第六章 手术基本操作技术第六章 手术基本操作技术手术种类繁多，范围、大小和复杂手术种类繁多，范围、大小和复杂程度不同，但基本操作技术是相同的程度不同，但基本操作技术是相同的手术顺利完成，一定意义上取决于手术顺利完成，一定意义上取决于基本操作的熟练程度及其理论的掌握基本操作的熟练程度及其理论的掌握理论指导下的不断实践，是唯一的理论指导下的不断实践，是唯一的正确途径。正确途径。稳、准、巧、轻、快是基本要求。稳、准、巧、轻、快是基本要求。

（一）种类（一）种类44 、、 66 、、 88 号刀柄配号刀柄配 1919~~2424 号刀片。号刀片。33 、、 55 、、 77 号刀柄配号刀柄配 1010 、、 1111 、、 1212 、、1515 号刀片号刀片专用手术刀，如眼科刀等。专用手术刀，如眼科刀等。高频电刀。高频电刀。

第一节 常用外科器械及其使用第一节 常用外科器械及其使用

一、手术刀一、手术刀

Sharp scalpel with disposableSharp scalpel with disposable

1010

号小圆刃

号小圆刃

1111

号角形尖

号角形尖

刃刃

1212

号号弯形尖刃

号号弯形尖刃

1515

号小圆刃

号小圆刃

33 号刀柄号刀柄

88 号刀柄号刀柄

HandlesHandles

Handles and Blades Handles and Blades

Blades #10, 11, 12, 15 fit the #3 handle, #22, #23 fit Blades #10, 11, 12, 15 fit the #3 handle, #22, #23 fit the #4 handle , commonly used for large animals. the #4 handle , commonly used for large animals.

Disposable ScalpelDisposable Scalpel

高频电刀高频电刀

Electrosurgical scalpelElectrosurgical scalpel

（二）手术刀的使用（二）手术刀的使用

装刀片法装刀片法 取刀片法取刀片法

装刀片

装刀片

Three basic grips for Three basic grips for holding the scalpelholding the scalpel

Pencil gripPencil grip Fingertip gripFingertip grip

Palm gripPalm grip

Scalpels Scalpels

The scalpel is held with thumb, midThe scalpel is held with thumb, mid

dle and ring finger while the index fidle and ring finger while the index fi

nger is placed on the upper edge to hnger is placed on the upper edge to h

elp guide the scalpel. elp guide the scalpel.

Long gentle cutting strokes are less tLong gentle cutting strokes are less t

raumatic to tissue than short choppiraumatic to tissue than short choppi

ng motions. ng motions.

The scalpel should never be used in a "stabbing" motion The scalpel should never be used in a "stabbing" motion

二、二、 surgical scissorssurgical scissors

组织剪

组织剪

剪线剪线

剪剪

Commonly used surgical scissorsCommonly used surgical scissors

Classification by type of pointsClassification by type of points

All types of scissors can have blunt or sharp All types of scissors can have blunt or sharp blades (A: Sharp:Sharp, B: Blunt:Blunt). blades (A: Sharp:Sharp, B: Blunt:Blunt).

All types can have either All types can have either straight or curved blades straight or curved blades

Mayo and Metzenbaum Mayo and Metzenbaum

Mayo scissors (B) are used for cMayo scissors (B) are used for cutting heavy fascia and sutures.utting heavy fascia and sutures. Metzenbaum scissors (A) are moMetzenbaum scissors (A) are more delicate than Mayo scissors.re delicate than Mayo scissors. Metzenbaum scissors are used to Metzenbaum scissors are used to cut delicate tissues and scissors hcut delicate tissues and scissors have a longer handle to blade ratiave a longer handle to blade ratio.o.

执剪的方法执剪的方法 剪线的方法剪线的方法

三、三、 tissue forcepstissue forcepsA.Different tissue forceps

B.Pencil grip for thumb forcep in use

C.Palmed position for thumb forcep being carried

Thumb forceps are held like a pencil Thumb forceps are held like a pencil

Thumb Forceps are not held like a knife Thumb Forceps are not held like a knife

镊子在手术中的使用

镊子在手术中的使用

四、止血钳

四、止血钳

五、持针钳

五、持针钳

Hemostatic foHemostatic forcepsrceps Needle Needle

holderholder

持针钳在手术 持针钳在手术中的应用中的应用

Classification by size and shape and size of tipsClassification by size and shape and size of tips

Hemostatic forceps and hemostats Hemostatic forceps and hemostats may be curved or straight. may be curved or straight.

Kelly Hemostatic Forceps and Mosquito Hemostats Kelly Hemostatic Forceps and Mosquito Hemostats

Both are transversely serrated Both are transversely serrated

Mosquito hemostats (A) are more delicate Mosquito hemostats (A) are more delicate than Kelly hemostatic forceps (B). than Kelly hemostatic forceps (B).

Mosquito hemostats (A) have a smaller, finer tip Mosquito hemostats (A) have a smaller, finer tip

Comparison of Kelly and Mosquito tips Comparison of Kelly and Mosquito tips

Carmalt Carmalt

Mayo-Hegar Mayo-Hegar

Heavy, with mildly tapered jaws. No cutting blades. Heavy, with mildly tapered jaws. No cutting blades.

