Access planning and skin incision
The choice of surgical access directly depends on the topography of the target organ and its projection onto the body surface. Access can be direct (performed strictly along the organ's projection) or extra-projectional (performed away from it, if required by the goal of the operation).
Before making an incision, the skin and underlying subcutaneous tissue must be fixed. Due to the natural mobility of these layers, the surgeon pulls them taut firmly with the thumb (I) and index finger (II) of the left hand. The incision itself is made along with the subcutaneous tissue and should be a single continuous, smooth movement.
The algorithm for using a scalpel is as follows:
- Puncture: the blade is placed perpendicularly to the skin surface (at an angle of $90^\circ$).
- Main incision: the instrument is tilted at an angle of $45^\circ$ for smooth guidance of the line.
- Withdrawal: at the end of the incision, the scalpel is returned to the vertical position (at an angle of $90^\circ$) and removed.
Dissection of deep layers: fascia, aponeuroses, and muscles
When moving on to deeper structures, the technique changes. Fasciae and aponeuroses must strictly not be dissected along the entire length of the wound at once, as there is a high risk of accidentally damaging underlying blood vessels or muscles.
Safe technique for fascial dissection:
- First, a small starting incision is made.
- A grooved director is carefully inserted into the resulting opening beneath the aponeurosis (curved scissors or forceps can be used as an alternative).
- Tissues are separated from underlying structures.
- The final dissection is performed with a scalpel strictly along the inserted instrument.
As for muscle tissue, to minimize surgical trauma, it is preferable to separate it bluntly—that is, by carefully parting the fibers along their course without resorting to cutting with a blade.
Positions of surgical instruments
Depending on the stage of the operation and the type of tissues, the surgeon changes their grip on the instruments.
Four main scalpel positions:
- Bow grip: used for wide, long, and superficial incisions. Provides maximum range of motion and smoothness.
- Dinner knife grip: used for deep incisions where significant physical force is required.
- Amputation knife grip (fist grip): used for major limb amputations.
- Pen grip: ideal for the most precise, short, and fine incisions (e.g., in facial surgery).
Working with forceps: Anatomical or surgical forceps are always held with three fingers of the working hand — exactly like an ordinary pen. This ensures a secure grip and high precision of manipulations.
Methods of dissecting various tissues
Surgical dissection is adapted to the density and structure of the specific tissue.
- Soft tissues are divided using two main methods. The blunt method (along the fibers) is optimal for muscles. The sharp method (using scalpels, knives, or scissors) is used when a wide retraction of the wound edges is needed — in this case, aponeuroses and muscles are transected perpendicularly to the course of their fibers.
- Bone tissue requires the use of specialized heavy-duty instruments: surgical saws and chisels.
- Physical methods. In modern operative surgery, alternative physical modalities such as electrosurgery (electric knives), laser units, and ultrasound are actively used for tissue dissection. They allow tissues to be cut with simultaneous hemostasis.
Briefly: answers to topical questions
For grasping which specific tissues are anatomical and surgical forceps used?
- Anatomical forceps — used for grasping soft tissues, blood vessels, and the intestine.
- Surgical forceps — have teeth; their use for specific tissues is not specified in the provided sources.
What types of scalpels by blade shape are used for soft tissue dissection?
- Belly (commando) scalpel — the long axis runs along the back of the blade, used for long linear incisions on the body surface.
- Pointed scalpel — the long axis is in the middle, used for deep incisions and tissue punctures.
- Ophthalmic scalpel — used for delicate surgeries on small structures.
What types of surgical saws are used for bone transection during operations?
- Bow saws — the blade is inserted into a frame and can be secured at any angle.
- Plate saws — designed with a handle similar to a hand saw.
- Gigli-Olivecrona wire saw — cuts when pulled back and forth.
- Chain saw — used similarly to a wire saw.
The formula for an ideal scalpel incision: "Straight — Tilt — Straight" (90° — 45° — 90°). This rule prevents the formation of "steps" at the edges of the skin wound.
Class and exam questions
How to properly hold forceps during surgery?
Both surgical and anatomical forceps must be held with three fingers, much like a writing pen.
In what case are muscles transected perpendicularly to their fibers?
Sharp transection of muscles perpendicularly to the fiber course is used only when it is necessary to provide the maximum possible retraction of the wound edges (wide surgical access).
What else to study on this topic
- Organ topography and the choice of direct or extra-projectional access
- Technique of using a grooved director when working with fascia
- Differences in the application of anatomical and surgical forceps
- Physical methods in surgery: features of electrosurgical knives and lasers
- Surgical saws and chisels: instruments for bone tissue
Master the complete topic in the "Topographic Anatomy" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Tissue Dissection Technique" and 2,777 more pages of the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 91 video lessons on the subject
Other topics in the section "General Operative Surgery. Equipment, Instruments. Anesthesia"
Free video lessons: topographic anatomyShort lessons with study notes — no registration required.
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.