SET UP THE MICROSCOPE

STEPS OF PREPARATION OF THE MICROSCOPE FOR THE OPERATION

- Position the microscope over the table for the operation, and
as required by the surgeon, be sure to leave space required
by the assistant, scrub nurse, anesthesia team, equipment
and sterile trolleys
- Arrange the path of the mains lead from the wall socket to
Ensure that it is not in the path of flow of the OT staff

- check and tighten, if necessary, the safety locks between
Microscope and stand

- Ensure that correct objectives and binocular tubes are
Inserted for the particular operation
- Clean the objectives and eyepieces of main, and assistants’
Microscope
- Switch on the microscope
First at the wall socket
Second at the stand
Switch on the lights
- After the operation this procedure of switch off must be reversed
- First switch off lights, next stand, lastly wall switch
- Ensure all sterilzable caps or drapes are available

WHEN NOT IN USE CARE

Dust is very harmful for microscopes thus they should be kept
Covered with a dust cover when not in use and never left without
Objective, binocular tube or eyepieces fitted.
* Cameras are kept locked up for security; the dust cap should be put on the outlet
* All accessories, spare objectives, and eyepieces, should be
kept in dust proof containers
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OPERATING MICROSCOPE

HOW IS DOCUMENTATION AND TRAINING HELPED BY USE OF MICROSCOPES?

It has been possible to document (photograph) different
stages of the procedure, and record the finding, as observed
through the microscope.
This progress have been achieved through
Fig.
- Introduction of high speed artificial light color films
- Introduction of 35 mm film color camera with automatic
Exposure control
- Introduction of co-axial flash equipment, controlled through
Sensor in the modern 35 mm. camera

Cine camera also has been adapted for the microscope work.

Today high quality color television cameras have also been
Introduced:
A. These have facilitated Video recording of procedures.
B.These Video films are cheaper than Cine films
C.Light weight, Solid state inexpensive cameras can provide
excellent observation facilities for training of Microsurgery trainees

WHAT CARE AND MAINTENANCE IS REQUIRED?

. At least two members of OT staff should be trained for round
The clock responsibility of checking, setting up and storing
the instrument
. These staff members keep contact with the manufacturer/supplier of the microscope on the performance of microscope
. They should have read the supplied instruction books
. Supplies of spare parts, such as lamps, fuses and
sterilizableA caps or disposable drapes are always kept in stock
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MAGNIFICATION IN SUGERY

OPERATING MICROSCOPE 2




HOW TO CONTROL the functions of the microcope during surgery?

In the case of the manual microscope, all controls such as
Focusing, magnification, change the tilt of the microscope, are
Done by different hand knobs.
- These can be covered with sterilzable rubber caps provided
with the microscope OR
\
- The complete instrument (besides the eye pieces) can be draped with a loose sterile plastic drape, and the knobs adjusted through this drape
OR
With motorized microscopes, the functions are controlled by a foot switch.
- The controls can also be built into a specially designed
surgeons Operating chair. OR

- Alternatively a hand switch, inserted into a sterile plastic
bag for use during operation

What are the parts of the ASSISTANTS' MICROSCOPE ATTACHMENT?
An assistant’s microscope is a separate binocular viewing
system with eye pieces.
-It provides the same stereo image as seen in the main microscope.
-This is through a beam splitter, which splits the image and directs it to the assistants' microscope, which has its own independent magnification control.
-This makes it possible for the assistant to participate and
assist in Surgical procedures.

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MAGNIFICATION IN SURGERY

OPERATING MICROSCOPES

WHAT ARE THE USES OF MAGNIFICATION?
The use of controlled magnification has been a recent addition to the instrument list.

Loupes and magnifying glasses have been used in the past, but operating microscopes have improved the clarity ease of use, the depth of focus, and the lighting of the site of the operation.
Complicated two layer suture on small structures
- can be performed quickly,
- accurately and in comfort
- With no strain on the neck muscles.
Operating microscope can be:
1. Floor Mounted Fig 6.1
2. Ceiling Mounted Fig 6.2

What are the Features of an Operating Microscope?
They can be;
* Hand operation or foot operation microscopes for focus
* Automatic focuses and zooms
* Can have Assistant Microscope view arm so he can view and assist
* Camera attachment arm for recording procedures.

WHERE IS a microscope USED?

The operating microscope is used for two purposes:
- The first is to provide a magnified view of small structures
(Small vessel and nerve anastmosis).
- The second is to provide a magnified view of larger
Structure upon which more precise surgical procedure needs
To be performed (Disc surgery).

