned; and in the 30 years which have
addressed the graduates 30 years after his own col- elapsed since the graduation of the class of 1874
lege graduation and reflected upon the progress of from Yale, probably more has been accomplished
surgery. Halsted writes: “Pain, hemorrhage, infec- to place surgery on a truly scientific basis than in
tion- the three great evils which had always embit- all the centuries which had preceded this won-
tered the practice of surgery and checked its drous period.” I must say I love these two great
progress, were, in a moment, in a quarter of a cen- sentences delivered by Halsted in New Haven,
tury (1846–1873) robbed of their terrors. A new CT. Halsted then goes on to be somewhat critical
314 C. J. Yeo
of the status quo, particularly in the USA,, and proud,” and “I love to cut.” I am often asked by
lauds the medical education in “the well-supported medical students, about a topic that was never dis-
medical departments of European universities.” cussed during my training, that is, the topic of
He further goes on to discuss “the problem of the work-life balance or the topic of burnout. I con-
education of our surgeons,” stating that it is still sider these difficult questions. I cannot count the
unsolved, and not sufficient for adequate training. number of times where I was “off duty” but was
He then delivers two of the most off-quoted sen- called upon to use my medical skills, use my sur-
tences ever composed in surgery: “We need a sys- gical expertise, and intervene on behalf of a
tem, and we shall surely have it, which will patient. It has happened at restaurants (Heimlich
produce not only surgeons but surgeons of the maneuver), on airplanes (applying oxygen to dys-
highest type, men (women) who will stimulate the pneic patients struggling to breathe in the rarified
first youths of our country to study surgery and air), in a movie theater (dealing with an inebriated
devote their energies and their lives to raising the individual), during a theater performance (inter-
standards of surgical science. Reforms, the need of vening on behalf of a patient with a seizure disor-
which must come on the side both of the hospital der), and even on the little league field (performing
and the university. unhampered by traditions… CPR on a spectator). I have used my surgical
providing the requisite opportunities for the pro- skills on the sidelines of a basketball game, a
longed and thorough training of those preparing rugby match, and while traveling through Ireland
for the higher careers in medicine and surgery…” (at a hurling match). I have witnessed automobile
Following Halsted’s death in 1922, one of his accidents and bicycle-pedestrian encounters and
colleagues and admirers, Dr. Rudolph Matas, the assisted those injured. I am sure all surgeons
professor of surgery at Tulane, delivered a speech intervene many times on behalf of patients
on the occasion of the first memorial meeting for unknown to them, during their lifetimes. In my
Dr. Halsted, held in Baltimore, on December 16, mind, there is great truth in the illustration
1923. Matas wrote “Professor Halsted died with- (Fig. 24.7): “Once you put on the white coat there
out offspring, but nature, as if repentant for her are no substitutions, there are no time outs.”
unkindness, endowed him with a brain of prodi-
gious fertility from which has sprung a numerous
intellectual family of supermen… He was great in 24.7 Atul Gawande
his art. He was great in his science… He was great
as the father and founder of a school of surgery One of my favorite authors is Atul Gawande, who
which since its existence has stood unsurpassed in has written about checklists and complications
surgical scholarship, in surgical craft, and in the and contributed a wonderful short book entitled
obtainment of surgical ideals and achievements. Better: a Surgeon’s Notes on Performance
But in none of these was he greater than in the (Fig. 24.8). In this book, Gawande defines what
selection of the group of young men (women) in he considers are the three core requirements for
whom he chose to carry on his apostolate and to success in medicine, those being (1) diligence,
transmit his teachings.” We should all note, as the necessity of giving sufficient attention to
implied by Matas above, isn’t one of the most detail to avoid error and prevail against obstacles;
lofty goals of an active surgeon to train the next (2) do right, medicine is fundamentally a human
generation and to train her or him for excellence? profession; and (3) ingenuity, thinking anew, a
willingness to recognize failure, and to change.
Furthermore, in Better, Gawande provides
24.6 There Are No Time-Outs five suggestions for how to make a worthy differ-
ence, that is, how to be a positive deviant in the
The training of a surgeon can be seen as long, culture in which you work. What a remarkable
complex, involved, and difficult. There can be no theme: how can each of us make a difference
doubt that it is rewarding. After all as noted by Dr. among our colleagues? I love these five
Thirlby in his Top Ten list, “your mother will be suggestions:
Fig. 24.7 Once you put

on the white coat
1. Ask an unscripted question: sometimes you Connecticut women have eclipsed the century
discover the unexpected. mark; 100+ consecutive victories). Much has
2. Don’t complain: resist it; it’s boring; it doesn’t been written about Coach Wooden—his philoso-
solve anything: be prepared with something phy, his training schemes, his quotes, his players,
else to discuss. and his personality. In my opinion one of his best
3. Count something: if you count something you works is Wooden on Leadership (Fig. 24.9),
find interesting, you will learn something which draws lessons from his private notebooks
interesting. and focuses on leadership, improving one’s per-
4. Write something: the power of the act of writ- formance, exceeding limitations, and achieving
ing or typing. “success.” The book includes Coach Wooden’s
5. Change—be an early adopter: this is a neces- “pyramid of success,” with the apex of the pyra-
sity, with the fast advancement of surgical mid (the goal of the pyramid) being “competitive
technology. greatness.”
With deference to Coach Wooden and with
remorse to those who feel that his pyramid is
24.8 Lessons from a Coach: Part Two inviolate, I have taken the liberty of modifying
his pyramid and have spoken often about what I
Returning to the basketball theme, John Wooden have termed “the surgery success pyramid,”
and his legendary men’s basketball team, the which has been adapted, with apologies, from
UCLA Bruins, won 10 NCAA National Coach Wooden (Fig. 24.10). While the five foun-
Championships, had 4 perfect (undefeated) sea- dational (1st tier) elements remain unchanged
sons, and once won 88 straight Division I games (industriousness, friendship, loyalty, coopera-
(of note, as of this writing, the University of tion, and enthusiasm), as do the four 2nd tier
316 C. J. Yeo
Fig. 24.8 Atul
Gawande, Better: A
Surgeon’s Notes on
Performance
elements (self-control, alertness, initiative, and Take-Home Points

intentness), I have modified some of the descrip-
tors within some of the elements to reflect the I would like to end with three final concepts,
profession of surgery, as opposed to the activity focusing on how to be successful in surgery, either
of basketball. as a medical student or as a surgical resident or as
Fig. 24.9 John
Wooden: Wooden on
Leadership
a junior faculty member. I have shown these lists For the medical student, study, practice, or
on various occasions, and I am often greeted by drill 4 h per day on average. No excuses, just do
wide eye stares, amazement, and hesitancy. it! Plan to write one paper for the literature per
Nonetheless, here are my thoughts for how to be a year, perhaps working on case reports or review
successful medical student (Fig. 24.11), how to be articles. If you chose to do lab work during medi-
a successful resident (Fig. 24.12), or how to be a cal school, affiliate yourself with a productive
successful junior faculty member (Fig. 24.13). laboratory and endeavor to compose a minimum
318 C. J. Yeo
Fig. 24.10 The surgery success pyramid (modified from Coach John Wooden)
Fig. 24.11 How to be a How to be a successful student

successful student • STUDY/PRACTICE – 4 hours/day; No excuses - period
• Write one paper per year, and a minimum of three per
year in the lab (if you choose to do lab work)
• Read journals weekly (NEJM,JAMA) and monthly …
• Grades matter. Be the best medical student you can be!
• Keep a journal or log of all patients, enumerating at least
one “item” per case that you learned
• Enjoy your time away from the classroom/hospital, and
keep your body fit and in shape
• Do not fall behind on your required tasks: presentations,
assignments, case logs, PELS, etc
of three papers per year. Without a doubt, read be. Aspire to get elected to the medical honor
journals or newsfeeds weekly and monthly. I still society, Alpha Omega Alpha. Keep a journal or
get the New England Journal of Medicine deliv- log of all the patients you see, listing at least one
ered to my door weekly (old school), and as a “item” (pearl or oddity) per case that you have
medical student, I read JAMA at the library each learned. Without a doubt enjoy your time away
week. With modern technology, this can be from the hospital or classroom, and exercise,
accomplished more easily with various news keeping your body fit and in shape. Lastly, do not
feeds and tables of contents sent directly to your fall behind on the various required tasks that you
handheld smart phone. Be aware that grades do have, whether this be presentations, assignments,
matter. Try to be the best medical student you can case logs, patient encounter log system (PELS),
Fig. 24.12 How to be a How to be a successful resident

successful resident • STUDY/PRACTICE –2 hours/day; No excuses -period
• Write one paper per clinical year, and a minimum of
three per year in the lab
• Read journals weekly (NEJM,JAMA) and monthly …
• Keep a list of processes/ systems/ things that do not
work efficiently – will be part of our next White Paper
• Keep a journal or log of all OR cases, enumerating at
least one “item” per case that you learned
• Enjoy your time away from the hospital, and keep your
body fit and in shape
• Do not fall behind on your required tasks: Work hours,
medical records, SCORE, M and M submissions, etc…
Fig. 24.13 How to be a How to be a successful junior

successful junior faculty faculty member
member • Focus on clinical practice and the attainment of mastery level
• Seek out a worthwhile and compatible mentor
• Embark upon new and varied challenges
• Volunteer outside of your comfort zone (say “yes”)
• Remember the basics: support stockings (hosiery), maximize
retirement benefits and participate in strenuous exercise daily
• Cherish time outside the hospital or clinical setting
• Read: medical and surgical literature and – “great books”
• Teach all comers about the wonders of the human body
• Enjoy the act of writing - contribute to the literature,
compose a poem or short story, write a grant, etc.
• Value your colleagues
etc. 4 years of medical school passes in a flash— case that you’ve learned. It is important to remain
be the best you can be. active, in shape, and fit. Enjoy your time away
My suggestions for how to be a successful from the hospital but make every effort to main-
resident are somewhat similar. I am a big fan of tain a high level of physical fitness. Lastly, do not
deliberate practice and study. Even during resi- fall behind on the tasks required of your resi-
dency, one should plan to study or practice at dency: log your work hours, keep up with your
least 2 h a day, on average. Some days this may assigned medical records, participate in some
not be possible, but other days it can be made up form of an academic curriculum such as SCORE,
for. There should be no excuses for not studying submit your M&M lists on time, study for the
or practicing. In similar fashion to the medical ABSITE, etc. Residency years similarly pass
students, plan to write one paper of some form quickly—you will tell stories of them to others,
per clinical year and a minimum of three papers but you must work hard to launch yourself to the
per year during your laboratory experience. Also, aspirational goal of surgical proficiency and
read journals (weekly and monthly) and take mastery.
advantage of newsfeeds, etc. Importantly, be a For the young faculty member, there certainly
positive deviant. Keep a list of processes, sys- are similar suggestions, but the scope of involve-
tems, and things that do not work efficiently and ment must necessarily be broader and more varied.
pass these on to your residency program director The young faculty member needs to focus on com-
or to your chair of surgery. We rely upon the resi- mencing a practice within the field of their interest
dents to quickly understand and embrace new and work toward mastery. I would recommend
technology and innovation, so try to make patient identifying (seeking out) a mentor and working
throughput more effective and the surgical expe- with that individual in some form of a mentee-
rience more satisfying. On every case that you mentor relationship. It is advisable to take on new
scrub, keep a journal or log, enumerating at least and varied challenges (new roles) in the areas of
one “item” (clinical pearl, trick, or neat idea) per education, research, and administration—the
320 C. J. Yeo
young faculty member should be encouraged to medical school, and residency by studying the
answer in the affirmative (say “yes”) when asked works of others—so enjoy the act of writing: con-
to participate in new endeavors, new initiatives, or tribute to the literature, compose a poem or short
new challenges. It is quite important to plan ahead story, write a grant or clinical protocol, etc. Finally,
for a full career in the field of surgery—hence, (a) assimilate into your practice setting (hospital,
wear support stockings or hosiery when faced with department, practice, division), and value your
long days of standing in the OR,, (b) take advan- colleagues—you share a long educational history
tage of the “miracle” of compound interest and and a love of surgery. For most of us, there is no
maximize retirement benefits, and (c) develop a more fulfilling life than the life of a surgeon.
regular (daily) strenuous exercise program so as to
insure physical fitness. Life outside the hospital or
clinical setting is to be valued, promoted, and cher- Suggested Readings
ished. I would recommend spending time with
family and friends weekly, as being part of a non- Carril P, White D. The smart take from the strong.
New York: Simon and Schuster; 1997.
medical community is essential. Read the litera- Gawande A. Better- a surgeon’s notes on performance.
ture—not only in the areas of medicine and surgery New York: Metropolitan Books; 2007.
but also (broadly defined) “the great books.” Do Gladwell M. Outliers- the story of success. New York:
not neglect the responsibility of teaching: find Little, Brown and Co; 2008.
Imber G. Genius on the edge: the bizarre double life of Dr.
learners in all settings and teach about the human William Stewart Halsted. New York: Kaplan; 2010.
body (anatomy and physiology), the pathology, Wooden J, Jamison S. Wooden on leadership. New York:
and the wonders of contemporary surgical tech- McGraw-Hill; 2005.
niques. Recognize that you completed university,
Fundamentals of Managing
the Operative Catastrophe 25
Idalid Franco, David L. Hepner, William R. Berry,
and Alexander F. Arriaga
25.1 Introduction best practices during management of an operative

