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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WOUND CLOSURE 4

LIGATURE and Sutures 4


WHAT IS POLYGLYCONATE?

Maxon (Davis & Geck):
This is a monofilament synthetic
absorbable suture prepared from a coplymer of glycolic acid and
trimethylene carbonate.
The process of absorption is by non-
enymatic hydrolysis. Approximately 70% of the original suture
strength remains 2 weeks after implantation, and approximately
55% of the original suture strength remains 3 weeks after
implantation.
Absorption is completed 6 months after
implantation.

Maxon is available in sizes 0.7 (6/0)-3 (2/0)(Clear), and
sizes 1(5/0)04(1)(Green), mounted on atraumatic needles.

WHAT IS POLYGLACTIN 910?

Vicryl is a pliable, smooth fibre, which is made in nine sizes
from 0.3 to 5. Date from implantation studies show that more
than 55% of the original strength remains at 14 days, and over 20
per cent at 21 days.

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WOUND CLOSURE 3

SUTURES AND LIGATURES 3





WHAT IS CATGUT Chromic?
The origin of this suture material is the same as catgut (plain)
The material obtained from animal intestine is treated by immersion in a dichromate bath.
It is sterilized and packaged in a similar manner as plain catgut. Its treatment in a chromic bath delays its disintegration and this
suture loses 70% of its strength later by the end of second week.

USES

It is used as a ligature for blood vassals, and also for
suturing the mucosa, of the G.I. Tract, Urinary Tract, Respiratory
Tract, Peritoneum, and Muscle.

Surgical catgut is wet packaged in alcohol in sealed pack and pre-sterilised

WHAT IS POLYGLYCOLIC ACID?

Dexon (Davis and Geck) - This is a synthetic polymer of glycolic acid. The strands are made by extrusion as fine threads which are then braided to form a uniform gauge thread of seven sizes from 0.7 to 4. Polyglycolic acid sutures are extremely inert and cause minimal tissue reaction.

Compared with catgut, dexon suture is stronger, do not fray and are
not slippery, when knotting.
The sutures are sealed in two coverings and sterilized by a two-stage ethylene oxide process. With this method, the inner envelope is sterilized before sealing.
Gas sterilizes the outer envelope to complete the sterilization.
The increased strength compared with catgut, Dexon and other sythetic absorbable sutures, generally a size smaller than for catgut can be used with safety.
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WOUND CLOSURE 2

SUTURES AND LIGATURES 2




WHAT ARE ABSORBABLE SUTURE?
Catgut (Plain):- The origin of the fiber, is from the intestine of animals, and after processing 98% of the extracted material is collagen, and is absorbed when left in body tissues.

Each of the strands, is then graded and separated into six metric
sizes:
from the thinnest to the thickest, 2(4/0), 3(3/0),
3.5(2/0), 4(0), 5(1), and 6(2). (The sizes refer to metric
gauge, the sizes in brackets are the USP equivalents).
The metric size approximates the diameter of the strand in
millimeters X 10.

USES
The finished catgut is cut into lengths of about 70 cm.(30 in) or
1.52 m(5 ft) to form ligatures or `needled' sutures.

The attachment of non-traumatic suture needles is a machine
procedure.

There are two basic methods of needle attachment Fig.
A hole may be drilled into the blunt end of the needle shaft, or the needle can be flanged at this end to form a grove.
Machines are used to close the prepared needle tightly around the suture material, which is the "pull tested" to ensure that it is firmly attached to the needle.
This material is then sterilized and package in a fluid in small easy to handle packages.

Catgut passes through tissues smoothly and easily.
- It swells and loses its strength at the end of one week there
is loss of 70% of its strength
- It disintegrates by proteolysis and is rapidly absorbed.
- There is an inflammatory response to its presence in the body
tissues.

It is used as ligature for small vessels and also as a suture
for a subcutaneous stitch under the skin.
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