Explain what ARE THE features OF OPERATING MICROSCOPES?

There are two basic types of operating microscope, with
Several variations, depending upon the surgical specialty
Involved.
- The first is the manual type, featuring hand controlled
Fixed magnification stepwise(x6x9...) and control knobs for
Focus Fig. 6.3
- The second type is the zoom system, this has the advantage
Of offering continuous magnification through the whole range
Of the magnification of the system including focus through
Foot controls.
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WOUND CLOSURE 7

SUTURES AND LIGATURES NON ABSORBABLE 2



Metallic wire

Suture wire is prepared mainly from three metals –
non-toxic Stainless steel,
the alloy Tantalum and
Silver.

All these may be obtained as a single-strand monofilament
suture
The first two as several strands, either twisted or
braided, known as multifilament wire.

Surgical stainless steel suture wire is used mainly in
orthopaedics and thoracic surgery.
A stouter wire of sizes 3 to 9(0 to 7) or 29 SWG would be needed for wiring fragments of bone together.

Metal clips (ligature)

Ligatures of flattened silver or tantalum wire are used in
Neurosurgery, and chest surgery, for arresting hemorrhage from
small vessels.
The insertion forceps and cartridges, allow their use for this purpose at depths with safety Fig 5.4.5.1

Metal clips (suture)

These are metal clips having two sharp points which when the
clip is closed, these points grip the edges of the skin incision
and hold them in apposition.

The original types in use are Michel and Kifa Fig 5.4.6.2

Staples

During the past few years there has been considerable
development in the field of suture staples.

These range from disposable magazines of staples which fit
an insertion instrument to completely disposable units.
Examples of two of the latter are
Proximate II(Ethicon) and
Appose (Davis & Geck) Fig 5.4.7.1a,b,c
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WOUND CLOSURE 6

WHAT ARE THE SYNTHETIC NON-ABSORBABLES?

Polymide (Nylon) Mono-filament

This is a single strand of polyamide supplied in sizes
rangeing from 0.2 to 2 (10/0 to 2).

The material can be obtained in multiple pre-cut lengths,
from 35 cm to 1 m.

Polyamide as a single thread is inert and can be safely used
in the presence of infection. It may be left in the tissues with
very little reaction occurring.

Monofilament examples of this material include Ethilon, blue
(Ethicon);
Surgidek, blue or black (Surgicraft); and
Dermalon, white, blue or black (Davis & Geck).

BRAIDED

This is used in a similar manner to braided silk.
The sizes available range from 0.7 (6/0) to 2(5), with the same tensile strengths as braided silk.
The two colours available, black and blue.
It is generally supplied in multiple pre-cut lengths of
between 35 cm (14 in) and 1 m(40 in), sterile in peel-open packs.
The material is available also armed with non-traumatic needles.

Examples of this material include Nurolon (Ethicon) and
Surgilon (Davis and Geck).

Polypropylene

The material is available in sizes 0.2 to 5 (10/0 to 2),
with or without needles.
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WOUND CLOSURE 5

Suturs and ligatures 5




WHAT ARE THE NON-ABSORBABLE LIGATURES AND SUTURES?

Non-absorbable sutures are not generally used in an infected
wound as they may cause sinus formation.

SILK

This material, generally white or black, is braided from
numerous fine strands of silk. It is supplied on sterilizable
spools 20 to 100 m (25 to 125 yds), or in multiple pre-cut
lengths ranging from 35 to 45 cm (14 to 18 in), and a single pre-
cut length of 1.8 m(72 in).

The sizes available are 0.4(8/0) (Virgin silk), and from 0.7
to 6(6/0 to 4) or even stronger. It is important to use serum-
proofed silk to reduce capillary attraction which is a
peculiarity of plaited or braided materials. Examples of theses
materials include D & G silk (Davis and Geck), Mersilk(Ethicon),
and Surgisilk(Surgicraft).

Alternatively, threaded needles can be autoclaved as
required for an operation.

USES

Silk can be used for approximation of soft tissues including skin
It can also be used for secure ligation of blood vessals.

LINEN

Origin from fibres of flax plant, it has a braided
construction, spun and twisted. Relatively pliant and easy to
handle. `Drags' through tissues, knots very securely. Evokes
minor to moderate tissue reaction. Gains strength on wetting.

USES

It is used as a general ligature where a strong firm tie is
essential.

COTTON

Origin from fibres of cotton bush and is braided is not as
strong as silk. Gains strength on wetting.

USES

It is used similar to silk.
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