Olsen-Hegar Olsen-Hegar

Includes both needle holding jaw and scissors blades. Includes both needle holding jaw and scissors blades.

The disadvantage to having blades within the needle The disadvantage to having blades within the needle holder is the suture material may be accidentally cut.holder is the suture material may be accidentally cut.

六、六、 surgical needlessurgical needles

1.needle point 2.needle body 3.needle length 4.needle diameter 5.needle chord length 6.needle ridus

A

B

CB.conventional cuttingB.conventional cutting

C.reverse cuttingC.reverse cutting

A.The shape of the point A.The shape of the point and body of nocuttingand body of nocutting

七、七、 retractoretractorr Rib retractorRib retractor Abdominal~Abdominal~

Perineal~Perineal~

Senn Senn

Blades at each end. Blades at each end. Blades can be blunt Blades can be blunt (delicate)(delicate) or sharp (more traumatic, used for or sharp (more traumatic, used for fascia). fascia).

HohmanHohman

Levers tissue away from bone Levers tissue away from bone during orthopedic procedures. during orthopedic procedures.

Weitlaner Weitlaner

Ends can be blunt or sharp. Ends can be blunt or sharp. Has rake Has rake tips.tips. Ratchet to hold tissue apart. Ratchet to hold tissue apart.

GelpiGelpi

Has single point tips. Ratchet to hold tissue apart. Has single point tips. Ratchet to hold tissue apart.

创钩在手术中的应用

创钩在手术中的应用

创沟的使用创沟的使用

创沟的使用创沟的使用

创沟的使用创沟的使用

八、八、 towel forceptowel forcep

九、九、 tissue forcepstissue forceps

Forceps: consist of two tines held together at Forceps: consist of two tines held together at one end with a spring device that holds the one end with a spring device that holds the tines open. Forceps can be either tissue or tines open. Forceps can be either tissue or dressing forceps. dressing forceps.

Dressing forceps have smooth or smoothly sDressing forceps have smooth or smoothly serrated tips. errated tips.

Tissue forceps have teeth to grip tissue. ManTissue forceps have teeth to grip tissue. Many forceps bear the name of the originator oy forceps bear the name of the originator of the design, such as Adson tissue forceps.f the design, such as Adson tissue forceps.

Rat Tooth: A Tissue ForcepsRat Tooth: A Tissue Forceps

Interdigitating teeth hold tissue without sInterdigitating teeth hold tissue without slipping. Used to hold skin/dense tissue lipping. Used to hold skin/dense tissue

Adson Tissue Forceps

Small serrated teeth on edge of tips. The AdsoSmall serrated teeth on edge of tips. The Adsons tissue forceps has delicate serrated tips desins tissue forceps has delicate serrated tips designed for light, careful handling of tissue gned for light, careful handling of tissue

Allis: An Intestinal Tissue ForcepsAllis: An Intestinal Tissue Forceps

Interdigitating short teeth to grasp and hold bInterdigitating short teeth to grasp and hold bowel or tissue. Slightly traumatic, use to hold iowel or tissue. Slightly traumatic, use to hold intestine, fascia and skin ntestine, fascia and skin

Babcock: An Intestinal Tissue Forceps Babcock: An Intestinal Tissue Forceps

More delicate that Allis, less directly traumatic. More delicate that Allis, less directly traumatic. BroBroad, flared ends with smooth tips.ad, flared ends with smooth tips. Used to atraumaticUsed to atraumatically hold viscera (bowel and bladder).ally hold viscera (bowel and bladder).

Sponge ForcepsSponge Forceps

Sponge forceps can be straight or curved, can hSponge forceps can be straight or curved, can have smooth or serrated jaws. Used to atraumatiave smooth or serrated jaws. Used to atraumatically hold viscera (bowel and bladder). cally hold viscera (bowel and bladder).

十、肠钳十、肠钳

Doyen Intestinal ForcepsDoyen Intestinal Forceps

Non-crushing intestinal occluding forceps with Non-crushing intestinal occluding forceps with longitudinal serrations. longitudinal serrations. Used to temporarily Used to temporarily occlude lumen of bowel occlude lumen of bowel

Payr Pylorus ClampsPayr Pylorus Clamps

A crushing intestinal instrument. Used to A crushing intestinal instrument. Used to occlude the end of bowel to be resected. occlude the end of bowel to be resected.

The thumb and ring finger The thumb and ring finger are inserted into the rings of are inserted into the rings of the scissors while the index the scissors while the index and middle finger are used and middle finger are used to guide the instrument. to guide the instrument.

The instrument should remain The instrument should remain at the tips of the fingers for at the tips of the fingers for maximum control. maximum control.