catastrophe can be common [2]. Utilizing a struc-
There are multiple studies in the literature that tured process in the development and testing of a
suggest management of operative catastrophes is set of crisis checklists, Arriaga et al. showed a
poor, likely because such events are rare to the reduction in failure to adhere to critical steps in
individual, are associated with a high degree of crisis management and improved team perfor-
intensity and uncertainty, and require a high level mance during operative catastrophes [3]. As these
of coordinated and effective teamwork/crisis events are rare and thus difficult to study through
resource management [1]. Failure to adhere to randomized clinical trials, studies have tackled
these issues through the use of high-fidelity sim-
ulation, surveys, and reports of individual clinical
case experience. Although other high-stakes
I. Franco fields, such as aviation, have long embraced stan-
Harvard Medical School, Boston, MA, USA dardized written procedures as a means to reduce
D. L. Hepner errors and improve performance in critical situa-
Department of Anesthesiology, Perioperative and tions, healthcare has been slower to embrace cog-
Pain Medicine, Harvard Medical School, Brigham
nitive aids in high-risk, high-stress situations,
and Women’s Hospital, Boston, MA, USA
possibly due to an ingrained culture which views
utilization of such tools as deficiencies in medi-
W. R. Berry cal competency. Yet, there is growing evidence to
support the use of cognitive aids, such as crisis
Center for Surgery and Public Health, checklists and emergency manuals, to improve
Boston, MA, USA clinician and team performance in addition to
Department of Health Policy and Management, patient outcomes [4].
Harvard School of Public Health, Boston, MA, USA The purpose of this chapter is to describe
A. F. Arriaga (*) some of the most common operating room catas-
Department of Anesthesiology, Perioperative trophes with supporting evidence on diagnosis
and Pain Medicine, Harvard Medical School,
Brigham and Women’s Hospital, Boston, MA, USA and management found in the medical literature
for members of the surgical team. It would be
Department of Anesthesiology and Critical Care,
University of Pennsylvania Health System,
impossible to cover all aspects of such a broad
Philadelphia, PA, USA topic, for which dedicated books and chapters
e-mail: aarriaga@post.harvard.edu have been written on regarding individual

322 I. Franco et al.
catastrophes and principles of crisis manage- 25.3 Technical/Practical

ment. Nevertheless, we intend to present high- Considerations/Safety
yield potentially lifesaving information for some Precautions
of the most common operative catastrophes
encountered by surgeons and suggest the reader 25.3.1 Advanced Cardiovascular
to become familiar with the availability and use Life Support
of key resources including crisis checklists
(available on www.projectcheck.org/crisis) and Advanced cardiovascular life support (ACLS)
emergency manuals (available at www.emergen- guidelines are routinely updated by the American
cymanuals.org). Heart Association (AHA). In addition, there are
“special circumstances of resuscitation” (e.g.,
cardiac arrest in pregnancy, cardiac arrest from
25.2 General Concepts local anesthetic toxicity). The interested reader
is strongly encouraged to review the guidelines
Before we dive into the specific details for that support the popular ACLS “pocket cards”
management of individual emergencies, it is commonly available [7, 8]. It is important to note
essential to discuss the fundamentals that are that knowledge of guidelines alone does not
(nearly) universal to any operative catastrophe. translate to adequate performance during critical
The same initial steps are highlighted in many events and retention of ACLS knowledge and
cognitive aids available for addressing emer- skills are poor among healthcare providers [9–
gency situations, which we hope will become 12]. Yet, even in these studies, those with train-
second nature to the reader by the end of this ing had less deviations from protocol illustrating
chapter, including calling for help, designating the importance of initial training, periodic rein-
a crisis manager/leader, and requesting addi- forcement of skills, and availability of structured
tional resources that are needed. These steps guidelines. In this section, we will review some
should be considered instinctively and without of the most fundamental emergencies specific to
delay to patient care. Of note, the use of a advanced cardiovascular life support, namely,
“checklist reader” has been shown in simulated unstable bradycardia, unstable tachycardia, and
emergency studies to assist the leader in exe- cardiac arrest, providing the surgeon with the
cuting all critical steps in a crisis situation by skills needed to diagnose and manage these cata-
removing the added cognitive burden of read- strophic operative events through structured,
ing the checklist and in that way allowing the evidence- based guidelines. While the section
leader to focus fully on gathering clinical below is based on the latest guidelines at the
information and effectively managing team time this chapter was written, guidelines such as
communication and coordination [5, 6]. those from the AHA on ACLS are frequently
The following section will provide the techni- updated. When a surgeon is integrating the sec-
cal and practice considerations when dealing tion below together with his/her institution-spe-
with an operative catastrophe. These situations, cific protocols, a quick search for the latest
which may present with non-specific signs, pose ACLS protocols is prudent.
time-sensitive diagnostic and management deci-
sions to be recalled by even the most experienced 25.3.1.1 Bradycardia: Unstable
clinician. It is therefore our goal to frame the
events below in a format that includes a brief Introduction
introduction, information for clinical diagnosis, There are numerous potential causes of bradycar-
and guideline-based treatment recommendations dia, ranging from electrical disturbances
that can be quickly referenced during a crisis (e.g., heart block) medication-related causes
situation. (e.g., beta-blocker overdose, side effect from
25 Fundamentals of Managing the Operative Catastrophe 323
c ertain anesthetic/analgesic agents) or anatomi- acute changes in mental status [7, 8]. This defini-
cal reflex manifestations (e.g., carotid sinus tion, which is based on the definition used by the
reflex, oculocardiac reflex, von Bezold-Jarisch AHA as part of the ACLS guidelines, may not be
reflex, or other phenomena that may be referred fully applicable in patients under general anes-
to vaguely as a “vagal response”). Additionally, a thesia who are unable to communicate symptoms
lower heart rate can be a common phenomenon of ischemic heart pain or acute changes in mental
in certain populations, including athletes or status. In these situations, it is essential for sur-
patients on chronic beta-blocking agents, result- geons to communicate with anesthesiologists to
ing in baseline heart rates in the 40s–50s, without (1) gain a full understanding of the clinical signs
the symptoms or concerns associated with unsta- and symptoms, (2) convey information on what
ble bradycardia. In the general adult population, has acutely been done or given that may explain
however, normal heart rate is generally expected the bradycardia, and (3) promptly address and
to remain within the range of 60–100 beats per remove potential causes. The surgeon should
minute (bpm). Given this variability in expected keep in mind that placement of abdominal retrac-
heart rate, in conjunction with the understanding tors can cause a vagal response, resulting in bra-
that preoperative patient anxiety can cause tachy- dycardia, that can be partially addressed by
cardia and anesthetics may cause a degree of bra- loosening or removing the retractors until ade-
dycardia, patient context should be considered quate hemodynamics have been restored.
when interpreting the heart rate (i.e., unexplained
drop in heart rate more than 20% of the patient’s Treatment
baseline, especially if the resulting rate is below The goals of treatment for unstable bradycardia
50 bpm). Unstable bradycardia can be viewed revolve around restoring hemodynamic stability
and approached as an operative catastrophe when to prevent organ hypoperfusion and cardiovas-
the low heart rate is coupled with signs and symp- cular collapse. As with any operative catastro-
toms of hemodynamic instability, such as low phe, an immediate call for help, request of a
blood pressure, acute and otherwise unexplained code cart, and assignment of a crisis manager/
decline in mental status of an awake patient, or leader should all be done without delaying treat-
signs of shock and cardiac compromise. In these ment. Depending on the institution, the “code
situations, the surgeon, anesthesiologist, and cart” and defibrillator/pacer might not be
operating room team must maintain open and attached to each other, but the person getting
coordinated communication to effectively diag- these items should understand that both can be
nose and treat unstable bradycardia. The essential to the management of this situation (as
American Heart Association guidelines for bra- well as other ACLS scenarios). The surgeon can
dycardia outline detailed and evidence-based also be in constant communication with the
steps for management of this condition, and cog- anesthesiologist regarding the patient’s hemo-
nitive aids formatted for the operating room are dynamic status and clinical condition including
available. ventilation and oxygenation. The surgeon can
stop the surgical stimulation if present (i.e.,
Clinical/Diagnosis removing abdominal retractors or desufflation
As described above, unstable bradycardia may be of the abdomen in laparoscopic cases). The
considered in the setting of a drop in heart rate to anesthesiologist may increase the FiO2 to 100%
less than 50 bpm, with resulting hemodynamic and ensure the airway is maintained while con-
instability manifested as a drop in blood pressure sidering the initial drug of choice. While glyco-
below normal range (hypotension), signs of pyrrolate is sometimes given for cases of mild,
shock (resulting in organ hypoperfusion), cardiac less concerning bradycardia, the initial drug of
compromise (presenting as acute heart failure) or choice for severe/unstable bradycardia is atro-
chest discomfort (associated with ischemia), and pine. Although certain clinical conditions, such
as a complete heart block or recent heart trans- other patient vital signs including the presence of
plant, may not benefit from atropine, this drug a palpable pulse, to decide on the best course of
has long been listed in ACLS guidelines and in action. Determining if there is a narrow versus
many instances can be an appropriate choice. As wide complex and regular versus irregular rhythm
this is being done, the nursing team can obtain can guide appropriate treatment options, and as
the code cart and pacer/defibrillator and then such providers are encouraged to develop a
connect this device to the patient to allow for familiarity with the distinct electrocardiographic
transcutaneous pacing. If atropine is not effec- features of tachycardia (i.e., sinus tachycardia,
tive, the decision can be made to initiate trans- narrow-complex supraventricular tachycardia
cutaneous pacing or utilize alternative drug [QRS <0.12 s], and wide-complex tachycardia
choices such as an epinephrine or dopamine [QRS ≥0.12 s]). In the case of a ventricular fibril-
infusion. Expert consultation should be consid- lation or ventricular tachycardia without a blood
ered, as transvenous pacing might be necessary. pressure/pulse, the scenario should be managed
It is also critical that other causes of bradycardia according to the cardiac arrest guidelines listed in
are simultaneously investigated including over- the following section. In other cases of unstable
dose of beta-blockers or digoxin, both of which tachycardia, immediate synchronized cardiover-
have available pharmaceutical treatments. sion is the initial treatment of choice.
Surgeons are encouraged to familiarize them-
selves with the defibrillator/pacer of their insti- Treatment
tution as the device settings differ slightly across As noted above, outside of ventricular fibrillation
different models. and pulseless ventricular tachycardia, the treatment
for unstable tachycardia is immediate synchro-
25.3.1.2 Tachycardia: Unstable nized cardioversion. Synchronized cardioversion is
defined as the delivery of a shock on the R-wave of
Introduction the patient’s QRS complex, avoiding the delivery
Similar to bradycardia, there are many potential of a shock on the refractory period symbolized by
causes for tachycardia, including pain, fever, the T-wave of the patient’s ECG rhythm, which can
hypovolemia, and arrhythmias. It is therefore cause an “R on T” phenomenon, leading to a poten-
helpful to put the patient’s observed heart rate tially lethal arrhythmia. As a surgeon, it is impor-
into the context of the clinical scenario, including tant to familiarize yourself ahead of time with the
the baseline heart rate and potential secondary defibrillator/pacer manufacturer/model being used
causes of the tachycardia that would not be at your institution. Different machines have differ-
addressed by simply returning the patient’s heart ent button types to engage the synchronization
rate into a normal adult range of 60–100 bpm. An mode. The time of unstable tachycardia is not the
overall clinical evaluation, including assessment best time to refresh oneself or learn the buttons of
of the heart rhythm, is crucial to differentiating the particular machine at your institution. An
the cause of the tachycardia. This distinction is example of the machine steps, spelled out for the
vital in allowing the providers to respond with manufacturer/model of a particular institution, can
appropriate and timely treatment. This section be found on the “tachycardia unstable” entry of the
will describe the diagnosis and management of “operating room crisis checklists” for the Brigham
unstable tachycardia, described by the AHA as and Women’s Hospital [13]. A general guideline of
tachycardia with “hypotension, acutely altered biphasic doses is given in the ACLS guidelines for
mental status, signs of shock, ischemic chest dis- “Adult Tachycardia (with Pulse),” all with increased
comfort, and acute heart failure” [7, 8]. joules delivered incrementally if prior attempts
were unsuccessful [7, 8]. An additional consider-
Clinical/Diagnosis ation is the use of intravenous adenosine given via
In the case of unstable tachycardia, it is important the access area closest to the heart in scenarios
to determine the heart rhythm, in addition to the where the rhythm is narrow complex and regular.
This should only be considered if administration “These experiences but emphasize the impor-
will not delay cardioversion. Communication tance of an efficient routine instantly available
between the surgeon and the team is critical during for resuscitation in every operating room.” Nearly
management of unstable tachycardia. Potentially 30 years later, another prominent physician who
reversible causes of the tachycardia can be sought began his career as a surgical trainee and finished
by team members at the same time as stabilizing his residency training in anesthesiology, Dr. Peter
measures are being done including supplemental Safar, became known as the “father of CPR” for
oxygen, determining adequate ventilation and oxy- his life’s work on cardiopulmonary resuscitation
gen saturation, monitoring blood pressure, and [15]. This section will review the key details in
establishing intravenous access. As with any opera- the diagnosis and management of cardiac arrest
tive catastrophe, immediately calling for help, as an operative catastrophe. A key initial consid-
requesting a code cart with pacer/defibrillator, and eration for a patient in cardiac arrest is determin-
assignment of a crisis manager/leader are critical ing whether the patient has a shockable or
first steps. In addition, a 12-lead ECG can also aid non-shockable rhythm. Additional considerations
in diagnostics. Expert consultation can be consid- on special circumstances of resuscitation are also
ered to assist the operating room team and can help addressed in the AHA guidelines, including top-
determine the need for additional antiarrhythmic ics on pregnancy and local anesthetic systemic
medications or maneuvers once the patient has toxicity, which will not be covered in this section
been stabilized. [16]. The following is a review of the 2015
American Heart Association guidelines for car-
25.3.1.3 Cardiac Arrest diopulmonary resuscitation and emergency car-
diovascular care, which was updated through an
Introduction in-depth evidence review process and is stratified
An unanticipated cardiac arrest can be an acutely by the presence of shockable vs. non-shockable
stressful situation for any surgeon and operating heart rhythms.
room team. This section will focus on uninten-
tional cardiac arrest. Intentional circulatory Clinical/Diagnosis
arrest, such as that which is sometimes needed It is important to look at the heart rhythm in a
for certain cardiac or vascular procedures, is patient in cardiac arrest, keeping in mind that
beyond the scope of this chapter and will not be there are four rhythms that can cause cardiac
discussed. In addition, post-cardiac arrest care arrest and can be grouped into shockable and non-
and the role of therapeutic hypothermia are ongo- shockable rhythms. The first two types of cardiac
ing discussions in the literature, and the reader is arrest, asystole and pulseless electrical activity
encouraged to learn about the policies in place (PEA), are considered together as non-shockable
for these situations at their individual institution rhythms. Asystole refers to the complete absence
as well as be familiar with the most recent studies of electrical and mechanical activity of the heart,
on these scenarios. while PEA is the presence of an electrocardio-
Frustrations with intraoperative cardiac arrest graphic rhythm that is unable to sustain the
management have been described for nearly a mechanical contractions needed to produce a
century, dating back to the 1920s [14]. In a measurable pulse or blood pressure [7]. Both of
famous 1924 article published in Anesthesia & these situations result in an inability of the heart to
Analgesia, the prominent surgeon Dr. W. Wayne perfuse adequately and can lead to both cerebral
Babcock posed the question “Have you a plan of and cardiac demise. The shockable rhythms
action so developed that the right thing is always include ventricular fibrillation, a disorganized
done in the emergency and time is not fritted electrical activity, and pulseless ventricular tachy-
away with useless or non-essential details?” Dr. cardia, an organized electrical activity of the ven-
Babcock described his personal experiences in tricles, neither of which is able to generate
the OR and concluded the article by stating sufficient forward flow of blood by the heart [7].
As with any emergency situation, a crucial step in that is, persistent or recurrent after one’s shock,
the efficient diagnosis and treatment includes an an antiarrhythmic such as amiodarone can be
evaluation and removal of potential underlying given, which is done to “facilitate the restoration
causes in conjunction with treatment and and maintenance of spontaneous perfusing
restoration of hemodynamic stability. In any case rhythm in concert with the shock termination”
of cardiac arrest, the team must consider the “H’s [8]. Communication is critical for the successful
and T’s” that comprise some potentially revers- implementation of all steps, including tasks such
ible causes, including hydrogen ion (acidosis), as chest compressions, maintenance of the
hypo-/hyperkalemia, hypothermia, hypovolemia, patient’s airway, optimization of vascular access,
hypoxia, tamponade (i.e., cardiac tamponade), timekeeping, and the other steps noted above.
tension pneumothorax, thrombosis (pulmonary, Defibrillator settings differ slightly by model,
coronary), and toxins. Targeted treatment in each and the surgeon is encouraged to familiarize
of these cases is essential, and recall of the H’s themselves with utilization of the devices at their
and T’s in a stressful e nvironment can be prompted institution prior to an emergency situation.
by the use of cognitive aids such as a crisis check- Consistent reevaluation of patient status is
list/emergency manual. recommended, with physiological clues such as a
sudden increase of ETCO2 to >40 mmHg
Treatment potentially indicating a return of spontaneous

