· SEPERATION OF THE TISSUES:

While performing operations, soft tissues are seperated using sharp surgical instruments like scalpel and scissors. The general principle behind the seperation of the soft tissues is their level-by-level sectioning. The direction of the incision must correspond to the the underlying large blood vessels and nerves in order to avoid damaging them; and it is also very important to take into view the Langer’s lines, locations of which characterize the direction of the connective tissue fibers in the deep layers of the skin.

1 " as a “kitchen-knife” (положение «кухонного ножа»),

2 " as a “pen-grip” (положение «писчего пера»),

3 " as a “fiddlestick” (положение «смычка»),

The procedure is:

1. Handling of the edges of a skin wound:

The edges of the skin wounds must be carefully handled, as it is the edges that help in the closing of the wound and in turn, in their better healing. The wound edges can be held with the help of anatomical forceps, sharp or blunt -two or four toothed retractors. Only those sites of skin that are to be later removed can be handled with the surgeon’s forceps.

2. Dissection of the soft tissues:

The surgeon dissects the skin, fascias, muscles and peritoneum and then mobilizes the underlying blood vessels and nerves.

Fascias: After the incision on the skin, the surgeon lifts the fascias along with the subcutaneous fatty layer from the centre with the help of two surgical forceps. Then holding the scalpel blade upwards, the fascia is dissected throughout the length of the skin incision.

Muscles: The muscles of the abdominal walls must not be dissected inorder to prevent the possibilities of formation of post-operative hernias. The muscles must be simply moved apart along the direction of the fibers with the help of blunt instruments.

Peritoneum: The parietal leaf of the peritoneum is to be held apart with the help of two anatomical forceps, and cut open with the help of scissors along the length of the skin incision, in such a way that the surgeon is able to insert his II nd and III rd fingers inside the peritoneal cavity.

Fig. 2. Dissection of parietal peritoneum.

    Blood vessels: Assistant applies pressure on those blood vessels that were cut with gauze tampons. Then the bleeding is stopped immediately with the help of haemostatic Pean’s or Kocher’s clamps, followed by their ligation. Haemostasis can be done using diathermo-coagulation.

·SUTURING OF THE TISSUES:

    Suturing the tissues can be done either manually by using continuos sutures and knots or mechanically with the help of suturing instruments or by sticking the ends together by polimerization when the liquid monomers are exposed to the tissue liquids accompanied by fast hardening. The choice of method of suturing depends on the kind of tissues, the complication level of the operation and the availability of instruments in the clinic. 

  The manual method of the application of the sutures is the most commonly used method of tissue connection. Sutures are applied with the help of needles, needle holder and suture materials.

  There are wide varieties of suture materials like silk, catgut, wire, etc. The choice of the sutre material depends on the suture demands, for which comparison of the quality, advantages, and disadvantages of each of these materials. For example, the silk thread does not resorb with the tissues, while the catgut can resorb with the tissues within 12-24 days: however, the reliability and durability of the catgut is lower. In those cases when the durability of the suture is demanded, silk is more often used (for example suturing the aponeurosis while treating hernias).

    Cutting needles, which are three - edged on cross section ae used for suturing relatively dense tissues like skin and aponeurosis. Pricking needles, which are round on section, are used for suturing reelatively compliable tissues like the intestines and the muscles.

  The needle is held at the posterior 1/3 rd end of the needle holder. Suture materials of length of 15-18 cm are used for knot sutures and longer for continuous sutures. The thread is inserted into the needle. Intestinal sutures are sometimes applied with the help of straight needle without the needle holder.

Fig. 3. The needle is held at the posterior 1/3 rd end of the needle holder.

      The thread is inserted into the needle.