This is the This is the wrong waywrong way to hold the scissors. The to hold the scissors. The ring finger should be inserted into the ring ring finger should be inserted into the ring

This is also the This is also the wrong waywrong way to hold the scissors. The to hold the scissors. The tips of the scissors should be pointing upwards tips of the scissors should be pointing upwards

十一、器械的传递十一、器械的传递手术剪的传递手术剪的传递

持针钳的传递持针钳的传递

An acceptable hand An acceptable hand signal for a needle signal for a needle holder with sutureholder with suture

An acceptable hand sAn acceptable hand signal for thumb forceignal for thumb forcepp

ＡＡ .An acceptable sign.An acceptable signal for scalpelal for scalpel

A Ｂ

ＢＢ . An acceptable hand . An acceptable hand 　　 signal for a hemostatsignal for a hemostat

AA 、、 B.Passing an instrumenB.Passing an instrument pack to a scrubbed membet pack to a scrubbed member of the operating teamr of the operating team

A B

C.An acceptable way of chaC.An acceptable way of changing positions during a sunging positions during a surgical procedurergical procedure

C

第二节　显　露第二节　显　露

指手术视野的暴露要清楚。指手术视野的暴露要清楚。切开组织，打开手术通路是切开组织，打开手术通路是显露的主要内容。既要有利显露的主要内容。既要有利于显露术野，又不能造成过于显露术野，又不能造成过多的组织损伤。多的组织损伤。

麻醉方法麻醉方法 保定体位保定体位 照明条件照明条件 辅助器械辅助器械 止血措施止血措施

一、充分显露手术视野的影响因素一、充分显露手术视野的影响因素

二、切口的部位、大小、方向二、切口的部位、大小、方向 切口下最好能直接暴露或接近病变部切口下最好能直接暴露或接近病变部位，必要时便于延长扩大切口。位，必要时便于延长扩大切口。切口部位尽可能避开大血管、神经和切口部位尽可能避开大血管、神经和腺体的输出管。腺体的输出管。切口应有利于创液、脓汁等排出。切口应有利于创液、脓汁等排出。二次手术时，应避免在瘢痕上切开二次手术时，应避免在瘢痕上切开 。。

切口的大小、形状、方向除切口的大小、形状、方向除考虑到便于主手术操作外，还考虑到便于主手术操作外，还应考虑到术创愈合的牢固，不应考虑到术创愈合的牢固，不影响局部的生理功能或动物的影响局部的生理功能或动物的容貌，并在此前提下，尽可能容貌，并在此前提下，尽可能选择组织 结构简单、有利于少选择组织 结构简单、有利于少损伤无关组织的部位 做切口。损伤无关组织的部位 做切口。

三、注意事项三、注意事项

按解剖层次分层切开组织， 并注意保按解剖层次分层切开组织， 并注意保

持切口 从外到内的大小相同。持切口 从外到内的大小相同。力求一次切开组织，必要时可 补充用力求一次切开组织，必要时可 补充用

刀，不可反复多次在同一 平面上切割。刀，不可反复多次在同一 平面上切割。切开腹膜、胸膜时，防止内 脏损伤。切开腹膜、胸膜时，防止内 脏损伤。避免损伤大血管、神经、腺体分 泌管避免损伤大血管、神经、腺体分 泌管

第三节 组织切开和分 离第三节 组织切开和分 离

一、方法一、方法1.1.锐性锐性切开切开 用刀或剪对组织 进行准确、精用刀或剪对组织 进行准确、精细的切割。必须熟悉解剖，在细的切割。必须熟悉解剖，在直视条件下进行。直视条件下进行。

2.2. 钝性钝性分离分离 用刀柄、止血钳或手用刀柄、止血钳或手指等进行。适于正常肌肉、筋膜指等进行。适于正常肌肉、筋膜和良性肿瘤等的分离。钝性分离和良性肿瘤等的分离。钝性分离时，组织损伤 较重，往往残留许时，组织损伤 较重，往往残留许多失去活性的组织 细胞，术后组多失去活性的组织 细胞，术后组织反应较重，愈合较慢。织反应较重，愈合较慢。

（一）皮肤切开法（一）皮肤切开法1.1.紧张切开紧张切开 两掌紧张、指指紧张 两掌紧张、指指紧张 2.2. 皱壁切开皱壁切开 切口下有大血管、神经、 切口下有大血管、神经、分泌管和重要器官，而皮下组织 甚分泌管和重要器官，而皮下组织 甚为疏松时适用。为疏松时适用。

二、种类二、种类

术者指指紧张，锐性切开牛腹壁皮肤术者指指紧张，锐性切开牛腹壁皮肤

躺卧保定时的皮肤切口躺卧保定时的皮肤切口

皱壁切开牛脐疝皱壁切开牛脐疝

食管阻塞时颈部皮肤皱壁切开食管阻塞时颈部皮肤皱壁切开

3.3. 皮肤切口的形状皮肤切口的形状梭形切口梭形切口 用于切除如肿瘤、瘘管、放 用于切除如肿瘤、瘘管、放线菌病灶、过多皮肤等。线菌病灶、过多皮肤等。““丅”和“十”字形切口丅”和“十”字形切口 需暴露深 需暴露深部组织和 摘除时使用。部组织和 摘除时使用。“—”“—” 切口切口 最常用的直线形切口 最常用的直线形切口““U”U” 和“和“ ΠΠ”” 字形切口字形切口 脑部和副 脑部和副鼻窦圆锯术时使用。鼻窦圆锯术时使用。