AHA guidelines emphasize high-quality CPR as circulation.
the foundation of successful ACLS, in addition to
defibrillation for the shockable rhythms VF and
pulseless VT, which can significantly increase the 25.3.2 Failed Airway
chance of survival to hospital discharge [8]. As
with other operative catastrophes, immediately 25.3.2.1 Introduction
calling for help, requesting a code cart, and Much of the airway management for non-head
assignment of a crisis manager/leader should all and neck cases (such as non-tracheostomy, non-
be done without delaying treatment. A back- otolaryngology cases) falls within the purview
board, placed under the patient in supine posi- of the anesthesiologist. Accordingly, there are
tion, can be considered to assist with the quality guidelines for difficult airway management,
of CPR. Additionally, FiO2 can be increased to most of which involves modalities typically
100% to improve oxygen delivery. In shockable done by an anesthesia provider. The American
rhythms, an initial shock delivery via the defibril- Society of Anesthesiologists (ASA) has difficult
lator is recommended in 2 min intervals with airway guidelines [17], and the Difficult Airway
intervening high-quality CPR described as “hard Society has published guidelines on this topic as
and fast” chest compressions to a depth of 2 in. at well [18]. Nevertheless, the surgeon needs to be
100–120/min while allowing full chest recoil. prepared for the urgent need of a surgical air-
The person performing chest compressions way. The surgeon should therefore have a basic
should be rotated every 2 min to avoid a decrease familiarity with difficult airway guidelines to
in quality due to fatigue. While this is occurring, strengthen their situational awareness of the
the anesthesiologist or an available team member potentially urgent need for a surgical airway.
can monitor the physiological response to CPR There is value in a surgeon who knows where
delivery, such as the patient’s end-tidal CO2 and/ the closest difficult airway cart and emergency
or intra-arterial diastolic pressure. Interruptions surgical airway equipment/kits can be found. It
of chest compressions must be minimized and is not uncommon for a patient who is difficult to
excessive ventilation avoided. In either shockable ventilate and intubate to also be a difficult
or non-shockable rhythm, epinephrine should be surgical airway. This section will describe the
given. In cases of refractory VF or pulseless VT, management of a failed airway through a crico-
thyrotomy. Cummings Otolaryngology defines a will describe and illustrate the necessary steps
cricothyrotomy as “the establishment of a surgi- for management of a failed airway including cre-
cal opening into the airway through the crico- ating a surgical airway via a cricothyrotomy
thyroid membrane (CTM) and placement of a while understanding that other invasive tech-
tube for ventilation” [19]. The importance of niques may also be considered by the team (e.g.,
understanding the diagnosis and management of needle cricothyroidotomy).
a difficult airway and emergent treatment is crit-
ical to the practicing surgeon, as operative 25.3.2.3 Treatment
catastrophes related to inadequate airway and In a failed airway scenario, immediately calling
ventilation have continuously been found to be for help, designating a crisis manager/leader, and
some of the leading causes of serious and life- requesting a difficult airway cart and video laryn-
threatening intraoperative and perioperative goscope are all essential steps. If ventilation is
complications [1, 20, 21]. inadequate and an experienced anesthesiologist
has failed to achieve a controlled airway after
25.3.2.2 Clinical/Diagnosis multiple attempts, the surgeon should communi-
ASA practice guidelines acknowledge the varia- cate with the team and prepare for the possibility
tion of definitions of “difficult airway” in the lit- that a surgical airway will be urgently needed.
erature and define this term as “the clinical While the anesthesiologist continues to attempt
situation in which a conventionally trained anes- to optimize ventilation, possibly through place-
thesiologist experiences difficulty with facemask ment of a laryngeal mask airway, alternative
ventilation of the upper airway, difficulty with supraglottic devices, or other approaches, the sur-
tracheal intubation, or both.” They provide a geon should begin to consider what is available to
description of a “failed intubation” as “place- prep the neck (such as the prep solution available
ment of the endotracheal tube fails after multiple for the surgical case) and how to obtain supplies
attempts.” Similarly, one could think of a “failed needed for an urgent surgical airway. Cummings
airway” as the failure to achieve a controlled air- describes a modified “rapid five-step technique”
way after multiple attempts by an airway expert which is “simple to learn and faster in obtaining a
(or an experienced anesthesiologist). Failed air- surgical airway.” This technique is comprised of
way, resulting from an inability to intubate and (1) Identifying landmarks and stabilizing the air-
ventilate, has been estimated to occur in the way, (2) making a vertical skin incision, (3) mak-
range of 0.01–2 per 10,000 patients with difficult ing a horizontal incision through the cricothyroid
endotracheal intubation ranging between 5 and membrane, (4) inserting a clamp to spread and
35 per 10,000 patients and difficult mask ventila- elevate the airway, and (5) inserting a tracheos-
tion at an incidence of about 5% [19]. A failed tomy tube or small endotracheal tube. The
airway can quickly lead to anoxic brain injury Manual of Emergency Airway Management pro-
and death. The surgeon and operating room team vides detailed illustrations of the technique used
are encouraged to be prepared to quickly and for an emergency cricothyrotomy (Figs. 25.1,
accurately diagnose and address this situation 25.2, 25.3, 25.4, 25.5, 25.6, 25.7) [22]. (Used
and provide a mechanism for adequate ventila- with permission from Walls RM, Murphy MF,
tion and oxygenation when less invasive tech- editors. Manual of emergency airway manage-
niques have failed. A key piece of information in ment; Fourth Edition. Philadelphia: Lippincott
the management of a failed airway is whether the Williams & Wilkins; 2013).
patient is able to receive adequate ventilation While ventilation status may change over the
(such as bag-mask ventilation) while further course of treatment, which alters the acuity of the
decisions are being made (ranging from awaken- situation, a surgeon who communicates well and is
ing the patient to considering alternative prepared for the possibility of a surgical airway can
approaches to securing the airway). Below, we be a life-saving member of this critical scenario.
b
Fig. 25.2 With the index finger moved to the side but
continued firm immobilization of the larynx, a vertical
midline skin incision is made, down to the depth of the
laryngeal structures. (Used with permission from Walls
RM, Murphy MF, editors. Manual of emergency airway
management; Fourth Edition. Philadelphia: Lippincott
Williams & Wilkins; 2013)
ical exam findings, anesthetics given, and oper-

