Preparation and General Operating Principles
Any operation is subject to fundamental rules protecting the patient from complications: secondary bleeding and purulent-inflammatory processes. The most important of these is gentle tissue handling. The surgeon must avoid rough compression of structures with instruments, as well as overstretching and tearing.
Work begins with ensuring sterility. Preparation of the operative field is performed strictly after inducing anesthesia or administering local anesthesia.
- Skin cleansing: ammonia solution or diethyl ether is used beforehand.
- Primary preparation: classically performed according to the Grossich-Filonchikov method.
- Draping: the skin is isolated with sterile linen (sheets for major interventions, towels for minor ones) or modern self-adhesive sterile drapes are applied.
- Final step: the isolated area directly at the incision site is treated with an alcoholic solution of iodine or chlorhexidine.
If the patient has a contamination focus (gangrene, purulent or intestinal fistulas), it must be isolated in advance: the limb is wrapped in a towel, and temporary sealing sutures are applied to the fistula. Strict discipline is maintained in the operating room: masks are mandatory for all present to prevent airborne infection, and walking around or unnecessary talking are prohibited.
Stage 1: Surgical Access
The first step of the operation aims to expose the organ or pathological focus. Proper access must be minimally invasive while providing a sufficient angle of operative action—that is, creating a convenient working space for the surgeon's manipulations.
A well-planned access allows to:
- Minimize trauma to wound edges caused by rough retraction with hooks and retractors.
- Obtain full visual control over the surgical field.
- Effectively achieve hemostasis (arrest bleeding).
Standardized approaches have long been developed for most routine operations. In atypical interventions (e.g., massive gunshot wounds or complex polytrauma), the incision is planned individually. Immediately after tissue dissection, the wound edges are protected with towels or sponges to prevent contact infection.
Stage 2: Main Surgical Maneuver
This is the culmination of the operation, during which its main goal is achieved: the organ is removed, tissue integrity is restored, or resection is performed. Technical execution depends entirely on the specifics of the disease.
When working with purulent or contaminated structures (opening the intestinal lumen, removing a phlegmonous gallbladder), the surgeon is required to isolate the surrounding healthy tissues with gauze sponges. This prevents pus or intestinal contents from entering the clean wound.
If the operation transitions from a "dirty" stage to a less infected one (for example, closing the abdominal wall in layers after repairing an intestinal defect), the surgical team is required to change instruments, needles, needle holders, and sponges.
Critical moment: before completing the main stage, the surgeon must perform a thorough check for hemostasis. This is the key way to prevent dangerous secondary bleeding in the postoperative period.
Stage 3: Wound Closure
The final stage requires no less precision. First, all isolating sponges are removed from the wound, instruments are changed, and the skin is re-treated with an antiseptic (iodonate or iodine solution).
Strict rules are observed when placing sutures:
- Absence of dead spaces: the wound is sutured layer by layer so that no "pockets" remain inside where blood or inflammatory fluid could accumulate.
- Precise adaptation: tissue edges must be accurately aligned without the risk of suture cutout.
- Knot security: ligatures are tied firmly to prevent untying.
- Optimal tension: sutures are tightened with moderate force—just until the walls come into contact. Insufficient tension will lead to edge dehiscence, while excessive tension will cause tissue ischemia and necrosis.
Special difficulties arise in atypical interventions, when defects are closed with transferred flaps or free skin grafts are applied. Depending on the situation, the wound may be closed tightly, left drained, temporarily sutured for re-exploration, or left entirely open.
Briefly: answers to topical questions
What are the rules for preparing the surgical field according to the Grossich-Filonchikov method?
The rules for preparing the operative field according to the classical Grossich-Filonchikov method include fourfold application of an antiseptic. A 5% alcoholic iodine solution or iodophors (iodine with potassium iodide, povidone-iodine) are used as the antiseptic.
Stages of preparation:
- First stage — wide application of antiseptic to the field before draping.
- Second stage — application to the surgical site after draping with sterile linen.
- Third stage — preparation before placing skin sutures.
- Fourth stage — preparation after placing sutures.
What are the indications for leaving a drain in a wound during closure?
Indications for drainage include retention of purulent discharge and secondary bleeding. Active aspiration is used for a sealed drained cavity, including in closed sutured wounds, pleural empyema, purulent arthritis, and abscess cavities.
What methods of temporary and definitive hemostasis are used during surgical stages?
Temporary methods of bleeding cessation include digital pressure of the artery proximal to the wound, wound packing and pressure bandage application, tourniquet application, vessel clamping in the wound, hemostatic clamp placement, and temporary clamping of major vessels.
Definitive hemostasis includes vessel ligation, electrocoagulation, hemostatic sponge application, complex compression hemostasis, ligation or temporary clamping of major vessels, and endovascular methods. Compression uterine sutures are used for hypotonic bleeding when other methods of surgical hemostasis fail.
Class and exam questions
When is the surgical field prepared?
Skin preparation with antiseptic solutions begins strictly after the patient has been anesthetized or local anesthesia has been performed.
What is the most critical action before closing the wound?
Before starting wound closure, the surgeon must thoroughly check for hemostasis. This protects the patient from life-threatening secondary bleeding.
Why change instruments right during the surgery?
Changing instruments, sponges, and needle holders is necessary when transitioning from an infected step of the procedure to a clean one to prevent implantational tissue infection.
What happens if sutures are tied too tightly?
Excessive tension of sutures disrupts microcirculation, leading to ischemia and subsequent necrosis of the wound edges.
What else to study on this topic
- Grossich-Filonchikov method of surgical field preparation
- Closure of wound defects with transferred flaps
- Free skin grafting in surgery
- Indications for leaving a postoperative wound open
- Types of sutures: primary, secondary, and delayed
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