SURGICAL THERAPY

SURGICAL THERAPY

 Major categories of surgery

1. Treating wounds

Wound heal in three ways:

1) primary intention (wound edges are brought together, as in a clean surgical wound),

2) secondary intention (the wound is left open and heals by epithelization), or

3) third intention, or delayed closing, whether they were caused by an accident or a surgical

scalpel (the wound is identified as potentially infected, is left open until contamination is

minimized, and is then closed).

The optimum procedure depends on a number of factors, including the presence of severe bacterial

contamination, the ability to identify and remove all necrotic material and foreign bodies, and the ability

to control bleeding. Clean wound edges and close opposing without putting too much strain on the

tissue are essential for normal healing to occur. The wound necessitates an adequate blood flow. The

blood supply will be compromised if the tissue is too tight and the margins can't be closed without

putting pressure on them. The edges can be pulled together more easily if the subcutaneous tissue is

removed by cutting under the skin. Skin grafts or flaps are utilized to close the wound if direct

approximation is still not achievable.

After the wound has been thoroughly cleaned, a local anesthetic, such as lidocaine, is used and left in

place for one to two hours before the incision is sealed shut. Local anesthetic injections might be

followed by additional washing of the wound, especially if foreign material is present. Scrubbing

aggressively is essential to remove the many small pieces of debris that are embedded in the skin if the

injury was caused by a fall on gravel or asphalt. Drenching the affected area in high-pressure saline

solution will eliminate most foreign material and limit the risk of further infection. As tetanus is a

disease caused by infection with Clostridium tetani, wounds that have been contaminated must be given

proper immunizations.

Sutures are the most often used method of wound closure, but staples and sticky tissue tape may be

more suited in some cases. To seal skin wounds, silk sutures were initially used, however nylon is more

durable and less likely to trigger tissue reaction than silk. As a general rule, sutures should be as small in

diameter as possible while still ensuring that the wound edges are kept as close together as possible.

Catgut (produced from sheep intestines) or a synthetic material like polyglycolic acid are used to imitate

the deeper layers of tissue beneath the skin in order to reduce tissue response. In order to speed up

healing or prevent fluid from accumulating, the goal is to fill in any empty spaces. Open suction drains

are used to prevent the accumulation of liquid, but drains are a source of contamination and only

seldom used. Staples allow for a quicker skin closure, although they lack the precision of sutures. Tape is

a great tool if the edges can be pulled together effortlessly and tension-free. However, tape can come

loose or be removed by the patient and is less effective if there is substantial wound edema even

though it is comfortable, quick to apply and avoids the markings produced by sutures.

Depending on the location, the desired cosmetic outcome, the blood flow to the area, and the degree of

reactivity around the sutures, sutures are normally removed after 3 to 14 days. In order to avoid visible

scarring, sutures in the facial area are normally removed within three to five days of placement. Tape is

commonly used to support the wound for the time it takes to heal. If there is a lot of tension on the

wound, sutures in the trunk or leg will be removed in 7 to 10 days or even longer. The horizontal neck

incision for thyroidectomy minimizes scarring and tension by placing an incision parallel to normal skin

lines.

Dressings keep the site clean and allow drainage to be absorbed more easily. During the first 24 hours

after surgery, a surgical wound is most vulnerable to surface contamination, hence an occlusive dressing

of gauze and tape is used. Transparent semipermeable membranes allow the wound to be viewed

without the dressing being removed, thereby protecting the wound from contamination. Compression

aids healing in the same way that skin grafts do.

When a wound heals, a scar forms; the goal is to have a scar that is strong but not overly visible.

Regardless of how meticulously the incision was closed, some people develop a keloid, a dense

overgrowth of scar tissue. Irritation and migration are followed by migration and proliferation, and

finally scar formation and closure. During the first 24 hours, platelets form a clog by attaching to the

collagen revealed by blood artery injury. The platelets and fibrin combine to create a clot, and the white

blood cells enter to remove any foreign material that may have gotten into the wound. In order to

increase the amount of blood flowing to the injured region, the vessels in the area widen, which speeds

up the healing process. Fibroblasts and macrophages invade the wound during the migratory phase to

begin healing. A scab is formed when epithelial cells migrate across a blood clot and connect with

nearby capillaries to produce new blood vessels. new epithelial cells cover and connect to build new

blood vessels in the proliferative phase. Fibroblasts release collagen to promote healing strength. Late in

the healing process, the scar is remodeled, blood vessels expand, and the epithelium on the surface of

the wound heals.

Wound healing can be affected by a variety of conditions, including diabetes mellitus and drugs. If the

blood glucose level is too high, wound healing may be impaired and the wound may be more susceptible

to infection in patients with well-controlled diabetes. Wound healing can be delayed by kidney or liver

failure, malnutrition, and poor circulation caused by arteriosclerosis. Steroids, anticancer treatments,

and other medications might interfere with the body's natural healing process.