ating room course is key to adequate assessment
and optimal treatment. When faced with situa-
tions where the diagnosis is unclear, especially
when multiple abnormalities in signs and
symptoms are observed, it is important to
understand the abnormality representing the
Fig. 25.1 (a) Surface anatomy of the airway. (b) The
thumb and long finger immobilize the superior cornua of primary problem as this will prevent unneces-
the larynx; the index finger is used to palpate the cricothy- sary or invasive procedures that can cause harm
roid membrane. (Used with permission from Walls RM, to the patient or delay of appropriate treatment.
Murphy MF, editors. Manual of emergency airway man- Within the incident reports for 4000 cases of
agement; Fourth Edition. Philadelphia: Lippincott
Williams & Wilkins; 2013) the Australian Incident Monitoring Study
(AIMS), 438 reports included the words “hypo-
tension,” “cardiovascular collapse,” or “cardiac
25.3.3 Intraoperative Emergencies arrest” (~11%), and 706 contained the word
Where the Diagnosis “desaturation” (~18%) [23, 24]. In both hypo-
Is Unclear tension and hypoxemia, there were multiple
potential causes for the observed abnormality,
25.3.3.1 Hypotension and Hypoxemia with other associated signs and symptoms. The
use of a structured algorithm was considered to
Introduction have resulted in a better and/or more prompt
Hypotension and hypoxemia present a particu- resolution in 6% of hypotension cases and 15%
larly difficult situation for operating room of hypoxemic cases. It is known that both of
teams due to their broad differential and subse- these operative catastrophes have the potential
quent difficulty for accurate and efficient diag- to result in irreversible damage to organs lead-
nosis and treatment. In these situations, clinical ing to a high degree of morbidity and mortality.
judgment relative to the patient’s history, phys- Thus, this time-critical need for efficient and
Fig. 25.3 With the skin incised, the index finger can now
directly palpate the cricothyroid membrane. (Used with
permission from Walls RM, Murphy MF, editors. Manual
of emergency airway management; Fourth Edition.
Philadelphia: Lippincott Williams & Wilkins; 2013)
effective treatment highlights the importance b

for the surgeon to have a structured set of key
steps to guide the differential diagnosis and Fig. 25.4 (a) A horizontal membrane incision is made
treatment management considerations inherent near the inferior edge of the cricothyroid membrane. The
to unclear/sustained hypotension/hypoxemia. index finger may be swung aside or may remain in the
wound, palpating the inferior edge of the thyroid carti-
lage, to guide the scalpel to the membrane. (b) A low cri-
Clinical/Diagnosis and Treatment cothyroid incision avoids the superior cricothyroid
Due to the broad differential for these common vessels, which run transversely near the top of the mem-
scenarios, we present this section in the format of brane. (Used with permission from Walls RM, Murphy
MF, editors. Manual of emergency airway management;
crisis checklists that have been adopted by Fourth Edition. Philadelphia: Lippincott Williams &
an institution. Figures 25.8 and 25.9 are examples Wilkins; 2013)
Fig. 25.5 (a) The tracheal hook is oriented a

transversely during insertion. (b, c) After insertion,
cephalad traction is applied to the inferior margin of
the thyroid cartilage. (Used with permission from
Walls RM, Murphy MF, editors. Manual of emergency
airway management; Fourth Edition. Philadelphia:
Lippincott Williams & Wilkins; 2013)
c
a a
b
b
Fig. 25.6 (a) The Trousseau dilator is inserted a short

distance into the incision. (b) In this orientation, the dila- c
tor enlarges the opening vertically, the crucial dimension.
(Used with permission from Walls RM, Murphy MF, edi-
tors. Manual of emergency airway management; Fourth
Edition. Philadelphia: Lippincott Williams & Wilkins;
2013)
from (the crisis checklists for structured

approaches in the setting of hypotension and
hypoxemia (the crisis checklists in their native
format are available at www.projectcheck.org/
crisis). In both cases, one can see that there are
many causes to consider. There can be benefit of
a team running through these causes together and
attempting to narrow the differential, similar to Fig. 25.7 (a) Insertion of the tracheostomy tube. (b)
how one would run though the “H’s and T’s” in Rotation of the Trousseau dilator to orient the blades lon-
cardiac arrest”. gitudinally in the airway facilitates passage of the trache-
ostomy tube. (c) Tracheostomy tube fully inserted,
instruments removed. (Used with permission from Walls
RM, Murphy MF, editors. Manual of emergency airway
management; Fourth Edition. Philadelphia: Lippincott
Williams & Wilkins; 2013)
9 Hypotension
Unexplained drop in blood pressure refractory to initial treatment
START
1 Call for help and a code cart 7 Consider actions... DRUG DOSES and treatments
Ask: “who will be the crisis manager?” Place patient in Ephedrine: 5 − 25 mg IV, repeat as needed
Trendelenberg position Phenylephrine: 100 − 500 mcg IV,repeat as needed
2 Check...
Obtain additional IV access Epinephrine BOLUS: 5 − 10 mcg IV
Pulse
INFUSION: 0.1 − 10 mcg/kg/min IV
Place arterial line
Blood pressure
Equipment 8 Consider causes...
Heart rate Operative field Breathing
If BRADYCARDIA, go to CHKLST 3 Mechanical or surgical manipulation Increased PEEP
:Insufflation during laparoscopy Hypoventilation
Rhythm
Retraction Hypoxia go to CHKLST 10
If VF / VT, go to CHKLST 5
Vagal stimulation Persistent hyoerventilation
If PEA, go to CHKLST 4
Vascular compression Pneumothorax
3 Run IV fluids wide open Pulmonary edema
Unaccounted blood loss
Blood in suction canister Circulation
4 Give vasopressors and titrate to response
Bloody sponges Air embolism go to CHKLST 1
MILD hypotension:
Blood on the floor Bradycardia go to CHKLST 3
Give ephedrine or phenylephrine
Internal bleeding Malignant hyperthermia go to CHKLST 11 9
SIGNIFICANT/REFRACTORY hypotension: Tachycardia go to CHKLST 12
Drugs / Allergy
Give epinephrine bolus, consider starting Bone cementing (methylmethacrylate effect)
epinephrine infusion Anaphylaxis go to CHKLST 2
Myocardial ischemia
Recent drugs given
Emboli ( pulmonary, fat, septic, amniotic,CO2)
5 Turn FiO2 to 100% and Dose error
Severe sepsis
turn down volatile anesthetics Drugs used on the field
Tamponade
(i.e., Intravascular injection of local
6 Inspect surgical field for bleeding anesthetic drugs)
If BLEEDING, go to CHKLST 8 Wrong drug
All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials
lies with the reader. Revised July 2013 (072413.1)
Fig. 25.8 Crisis checklist for hypotension. In Ariadne is also available at: www.projectcheck.org/crisis. Image
Labs. Operating Room Crisis Checklists. With permis- compressed to meet publication requirements. For native
sion. A version from the Brigham and Women’s Hospital version, see URL provided. Accessed April 23, 2017
25.3.4 Other Emergencies the Stanford Cognitive Aid Group (available at

www.emergencymanuals.org).
As noted above, the goal of this chapter was to In the suggested reading section, we refer to
familiarize the surgeon with some common oper- some essential resources for emergency cognitive
ative catastrophes that every surgeon should aids specific to the O.R. environment. For exam-
know. However, we hope that this chapter also ple, for malignant hyperthermia, an exceptionally
encourages the reader to obtain familiarity with rare but life-threatening event, there exist a crisis
other operative emergencies that simply could checklist [13], a critical event checklist geared to
not be covered due to the space constraints. the pediatric population [http://www.pedsanes-
Hemorrhage, for example, is an operating room thesia.org/wp-content/uploads/2017/03/Critical_
emergency that crosses many different disci- Event_Checklists.pdf], an emergency manual
plines (surgery, obstetrics, anesthesia, nursing, entry [25], posters from the Malignant
hematology, and potentially trauma, vascular, Hyperthermia Association of the United States
interventional radiology, and other specialties) (MHAUS) [http://www.mhaus.org/healthcare-
and is often presented with dedicated chapters in professionals/managing-a-crisis], and other
and of themselves. For this specific emergency, resources (www.emergencymanuals.org). We
we provide Fig. 25.10, which is an example of strongly encourage the reader to use these
the hemorrhage emergency manual entry from resources to familiarize themselves with opera-
10 Hypoxia
Unexplained oxygen desaturation
START
1 Call for help and a code cart 7 Consider causes...
Ask: “Who will be the crisis manager?" Is Airway / Breathing issue suspected?
2 Turn FiO2 to 100% at high gas flows
NO airway issue suspected YES airway issue suspected
Confirm inspired FiO2 = 100%
on gas analyzer Circulation Airway/ Breathing
Confirm presence of end-tidal CO2 and • Embolism • Aspiration
changes in capnogram morphology – Pulmonary embolus • Atelectasis
3 Hand - ventilate to assess Compliance – Air embolism-Venous go to CHKLST 1 • Bronchospasm
– Other emboli (fat, septic, CO2, amniotic fluid) • Hypoventilation
4 Listen to breath sounds • Heart disease • Obesity/positioning
– Congestive heart failure • Pnmumothorax
5 Check...
– Coronary heart disease • Pulnonary Edema
Blood pressure,PIP, pulse – Myocardial ischemia • Right mainstem intubation
ET tube position – Cardiac lamponade • Ventilator settings,
Pulse oximeter placement Corgenital anatomical defect leading to auto-peep
Circuit integrity: look for disconnection,
• Severe sepsis
kinks,holes
• If hypoxia associated with hypotension,
go to CHKLST9
6 Consider actions to assess possible Additional DIAGNOSTIC TESTS
breathing issue...
Drugs / Allergy • Fiberoptic bronchoscope
Draw blood gas
• Recent drugs given
• Chest xray 10
Suction (to clear secretions, mucus plug) • Electrocardiogram
• Dose error / allergy/ anaphylaxis • Transesophageal echocardiogram
Remove circuit and use ambu-bag
• Dyes and abnormal hemoglobin
Bronchoscopy
(e.g., methemoglobinemia, methylene blue)
All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials
lies with the reader. Revised July 2013 (072413.1)
Fig. 25.9 Crisis checklist for hypoxemia. In Ariadne is also available at: www.projectcheck.org/crisis. Image
Labs. Operating Room Crisis Checklists. With permis- compressed to meet publication requirements. For native
sion. A version from the Brigham and Women’s Hospital version, see URL provided. Accessed April 23, 2017
tive catastrophes that they are likely to encounter potential reason for providers to not use check-
over the course of their practice. The practice pat- lists was the “perception of them being less
terns of the surgeon and institution are relevant skilled because they needed to use a ‘cheat
considerations (i.e., certain catastrophes may be sheet.’” Survey results showed 17% of providers
more common for the orthopedic surgeon, otolar- felt uncomfortable using a checklist in front of
yngologist, gynecological surgeon, pediatric sur- their team members and only 45% of providers
geon, and others). feeling comfortable [27]. Additionally, those
reporting uncomfortable feelings were more
likely to have fewer years of experience.
25.4 Current Controversies/ Addressing these issues necessitates cultural
Future Directions shifts and implementation from leaders within
the field to foster a culture that embraces the use
At present, there are no guidelines mandating of checklists and emergency manuals. To this
crisis checklists or emergency manuals be avail- end the Emergency Manuals Implementation
able or used during patient care [26]. This point Collaborative (EMIC) was formed to encourage
is amplified by existing cultural perceptions the use of manuals and address barriers to imple-
which attribute the use of cognitive aids to less mentation and dissemination by providing free
clinical competence and overall skills by health- access to multiple versions of emergency aids at
care providers. A survey done at the University www.emergencymanuals.org. Ultimately, these
of California, San Francisco, found that one tools must be readily available to be used in cri-
Fig. 25.10 (a, b) Emergency manual entry for hemor- compressed to meet publication requirements. For native
rhage. Used with permission from Stanford Anesthesia version, see URL provided. Creative Commons
Cognitive Aid Group. Emergency Manual: Cognitive aids BY-NC-ND. 2016 (Version 3) (http://creativecommons.
for perioperative critical events. See http:// org/licenses/by-nc-nd/3.0/legalcode) (see Footnote 1)
emergencymanual.stanford.edu for latest version. Image
sis situations and implementation is a key step in

ensuring availability and appropriate use. This clinicians under highly stressful
requires both an awareness of availability and conditions.
training with the use of crisis checklist and emer- • Under stressful circumstances that come
gency manuals [28]. from rare life-threatening events, failure
An additional point of controversy in the use to adhere to best practices can be com-
of crisis checklists/emergency manuals suggests mon when relying on memory alone. In
that the doctors’ use of a cognitive aid may cause these cases, cognitive aids can serve as
providers to become reliant on these cognitive an additional tool in the surgeon’s
aids, to the point where clinical judgment is no armory, utilized in situations where high
longer used and fixation on one particular course stress or high stakes may limit memory
of action can lead to a lack of flexibility and delay and recall of key steps and negatively
in appropriate care [29]. As we have stated impact team dynamics.
throughout this chapter, all clinical signs and • Clinical judgment relative to the
symptoms associated with the operative catastro- patient’s history, physical exam find-
phe must be interpreted in the context of patient ings, anesthetics given, and operating
history, physical exam, and current patient pre- room course is key to adequate assess-
sentation, such that clinical judgment continues ment and optimal treatment.
to be a primary driver of ultimate decision- • In any operative catastrophe, the first
making. In this setting, cognitive aids are imple- steps should include calling for help,
mented as an additional tool in the surgeon’s designating a crisis leader/checklist
armory, utilized in situations where high stress or reader, and requesting additional
high stakes may limit memory and recall of key resources needed.
steps and negatively impact team dynamics. • Crisis checklists and emergency manu-
As with anything else in medicine, there is no als should be adapted to reflect the most
“one solution fits all” approach. The recommen- up-to-date guidelines available and con-
dations presented in this chapter must be taken in sistently be evaluated for effectiveness
context with the culture and resources of indi- of content, design, and implementation,
vidual institutions and adapted for best use, prior ensuring that these tools meet the needs
to the occurrence of such events. Surgeons play a of the institution and practicing
unique role in coordinating and executing care providers.
for patients in the operating room, as they are
tasked with the responsibility of not only the
knowledge, clinical expertise, and technical skills As such, we present the topics in this chapter to
to treat patients but must also serve a leadership equip the surgeon with evidence-based guide-
role in managing and maintaining successful lines and tools to successfully address operative
team dynamics, incorporating effective commu- catastrophes and feel prepared to lead teams in
nication skills, assigning appropriate task man- these high-stress and high-stakes situations.
agement, maintaining situational awareness, and
ensuring successful team decision-making [30]. Acknowledgment This work is supported by grants from
the University of Pennsylvania, McCabe Fund, and Bach
Fund. The authors would like to thank Maryann Henry,
CRNA, MS, and Carlene McLaughlin, CRNA, MSN,
Take-Home Points PhD, for their review of the work and their efforts to
• Operative catastrophes are rare events advance the principles of crisis management and patient
that require time-sensitive diagnostic safety. The views expressed in this article are those of the
authors and do not necessarily represent the official views
and management decisions to be of supporting entities.
recalled by even the most experienced
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Core contributors in random order: Howard SK, Chu LF,

1
Goldhaber-Fiebert SN, Gaba DM, Harrison TK

Index
A Antiseptic agents, 77–79

Abdominal aortic aneurysms, 190 Antiseptic-related fires, 79–80
Abdominal compartment syndrome (ACS), 259 Antiseptic triclosan, 180
Abdominal compression, 75 Aortic occlusion, 127, 128
Abdominal incision Aponeurosis, 208, 211
advantages/disadvantages, 88 Argon beam plasma coagulator (APC), 133
oblique, 88 Army-Navy retractor, 27
paramedian, 86 Arteriotomy, 239, 242
retroperitoneal structures, 89 Ascites, 190
thoracoabdominal, 89 Association of periOperative Registered Nurses (AORN),
transverse, 88 78
types, 87 Association of Program Directors in Surgery (APDS),
vertical midline, 86 290
Abdominal laparoscopic procedure, 34 Asystole, 325
Absorbable suture, 41, 42 Atraumatic bowel grasper, 36
ABThera™, 269, 270 Atraumatic needles, 40
Accidental drain removal, 154
Accreditation Council for Graduate Medical Education
(ACGME), 289, 290 B
ACLS, see Advanced cardiovascular life support (ACLS) Balfour retractor, 27, 102
Active electrodes, 130, 132, 133, 135 Balloon dissection, 201
Acute cholecystitis, 200 Barbed suture, 49, 93
Adson tissue forceps, 25, 26 Bard-Parker knife handle, 23
Adson-type clamps, 120 Bariatric endoscopy, 165
Adult Tachycardia (with Pulse), 324 Barker drain system, 268, 269
Advanced cardiovascular life support (ACLS), 322 Barrett esophagus, 169
Advanced Trauma Life Support (ATLS) protocol, 253 Baseball stitch, 60
Agency for Healthcare Research and Quality, 67 Beckman retractor, 101
Allicin, 180 Binocular imaging system, 216
American Board of Surgery (ABS), 164–166, 289, 290 Bioabsorbable mesh, 177
American Society of Anesthesiologist’s, 66 Biologic mesh, 177
American Society of Colon and Rectal Surgeons disadvantage, 181
(ASCRS), 292 properties, 178
American Society of Regional Anaesthesia and Pain Bipolar devices, 129, 130, 133
Medicine (ASRA) guidelines, 12 Blake drainage system, 149
Aminoglycoside, 11 Bleeding
Anastomosis, stapler, 139 diffuse, 127
Andrews suction, 28 drain complication, 154
Anemia, 4 prevention, 120
Antenna coupling, 132 stop, 120, 126
Antibiotic prophylaxis, 7, 10, 179 See also Hemostasis
Antibiotic-coated material, 49 Blind suturing, 127
Antimicrobial prophylaxis Blood conservation, 4
benefit of, 7 Blunt dissection, 109, 201
dosing and re-dosing of, 11 Blunt needles, 45

F. Palazzo (ed.), Fundamentals of General Surgery, https://doi.org/10.1007/978-3-319-75656-1
340 Index
Blunt-tipped instrument, 120 Clinch grasper, 36

Bogota bag, see Silo technique Closed drain, 145
Bone wax, 281 G-tube, 146–147
Bonney tissue forceps, 25, 26 hollow viscus, 145–146
Bookwalter® retraction system, 103, 111 MIC G-tubes, 147
Bovie® electrodessication system, 20, 110 PEG tubes, 147
Bowel grasper, 36 pigtail catheter, 145
Bowel injuries, 258 with suction, 148–150
Bozzini’s device, 189 T-tube, 148
Brachial plexus injuries, 66, 68, 70 Clostridium difficile, 7, 8
Bradycardia Closure, 91
causes, 322 concepts, 83
diagnosis, 323 devices, 93
treatment, 323, 324 suture options for, 92
Braided suture, 41 Cochrane Review, 3, 5
Breast, incision, 90–91 Code cart, 323–326
Bronchopulmonary segments, 112 Cognitive bias, dissection techniques, 114
B shape of staple, 138 Colonoscopy, 169, 170
Colony-forming units (CFU), 76
Colotomy, 48
C Common bile duct (CBD), 108, 112–114
Calot triangle, 113 Compartment syndrome, 74
Capacitive coupling, 132 Computed tomography (CT), dissection techniques, 109
Cardiac implantable electronic device (CIED), 134–135 Connell stitch, 61–62
Cardiac injuries, pericardiotomy, 283, 285 Continuous running locking stitch, 60–61
Carril, Pete, 309, 310 Continuous subcuticular stitch, 59
Carter-Thomason laparoscopic port closure device, 38 Cosmesis, 92
Castroviejo needle driver, 26 Counter-traction, dissection techniques, 111
Catgut, 39 Cricothyrotomy, 326–327
CBD, see Common bile duct (CBD) Critical view of safety, 114
Cefazolin, 11 Crohn’s disease, 113
Cefazolin Safety Checklist, 7, 9 Current diversion injuries, 131–133
Celioscopy, 189 Curved Crile, 29
Center for Disease Control and Prevention (CDC), 78 Curved Kelly clamp, 30
Central nervous system tumors, 114 Cushing vein retractor, 27, 100
Cephalosporins, 7 Cutting needles, 45
Cerebrovascular autoregulation, 197 Cystic duct, 113, 114
Chemical prophylaxis, 198
Chest tube, 154
choosing location, 157 D
digital technology, 156 da Vinci Skills Simulator® (dVSS), 215, 217, 223
hemothorax, 158 Daily Top Ten List, 307, 308
insertion technique, 156 Damage control laparotomy, 253, 254, 265
large pleural effusion, 158 Davidson scapula retractor, 101
precautions, 158 Dead space, closure, 91–92
removal of, 158 Deaver retractors, 27, 100
shapes, 157 DeBakey forceps, 25, 26, 120
suction to, 157 Debulking, 114
three-bottle system, 155 Decellularization, 178
Chlorhexidine alcohol, 9 Decontamination process, 80
Chlorhexidine gluconate, 77–79 Deep vein thrombosis (DVT), 11, 198
Cholecystectomy, 109, 115 Dermis, 84
Chronic inflammation, 113 Dispersive electrode, 130, 131, 135
CIED, see Cardiac implantable electronic device (CIED) Dissection techniques
Cinch grasper, 36 blunt, 109–110
Circular stapler, 137 cognitive bias, 114–115
application of, 139–140 concept, 107–109
colorectal anastomosis, 233, 234 electrocautery, 110
Cirrhotic patients, 190 exposure and planning, 108
Clamps, 28 imaging, 108–109
Clamshell thoracotomy, 280–281 incision, 109
Index 341
inflamed tissue, 113–114 definitive management, 276