2. Surgical extirpation

In the treatment of cancer or other damaged or contaminated organs, the term "extirpation" refers to

the removal or eradication of an organ or tissue to its whole. All malignant tissue must be removed,

which usually entails removing both the visible tumor and any nearby tissue that may contain tiny tumor

expansions. A complete cure is guaranteed unless the cancer spreads through the lymphatic system,

which is the primary method of cancer dissemination. Therefore, it is common practice to remove

nearby lymph nodes at the same time that the tumor is surgically removed. The results of a node biopsy

will reveal whether or not the cancer has spread to other parts of the body (spread). Using this

information, doctors can determine if more treatment is necessary, such as radiation therapy or

chemotherapy. Palliative surgery, which offers pain relief but does not remove the tumor entirely, may

be an option if removing the tumor completely is not possible. In the early stages of breast cancer,

radical surgery may not be the best option. No more benefit has been proven in early breast cancer than

a lumpectomy (removal of tumor only) followed by radiation treatment to the area, but the patient's

psychological anguish is typically enhanced by this procedure. In recent years, however, advancements

in breast reconstruction techniques have reduced the severity of the trauma associated with a

mastectomy.

3. Reconstructive surgery

To replace tissue that has been severely damaged or removed during surgery or trauma, reconstructive

surgery is often required. If the wound cannot be closed properly, a skin graft may be required. Split-

thickness skin grafts are employed when a substantial region of skin needs to be replaced. In spite of the

fact that this type of graft has a higher survival rate and a faster healing rate than other grafts, their

appearance is visually unappealing. For tiny defects, such as those on the face or hands, a full-thickness

skin graft (epidermis and dermis) is performed, and skin from the ear or neck is most commonly

employed. A skin flap is necessary for exposing bone, nerve, or tendon. Both a local flap and a free flap

can be utilized to cover the defect, depending on how much tissue is available in the location where the

wound is located. Using nearby tissue (skin and subcutaneous tissue) rotated to cover a scar from skin

cancer removal is an example of a local flap. When the required amount of tissue isn't accessible locally,

like in a lower-leg injury caused by a car bumper, a free flap is employed. There are a variety of flaps that

can be employed depending on the amount of tissue needed and the blood supply available. A sufficient

blood supply is required to feed both the split flap and the wound edge.

Additional tissue can be generated using tissue expanders, which can be utilized to conceal a deformity.

Reservoirs are implanted under the skin of a neighbouring area using inflatable plastics. To stretch the

overlaying skin and cover the defect, saltwater is injected into the reservoir for several weeks.

Medical issues that can necessitate reconstructive surgery include but are not limited to: Implanting

prosthetic devices, such as artificial heart valves, pacemakers, joints and blood arteries, or bones, can be

necessary in some cases.

Replace sick tissue with a prosthetic device. Because they are created of a substance that does not

provoke rejection, they often perform better than donated tissue. Early in the 16th century, the first

attempts at creating artificial limbs were made. An aortic aneurysm graft, developed by American

surgeon Michael DeBakey and his colleagues in 1954, was one of the earliest prosthetic devices used in

cardiovascular medicine to replace dilated vessels that risk rupture and death. Later, grafts consisting of

identical materials were used to replace damaged arteries in the body. Metal joints and heart valves are

two further examples of prosthetic devices (e.g., hip, knee, or shoulder).

4. Transplantation surgery

The discovery of immunosuppressive cyclosporine in the early 1970s dramatically enhanced the success

of organ transplantation. It has since been created a variety of immunosuppressive medications such as

prednisone, macrolide lactone, and antibodies that have been shown to be effective in the treatment of

autoimmune diseases (e.g., muromonab-CD3 and basiliximab).

Transplant surgeries involving the kidney are among the most common. Living relatives frequently

donate their kidneys in order to increase the chances of a transplant recipient's long-term survival.

Identical twins have the best chance of surviving. There is also the utilization of cadaver transplants.

Ninety percent or more of grafts survive one year. Approximately 50 percent of grafts fail after 8 to 11

years, although some can endure for decades. However, the chances of a successful transplantation

decline rapidly with time, thus kidneys removed from living donors must be implanted within 24 hours

at the latest. They can be kept for up to 72 hours.

Success rates with this operation are steadily rising, and it can be performed for up to six hours. To

reduce the chance of rejection, blood and tissue types are closely matched. The donor and donated

organs should be the same size as the receiver and the recipient's organ, and the time between the

declaration of death and the procurement of the organ should be as short as feasible.

End-stage liver disease can be treated by a liver transplant in some patients. The mortality rate following

surgery ranges from 10% to 20%, depending on the patient's age and health. All survivors need long-

term immunosuppressive treatment.