instrumental, 110–111 equipment, 276
lighting during, 108 inframammary crease and/or xiphoid process, 277
neoplasm, 114 initial incision, 277
positioning, 107–108 median sternotomy, 282
retraction, 111 nipple/areola complex, 277
safety precaution, 109–114 patient position, 277
sharp, 86 pleural cavity, 278
technical and practical consideration, 109–114 sternum, 277
tissue planes, 112–113 survival rates, 275, 276
traction and counter-traction, 111 Emergency Manuals Implementation Collaborative
Distal pancreatectomy, 140 (EMIC), 333
Dobhoff tubes, 148 Endomechanical devices, 140
Double-layer and-sewn gastrojejunostomy, 230, 231 Endoscopic retrograde cholangiopancreatography
Drain (ERCP), 163, 166
care, 152–153 Endoscopic submucosal dissection (ESD), 165
chest tube (see Chest tube) Endoscopy
closed, 145 colonoscopy, 169
G-tube, 146, 147 concepts, 164–166
hollow viscus, 145 esophagogastroduodenoscopy, 166
MIC G-tubes, 147 history of, 163
PEG tubes, 147 natural orifices, 189
pigtail catheter, 145 practical consideration, 166
suction, 148, 149 procedures, 165–172
T-tube, 148 Energy devices, 129
complications, 153–154 adverse events, 131
concepts, 143 argon beam plasma coagulator, 133
cracking back, 152 cardiac implantable electronic devices, 134
French scale, 144 ultrasonic, 133
gauge system, 144 Energy-related emergencies, 133–134
genitourinary, 143 Enterocutaneous Fistula (ECF), 271
history, 143–144 Epidermis, 84
open, 145 Epithelialization, 84
pleural space, 154–158 Esophageal injury, pericardiotomy, 284
removal techniques, 153 Esophagectomy, 140
secure of, 152 Esophagogastric junction, 168, 169
sizes, 144 Esophagogastroduodenoscopy (EGD), 166
sump, 149–151 European Hernia Society guidelines, 180
technical consideration, 144–151 Expanded polytetrafluoroethylene (ePTFE) mesh, 177
types, 144 Exploratory laparotomy, trauma
Duodenal injuries, 263 abdominal aorta, 260, 261
contamination, 253
hemorrhage control, 256, 257
E incision, 255, 256
Eastern Association for the Surgery of Trauma (EAST), injury identification, 257, 258
292–293 IVC
Eastman retractor, 27 Cattell-Braasch maneuver, 259, 260
EGD, see Esophagogastroduodenoscopy (EGD) Kocher maneuver, 260
Electrocautery device, 20, 80, 110, 120 massive transfusion protocol, 254
Electromagnetic interference (EMI), 134 nonoperative management, penetrating
Electrosurgical injuries, 20, 130 wounds, 254
burn injuries, 129 positioning and prepping, 254, 255
prevention strategies, 132 preoperative setup, 254
types of, 131–133 retroperitoneal hematomas, 257
Electrosurgical unit (ESU), 130, 131, 133 surgical techniques, 253
Emergency department thoracotomy (EDT) Exploratory thoracotomy, 275, 276
advantages, 276 Exposure
anterolateral thoracotomy, 278, 281 incision and port placement, 96–97
Clamshell thoracotomy incision positioning and gravity, 95–96
exposure, 281 Extracavitary laparoscopic surgery, 201
complications, 286–287 Extraperitoneal hernia repair, 201
342 Index
F Gauze packing, 127

Fabric tape, 121 Gawande, Atul, 314, 316
Falciform ligament, 86 Gelfoam, 127
Fascial tension, 211 Gelpi retractor, 27, 101
Fasting, preoperative preparation, 6 Genitourinary drains, 143
Femoral neuropathy, 67 Gentamicin, 11
Fiber optics, 189 Gerald tissue forceps, 25
Finger fracture, 110 Gladwell, Malcolm, 311, 312
Fistula formation, 154 Glioblastoma multiforme, 114
Flexible Endoscopy Curriculum, 164 Granny knot, 52
Focused Assessment with Sonography for Trauma Gravity exposure, 95
(FAST), 276 Great vessel injury, 285–286
Forceps, 25, 26, 120
Fractured drain, 153
Frazier suction, 28 H
French scale, 144 Hair removal, preoperative preparation, 11
Fulcrum effect, 216 Hair trimming, 77
Fulguration, 133 Halsted, william stewart, 312–314
Fundamentals of Endoscopic Surgery, 164 Hand retraction, 112
Fundamentals of Laparoscopic Surgery (FLS), 221 Hand-assisted GelPort™, 201, 202
Fundamentals of Robotic Surgery (FRS), 221, 222 Hand-assisted laparoscopic surgery (HALS), 201, 202
Handheld retractors, 98, 100, 102
Hand-sewn two-layer gastrojejunostomy, 231, 232
G Harmonic® system, 111
Gambee stitch, 62 Harrington retractor, 27
Gastric tubes, 146, 147 Harrington sweetheart retractor, 101
Gastroesophageal (GE) junction, 151 Hasson technique, 48, 196
Gastrointestinal (GI) bleeding, 163 Hemicolectomy procedure, 112
Gastrointestinal (GI) tract, 164 Hemorrhage emergency, 332, 334
endoscopy (see Endoscopy) Hemorrhoidectomy, 47
stapler, 140 Hemostasis
Gastrointestinal anastomosis, 61 concepts, 119–120
anastomotic wound healing technical consideration, 120–128
intrinsic blood supply, 228 Hemothorax, chest tube, 158
local and systemic factors, 228, 229 Hepatic injuries, see Liver injuries
oxygen delivery, 229 Hepatic veins, 125
patient factors, 229 Hepatosplenomegaly, 190
atraumatic instruments, 230 Hercules knot, 50
automatic stapling devices, 227 Hernia repairs, 175, 190
circular end-to-end anastomosis stapler, 233 abdominal wall, 179
configuration, 229 antibiotic prophylaxis, 179
enterotomy, 228 mesh product (see Mesh)
granulation tissue, anastomosis, 228 Herniamed Registry, 180
hand-sewn end-to-side isoperistaltic Hilar twist technique, 283, 284
gastrojejunostomy, 230–232 Hollow viscus drain, 145, 146
hemostasis, 230 Hultl’s stapler, 137
history, 227, 228 Hybrid Vascular Graft, 249
indocyanine fluorescence green angiography, 235 Hydrodissection, 110
intestinal wall anatomy, 228 Hypertrophic scars, 92
linear stapled enteroenterostomy, 232 Hypobaric wound shield (HWS), 268
mesenteric defect closure, 233, 234
physiology of gastrointestinal wound healing, 228
stapling device, 229 I
surgical technique, 227, 230 Iatrogenic injury, 129
suture material, 229 Ileocecal valve, 171
undifferentiated mesenchymal cells, 228 Incision
unidirectional barbed suture, 234, 235 abdomen, 86
Gastrojejunal anastomosis, 139 advantages/disadvantages, 88
Gastrostomy tube (G-tube), 146–148, 168 oblique, 88
Gauge system, 144 paramedian, 86
Index 343
retroperitoneal structures, 89 L
thoracoabdominal, 89 Langer lines, 83, 84
transverse, 88 Laparoscopic surgery, 119
types, 87 abdominal findings, 190
vertical midline, 86 cholecystectomy, 112, 132, 189
breast, 90–91 in children, 203
concepts, 83 contraindications, 190
considerations, 85–86 in elderly, 203, 204
hernia formation, 208, 209 electrosurgical burn injury during, 129
neck, 89–90 graspers, 36
sharp dissection, 109 instruments, 192, 193
Infectious complications, 179, 180 medical history, 189
Inflamed tissue, dissection techniques, 113 medication history, 189
Inflow control, 127 operating room setup, 22, 190, 191
Infrarenal IVC injuries, 264 patient positioning, 191
Inguinal hernias, 175 patient safety monitoring, 202, 203
Insertion technique, chest tube, 156–157 physical examination, 190
Instrument tie, 52 postoperative care and complications
Instrumental dissection, 110 dietary restrictions, 204
Insulation failure, 131 injuries, 205
Intestinal mucosa, 228 normal activity, 204
Intestinal ostomy, 79 pain reduction, 204
Intra-abdominal contamination, 258 patient positioning, 205
Intra-abdominal pack tamponade, 253 postoperative nausea and vomiting, 204
Intraoperative cholangiography, 115 wound care, 204, 205
Intricate knots, 50 during pregnancy, 203
Inverted u-stitch, 60 retractors, 99, 104
Iodine-based solutions, 78 risks and benefits, 190
Iodophor-based solutions, 78 staplers, 138, 139
Iris scissor, 24 surgeon positioning, 191
Ischemia-reperfusion syndrome, 70 video monitoring, 191, 192
Ischemic injuries, 69 Laparotomy closure techniques, 163
abdominal wall, 207, 208
automated sewing machines, 212
J double-stranded absorbing suture, 209
Jackson-Pratt (JP) system, 149 experimental and clinical studies, 208, 211
Job security, 307 incisional hernias and infection, 207
Junior faculty member success, 317, 319 midline laparotomy (celiotomy) incision, 207
patient-related risk factors, 207
predictive models, 211
K prophylactic mesh, 212
Kelly retractor, 27 randomized controlled trial, 209
Keloid scar, 92 skin and fascial incision, 208
Kidney injuries, 263, 264 surgical site infection, 210–211
Knitted meshes, 175 surgical techniques, 212
Knot security, 51 suture and needles, 209
Knot tying, 50 suture material, 209
body cavity, 57–58 suture type, 209
under circumstances, 56 suturing fascia and muscle, 211
instrument tie, 52 suturing technique, 209
ligation around hemostatic clamp, 57, 58 technical considerations, 209
one-hand and two-hand techniques, 51 types, 211
practicing, 51 wound healing, 207
under tension, 56 wound length ratio, 209, 210
types, 52–53 Laparotomy incision, 208
Knotless suturing, 62 Laser dissection, 111
Kocher clamp, 30 Lateral decubitus position, 70, 73
Kocher incision, 88 Lateral position, operative room, 71, 73
Kocher maneuver, 112 Lembert suture, 61
Kraissl line, 84, 92 LigaSure® system, 111
344 Index
Ligatures, 50 Metzenbaum dissecting scissor, 24

Linea alba, 86 Metzenbaum scissor, 24, 109
Linearly stapled enteroenterostomy, 232 MIC G-tube, 147
Linear stapler, 139 Midline incision, abdomen, 86
Lithotomy position Miller’s knot, 50
dissection techniques, 108 Minilaparotomies, 189
operative room, 73, 74 Minimally invasive surgery (MIS), 65, 181
Liver injuries Mixter clamp, 120, 126
anterior hepatic packing, 261 Modern surgery, 1, 45
diaphragmatic movement, 261 See also Preoperative preparation
hemostatic agents and techniques, 262 Modified Gambee stitch, 63
lateral hepatic packing, 261 Modified radical mastectomy (MRM) incisions, 91
liver mobilization and vascular control, 261 Monofilament polyester mesh, 176
parenchymal lacerations with sutures, 262 Monofilament suture, 41, 152
posterior hepatic packing, 261 Monopolar devices, 129, 130, 133, 135
Pringle maneuver, 261, 262 Mosquito Crile, 29
severe hemorrhage, 261 Multidrug-resistant bacteria, 65
small parenchymal lacerations, 261 Multifilament suture, 41
suture repair, 262 Murphey’s system, 144
LoneStar®, 103, 111
Long-term effects of smoking, 3
Lower limb nerve injuries, 66 N
Lung injuries, 283–285 Nasogastric (NG) tube, 150–151
Lysostaphin, 180 National Aeronautics and Space Administration (NASA),
215
National Surgical Quality Improvement Program
M (NSQIP), 4
Magnetic resonance imaging (MRI), dissection Neck incision, 89
techniques, 109 Needle(s)
Malnutrition, 2 anatomy, 44
Mannitol, 134 body, 45
Maryland dissector, 36 comparison chart, 46
Mastectomy, 112 current controversies/future directions, 49
Maxon™, 47 driver
Mayo scissor, 24 advancing, 54
Mayo-Hegar needle driver, 26 handling, practicing, 55
McBurney incision, 88, 96 holding and loading, 54
Mechanical bowel preparation (MBP), 5 use of, 53
Median sternotomy, 281–283 history, 40
Medical student success, 317, 318 holder, 25, 53
Mentorship, 166 materials, 44–47
Mesenteric vessels, 125 modern surgical needles, 45
Mesh positioning, 53
bioabsorbable, 177 puncture, 40
biologic, 177, 178, 181 technical/practical considerations/safety precautions,
characteristics, 175 47
complications, 176 tissue entry and exit, 55
concept, 175–176 types, 44, 45
degradation, 179 Negative pressure therapy system (NPTS)
fixation techniques, 182–183 applications, 267
implantation, 181–182 sponge-based, 268–270
infectious complications, prevention, 179–180 towel-based, 267–269
permanent synthetic, 176, 177 visceral protection, 269
positioning of, 181 Negative-pressure wound therapy (NPWT), 158–160
products, 175 Neoplasm, dissection techniques, 114
selection, 181 Nerve injury
weight of, 175 lower limb, 66
Methicillin-resistant Staphylococcus aureus (MRSA) peroneal, 66, 69
biofilms, 180 ulnar, 67
Metronidazole, 11 Neuropraxia, 66
Index 345
Nipple areolar complex (NAC), 91 needle holder, 25

Nissen fundoplication, 164 NOTSS, 303
Nonabsorbable suture, 43, 152 obturator, 37
Nonanatomic stapled lung resection, 283, 284 open operative technique, instrumentation and
Nonmetallic Mesh Surgical Insert for Hernia Repair, 175 equipment for, 21–22
Non-perforating towel clip, 29 patient-centered care, 298
Nonremovable drain, 153 patient positioning, 65
Non-sterile members of OR team, 17 falls risk, 66
Normothermia, 8 lateral, 71, 73
NPWT, see Negative-pressure wound therapy (NPWT) lithotomy, 73, 74
Nutritional evaluation and supplements, 2 ocular injuries, 66
peripheral neuropathies, 66, 67
pressure ulcers, 67–70
O prone, 74, 76
Oasis™ dry suction water seal chest drain, 156 supine, 70, 71
Oblique abdominal incision, 88–89 technical/practical considerations, 70–76
Obturator, 37, 75 Trendelenburg position, 72
Ocular injuries, 66 perfusionists, 300
Omni system, 103 personal protective equipment, 20–21
Omni-Tract® retraction systems, 111 pharmacists, 300
Open drain, 145 pharmacy technicians, 300
Open wounds, 79 port closure device, 38
Operating room (OR) retractors, 25, 27
abdominal laparoscopic procedure, 34 safety culture, 298
anesthesia setup, 18 scalpel, 23
anesthesia team, 299 scissors, 24, 25
body exhaust suit, 21 shared mental model, 298, 300
camera, handling, 34, 35 situational awareness, 303
caring for patient, 17 specialized equipment, 20
clamps, 28 specialty physicians, 300
circulator, 299 sterile field, 18
code of behavior, 303 sterile instruments, 20
communication, 300–301 sterile vs. non-sterile members, 17
components, 18, 20 suction, 27
decision-making, 303 suction cannulae, 37
electrosurgical and powered devices, 20 surgeon’s team, 298–299
endoscope, 35 surgical cap/bouffant, 21
environment of, 65 surgical gown, 21
equipment, 18 surgical mask, 21
eye protection, 21 surgical safety checklist, 300, 301
feedback, 301–302 surgical technologist or scrub nurse, 299
fires, 129, 133 table, 19–20
electrosurgery (see Electrosurgery) team communication, 298
management, 134 trocars, 37–38
prevention strategies, 134 Operative catastrophes
followership, 301–302 ACLS, 322
forceps, 25 bradycardia
housekeeping personnel, 300 causes, 322
illumination during surgery, 20 diagnosis, 323
imaging system, 32, 34 treatment, 323–324
industry representatives, 300 cardiac arrest
IT support, 300 diagnosis, 325, 326
knife handles, 23 shockable or non-shockable rhythm, 325
laparoscopes, 28 treatment, 326
laparoscopic and robotic surgery, 22 cognitive aids, 321–323
laparoscopic graspers, 36 crisis checklists/emergency manuals, 333, 336
laparoscopic tower, 32 failed airway
lead, 21 airway anatomy, 328
leadership, 300–303 diagnosis, 327
Mayo scissor, 24 treatment, 327–331
346 Index
Operative catastrophes (cont.) lung injuries, 283–285

future directions, 336 median sternotomy, 281–283
hemorrhage emergency, 331–332, 334 one-handed compressions/angling, 279
hypotension tense pericardium, 279
assessment, 328 trapdoor incision, 283
causes, 328 Peripheral neuropathies, 66–67
crisis checklist, 329, 332 Peritoneal cavity access, 196
treatment, 331 Permanent synthetic mesh, 176
hypoxemia expanded polytetrafluoroethylene, 177
assessment, 328 polyester, 176
causes, 328 polypropylene, 177
crisis checklist, 329, 333 polyvinylidene fluoride, 177
treatment, 331 Peroneal nerve injury, 66, 69
tachyycardia Personal protective equipment, 20
causes, 324 Petz clamp, 137
clinical evaluation, 324 Phasix™, 177
diagnosis, 324 Pigtail catheter, 145
treatment, 324, 325 Pleural effusion, chest tube, 158
Optical trocars, 34 Pleural space drainage, 154–158
Ostomy, 79 Pneumoperitoneum, 193, 194
blunted trocar for Hasson technique, 196
carbon dioxide gas, 197
P high-pressure readings, 197
Palmer’s point, 34 insufflation, 197
Pancreatic adenocarcinoma, 114 optical trocar, 196
Pancreatic injuries, 263 physiologic effects
Pancreaticoduodenectomy, 112 gas specific effects, 197
Panniculectomy, 47 pressure specific effects, 197, 198
Parachute technique for anastomosis creation, 247 trocar placement, 198–200
Paramedian abdominal incision, 86–88 Veress needle, 195, 196
Parathyroid incisions, 89 Polydimethylsiloxane, 180
Parietex (PCO) composite mesh™, 176 Polyester mesh, 176
Passive drainage, 143 Polyethylene terephthalate (PET), 176
Patch techniques, 267 Polypectomy, 172
Patient education, preoperative preparation, 2 Polypropylene mesh, 175, 177
Patient positioning, operating room, 65 Polytetrafluorethylene (PTFE) patches, 268
falls risk, 66 Polyvinylidene fluoride mesh, 177
lateral, 71, 73 Poole suction, 28
lithotomy, 73, 74 Porcine dermal collagen mesh, 179
ocular injuries, 66 Port closure devices, 38
peripheral neuropathies, 66, 67 Portal veins, 126
pressure ulcers, 67, 70 Positioning, exposure, 95
prone, 74, 76 Postmastectomy drainage device, 144
supine, 70, 71 Postsurgical injuries, 65–67, 70
technical/practical considerations, 70–76 Potts scissor, 24
Trendelenburg position, 72 Powered devices, 20
Patients with diabetes mellitus, preoperative preparation, Prehabilitation, 4
3 Preoperative home showering, 77
PDS Plus, 49 Preoperative preparation
PDS™, 47 antibiotic prophylaxis, 7–8, 10
Peeling technique, 110 blood conservation, 4–5
Percutaneous endoscopic gastrostomy (PEG), 147, 163 fasting, 6–7
Perforating towel clip, 29 hair removal, 11
Pericardiotomy history and examination, 1–2
aortic cross clamp, 279–280 mechanical bowel preparation, 5
blood-filled chest, 283 normothermia, 8
cardiac injuries, 283, 285 nutritional evaluation and supplements, 2–3
clamshell thoracotomy, 280–281 patient education, 2
esophageal injury, 284 patients with diabetes mellitus, 3
great vessel injury, 285–286 prehabilitation, 4
Index 347
skin preparation, 9 Rhabdomyolysis, 70

smoking cessation, 3–4 Richardson retractor, 27, 100
stoma siting, 5–6 Richardson-Eastman retractor, 27, 100
surgery procedures, 8 Robotic arm docking sequence, 218
surgical checklist, 7 Robotic skill acquisition, 221
surgical site infection prevention, 7 Robotic surgery
venous thromboembolic prophylaxis, 11–12 automatic detection of errors, 217
Preperitoneal mesh placement, 182 intraoperative phase
Pre-peritoneal oblique incision, 89 instrument insertion, 220
Pressure ulcers, 67, 70 surgeon console, 220
Primitive esophagoscopies, 189 surgical cart, 218
Pringle maneuver, 128 trocar placement, 217
Proficiency-based training, FRS, 222 laparoscopic surgery
ProGrip™, 176 advatages, 216
Prone position, operative room, 74, 76 camera platform, 216
Proprietary knots, 50 degrees of freedom, 216
PROUD trial, 49 ergonomic equipment, 216
Pulmonary hilum control, 283, 285 instrument handling, 216
Pulmonary segmentectomy, 112 learning curve, 215
Purse-string suture, 61, 154 motion amplification adjustments, 216
motion reversal elimination, 216
surgeon’s hand motions, 216
Q three-dimensional anatomy, 215
Quill SRS™, 49 tremor elimination, 216
Quill™ Knotless Tissue-Closure Device, 49 operating room setup for, 22
postoperative phase, 221
preoperative phase, 217
R safety mechanisms, 217
Rack-and-pinion retractor, 278 simulation tasks, 224
Rake retractor, 27 surgeon competancy, 221
Rapid five-step technique, 327 team communication issues, 217
Reanastomosis, 140 telepresence, 215
Rectal anatomy, 112 Robotic trocars, 218
Reef knot, 52 Rumel tourniquet, 128
Renal injuries, 263, 264 Running whipstitch, 60
Resident success, 317, 319 Russian staplers, 137
Resuscitative endovascular balloon occlusion of the aorta Russian tissue forceps, 25, 26
(REBOA), 286 Ryder needle driver, 26
Retention sutures, 92
Retractors, 25, 95
dissection techniques, 111 S
effective recruitment of the operative assistant, 97 Sacrum position, 74
handheld retractors, 98, 102–103 Safety precaution
laparoscopic fan-style retractor, 102 dissection techniques, 109–114
laparoscopic procedures, 99 patient positioning, operating room, 70
laparoscopic retractors, 99, 104 Scalpel, 23
large-scale field exposure, 97 Scissors, 23
moment-by-moment adjustments, 97 Seldinger technique, 145
open procedures, 99 Self-retaining retractors, 98–99, 103
self-retaining retractors, 98–99, 103 Senn retractor, 27, 100, 103
Senn retractor, 103 Sequential compression devices (SCD), 198
types of, 97–102 Sewing, 50
wound protector, 102 Sharp dissection, 86, 109
Retroflexion, 168, 171 Short bite technique, 209
Retrohepatic injury, 261 Short stitch technique for laparotomy closure, 211
Retromuscular repairs, 182 Short-term effects of smoking, 3
Retroperitoneal hematoma, 257 Silo technique, 267
Retroperitoneal incision, 89 Simple knot, 52
Retrorectus repair, 182 Simulation-based curriculum, robotic surgery, 221, 224
Reverse cutting needle, 45 Single-incision laparoscopic surgery (SILS), 198–200
348 Index
Single-layer hand-sewn gastrojejunostomy, 232 care complexity, 291, 292

Skin layers, 84, 85 communities online forums, 291
Skin closure, 83, 91, 93 formal programs, 291
concepts, 83–85 intraoperative assistance, 291
suture options for, 92 mentorship, 291
Skin hooks, 100, 112 metrics, 291
Skin preparation, 76–77 operative and clinical performance
antiseptic agent, 78 assessments, 290
antiseptic-related fires, 79 preoperative planning, 291
hair trimming, 77 re-operative surgery, 291
preoperative home showering, 77 seeking out opinions, 291
preoperative preparation, 9 social media outlets, 291
sterilization process, 80 success, 291
surgical site, 77–78 surgical complications, 292–293
Slip knot, 52 transition, 290
Smoking cessation, 3 volume, 291
Society of American Gastrointestinal and Endoscopic Sutures, 50–51
Surgeons (SAGES), 164, 166, 293 absorbable suture, 42
Spinous process, 74 approximating skin and soft tissues, 58
Splenectomy, 262 baseball stitch, 60
Splitting technique, 109 bite size, 56
Square knot, 51, 52 body positioning, 55–56
S-retractor, 27 continuous running locking stitch, 60
Stapled enteroenterostomy, 233 continuous subcuticular stitch, 59–60
Stapled ileocolonic anastomoses, 227, 228 current controversies/future directions, 49–50
Stapled tractotomy technique, 283, 284 Gambee stitch, 62
Stapling device gastrointestinal anastomosis, 61
application of, 138, 139 goals of, 58
complication, 140 history, 39–40
history of, 137 inverted u-stitch, 60
linear vs. circular, 139 knotless, 62–63
mechanics of, 138–139 Lembert suture, 61
Sterile field, 18 ligatures, 60
Sterile members of OR team, 17 materials, 41–44
Sterilization process, 80 multifilament/braided, 41
Sterilizing agents, 81 natural materials, 41
Stoma siting, 5 needle curves and uses, 47
Straight Crile, 29 needle driver, 53–55
Straight Kelly clamp, 30 needle holder and correct needle positioning, 53
Stratafix™, 49 non-absorbable suture, 41, 43
Stratum basale, 84 package, anatomy/dissecting, 40–41
Stratum lucidum, 84 pressure and, 126
Subcutaneous tissue, 84 purse-string suture, 61
Suction cannulae, 37 simple interrupted, 58–59
Suction devices, 27, 37 size, 41
Sump drain, 149–151 synthetic materials, 41
Supine position, operative room, 70, 71 tail control, 56
Supraceliac control, 127 technical/practical considerations/safety precautions,
Supradiaphragmatic occlusion, 128 47–49
Suprarenal aortic injuries, 264 USP sizes, 44
Surgeon’s knot, 52 vessels and, 121
Surgeon’s overall effort, 312 Swaged sutures, 45
Surgical checklist, preoperative preparation, 7 Sweetheart retractor, 27
Surgical effort, 312 Synthetic meshes, 175, 182
Surgical knots, 52 bioabsorbable, 177
Surgical site infection (SSI), 7, 49, 76, 77, 91 expanded polytetrafluoroethylene, 177
Surgical site preparation, 78 polyester, 176
Surgical training polypropylene, 177
accreditation process, 290 polyvinylidene fluoride, 177
Index 349
T United States Surgical Corporation, 137

Tachycardia US Army retractors, 100
causes, 324
clinical evaluation, 324
diagnosis, 324 V
treatment, 324, 325 Vacuum-assisted closure (VAC) therapy, 158–160
Tapered needles, 44, 49 Vancomycin, 8, 11
Telepresence surgery, 215 Vascular anastomosis
Temporary abdominal wall closure, 258 anastomotic narrowing, 248
clinical scenarios, 265 anatomy, 243
damage control, 265, 271 anticoagulation, 242
indications, 266 arteriotomy and venotomy, 242
noncommercial methods, 268 atherosclerotic calcification, vessel, 240
NPTS autologous vein graft, 242
applications, 267 complications, 247, 248
sponge-based, 268–270 conduit, target vessel preparation, 242
towel-based, 268, 269 double-barreled, monofilament suture, 246
visceral protection, 269 emergency maneuvers, vascular control, 248
patch technique, 267, 268 exposure of vessels, 239, 240
practical/safety precautions four-quadrant repair, 246
early complications, 270 hybrid graft, 249
enterocutaneous fistulas, 271 iatrogenic/traumatic defect, 246
late complications, 271 instruments, 239, 240
postoperative care, 270–271 intraluminal insertion, 249
silo technique, 267 parachute technique, 247
skin-only closures, 266 patch repair, 245, 246
by vascular surgeons, 265 physiology, 245
Ten Commandments, 308, 309 postoperative bleeding, 248
Tenotomy scissor, 24 proximal and distal vascular control, 240, 241
Tensile strength loss, 44 PTFE graft, 241
Tension pneumothorax, 155 quadrant repair technique, 247
The Joint Commission on Accreditation of Healthcare single, continuous, monofilament suture, 246
Organizations, 91 suturing, 247, 249
Thopaz® digital chest drainage system, 156 traumatic/iatrogenic vascular injury, 248
Thoracoabdominal incision, 89 Vascular control
Thyroid incisions, 89 clamp-tie-divide-tie method, 123
Tissue plane, dissection techniques, 112 with division between clamps, 122
Tobramycin, 11 with suture ligature, 124
Tracheal hook, 330 Vascular injuries, 264
Tracheostomy, 89, 331 Vascular repair and anastomotic creation, 239
Traction Vascular shunts
dissection techniques, 111 anastomotic creation, 243
prevention, 75 distal perfusion, 244
Transportation process, 259 forward flow preservation, 244
Transverse incision, abdomen, 88 hemostasis and suture repair, 244
Trauma laparotomy, see Exploratory laparotomy, trauma reperfusion, 243, 244
Trauma thoracotomy, 275 vascular clamps, 244
Trendelenburg position, 72, 96, 107 Vascular surgery
Triclosan, 49 instruments, 249
Triple-channel Davol drain, 150–152 vascular clamps, 249
Trocars, 37 See also Vascular anastomosis
Trousseau dilator, 331 Veins
T-tube, 148, 149 hepatic, 125
portal, 126
Velcro®-like closing technique, 268
U Venotomy, 242
Ulnar neuropathy, 66, 67 Venous thromboembolic prophylaxis, 11
Ultrasonic energy devices, 133 Veress needle, 34
Ultrasound dissection, 111 Vertical midline incision, abdomen, 86
350 Index
Vessels Wooden, John, 315, 317, 318

mesenteric, 125 Work relative value units (wRVUs), 312
stenosis/occlusion, 245 Wound healing, 85, 92
suture and, 121 Wounds
Vinylidene difluoride, 177 open wounds, 79
V-Loc™ Absorbable Wound Closure device, 49 VAC therapy, 158–160
See also Closure
Woven mesh, 175
W
Water-jet dissection, 110
Weitlaner retractor, 27, 101 Y
Wittmann Patch™, 267, 268 Yankauer suction, 28

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What is the book about?

What is the book about?

What are some surgical instruments mentioned?

What are some surgical instruments mentioned?

Fundamentals of

ISBN 978-3-319-75655-4 ISBN 978-3-319-75656-1 (eBook)

Library of Congress Control Number: 2018941249

© Springer International Publishing AG, part of Springer Nature 2018

Printed on acid-free paper

It is with great excitement that we present to you the first edition of

We are indebted to the many superb authors who contributed chapters to

Philadelphia, PA, USA Francesco Palazzo

1 Fundamentals of Patient Preparation for the Operating

13 Fundamentals of Prosthetic Materials

Navid Ajabshir Mount Sinai Medical Center, Comprehensive Cancer

Katerina Dukleska Department of Surgery, Sidney Kimmel Medical

Joshua A. Marks Department of Surgery, Sidney Kimmel Medical College,

Michael J. Rosen Cleveland Clinic, Cleveland, OH, USA

1.1 General Concepts Finally, preoperative education is an important

© Springer International Publishing AG, part of Springer Nature 2018 1

Mechanical bowel preparation (MBP) before 1.2.8 Stoma Siting

Fig. 1.1 Cefazolin Have you had

Have you taken penicillin, a

Yes Did you ONLY experience GI

Table 1.2 Recommended antibiotics for prophylaxis of general surgery proceduresa

Table 1.3 Recommended dosing and re-dosing of antimicrobial prophylaxisa

consistently as recommended nor as often as sur- guidelines recommend delaying administration

physicians evidence-based clinical practice guidelines thromboembolism. Am J Health Syst Pharm.

2.1 Introduction cient operation for the patient. However, it is

© Springer International Publishing AG, part of Springer Nature 2018 17

2.1.1.2 The Sterile Field 2.1.2 Introduction to Operating

2.1.2.2 Operating Room Table It is important to be mindful where the base of

• OR scrubs should be changed at least daily. 2.2 Technical Considerations

2.2.2 Basics of Setup Surgery is an ever-evolving field with surgical

the arteriotomy or venotomy. In contract, scis- Needle Holders (Fig. 2.8)

the task at hand. They can be handheld or self-­ Suction (Fig. 2.11)

Clamps (Figs. 2.12, 2.13, 2.14, 2.15, 2.16,

Fig. 2.15 (a) Kocher

that is usually visualized in two dimensions. In Imaging System

Endoscopy in general surgery has many applica-

Fig. 2.19 Top to bottom, (a and c) 0° laparoscope, (b and d) 30° laparoscope

Fig. 2.20 Top to

Laparoscopic Graspers (Figs. 2.20

Most laparoscopic instruments have a 360° rotat-

 uction Devices and Cautery

Fig. 2.22 Top to

Port Closure Device (Fig. 2.24) 1. Kennedy L. Implementing AORN recommended prac-

3.1 Sutures and Needles wounds and tendency to cause suppuration.

© Springer International Publishing AG, part of Springer Nature 2018 39

Table 3.1 Physical properties of absorbable suture and common uses

Covidien = Surgipro 2 years, 66% at 11 years

Table 3.3 U.S.P. suture sizes 3.1.2.3 Needles

Fig. 3.3 Types of

General Surgery Cuticular

Taper Point Reverse Cutting

5/8 Circle 1/2 Circle

1/2 Circle Heavy Body Straight Cutting

CT-2 GS-22 HR26S 26 mm

between interrupted stitches to prevent the suture

Fig. 3.5 Types of surgical knots. (a) A simple knot is one

Philadelphia, PA, USA Francesco Palazzo

1 Fundamentals of Patient Preparation for the Operating

13 Fundamentals of Prosthetic Materials

1.1 General Concepts Finally, preoperative education is an important

Mechanical bowel preparation (MBP) before 1.2.8 Stoma Siting

2.1 Introduction cient operation for the patient. However, it is

2.1.1.2 The Sterile Field 2.1.2 Introduction to Operating

2.1.2.2 Operating Room Table It is important to be mindful where the base of

• OR scrubs should be changed at least daily. 2.2 Technical Considerations

2.2.2 Basics of Setup Surgery is an ever-evolving field with surgical

the arteriotomy or venotomy. In contract, scis- Needle Holders (Fig. 2.8)

the task at hand. They can be handheld or self- Suction (Fig. 2.11)

Clamps (Figs. 2.12, 2.13, 2.14, 2.15, 2.16,

that is usually visualized in two dimensions. In Imaging System

Laparoscopic Graspers (Figs. 2.20

uction Devices and Cautery

Port Closure Device (Fig. 2.24) 1. Kennedy L. Implementing AORN recommended prac-

3.1 Sutures and Needles wounds and tendency to cause suppuration.

Table 3.3 U.S.P. suture sizes 3.1.2.3 Needles

4.1 Introduction 4.2 General Concepts

The evolution of surgery from being performed 4.2.1 OR Environment

factor is the duration of the procedure, with 4.3.2 Basic Positions

4.4.4 Antiseptic Solutions

5.1 Introduction with describing the more optimal placement of

A pre-peritoneal oblique incision is per- 5.3.4 Incisions: Retroperitoneal

aspects of the outer and inner quadrants, cur- 5.4 Closures

5.5 Current Controversies/ • Three major goals of skin closure include

6.1 Introduction tors appear to be miniature versions of their open

6.3.2 Handheld Retractors Retractor blades are rectangular, positioned at

7.1 Introduction importance of the fundamentals of surgical tech-

7.2.2 Lighting Cross-sectional imaging has become an invalu-

7.4 Current Controversies

Surgical resection of a neoplasm requires several 7.4.1 Cognitive Bias in Surgery

8.1 Fundamentals of Surgical from a cumulative experience of 215 years of