Tissue Handling and Dissection

Module

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Introduction

• The core skills of a surgeon include:
  • Knowledge of relevant anatomy
  • Safe exposure of the anatomy
• Assuming knowledge of structural anatomy and skills in surgical dissection and tissue handling enables the surgeon to reveal anatomy without disrupting its structural and functional integrity
• The techniques listed in this presentation are universal skills, adaptable to the following approaches:
  • Abdominal
  • Laparoscopic
  • Robotic
  • Vaginal

Source: Rogers et al. Obstet Gynecol Clin N Am 2011

• Applying surgical dissection techniques and good tissue handling learned from expert mentors will allow the student surgeon to develop into a sound surgeon, minimizing complications and excessive blood loss.

• One cannot expect good surgical outcomes without good surgical dissection.

Source: Birkmeyer JD et al. NEJM 2013

History of Surgical Dissection

Halsted’s tenets:

• Gentle handling of tissue
• Meticulous hemostasis
• Preservation of blood supply
• Strict aseptic technique
• Minimum tension on tissues
• Accurate tissue apposition
• Obliteration of dead space

Surgical Dissection

• Purpose
  • Expose anatomic structures
  • Safeguard structural and physiologic integrity
• Goals
  • Maintain correct orientation and direction of dissection
  • Minimize bleeding
    • Allows for full visualization of tissues and relevant structures
    • Excessive bleeding may indicate wrong tissue plane
  • Thin out visceral connective tissues o Allows for identification of structures by sight or palpation
  • Maintain flexibility by reassessing the dissection site perspective and the instruments as necessary
• Surgical Movements
  • Dissection should be performed millimeter by millimeter
  • Gradual, deliberate, and controlled movements are essential for thinning out of connective tissues and revealing the structures within

Surgical Instrumentation: Scalpels

• 10 blade
  • This scalpel has a long broad cutting surface. The belly of the blade is the proper cutting surface. It is often utilized to make skin incisions or surgical dissection of planes in a straight line. It is best held as a violin bow.

  

• 15 blade
  • The blade of this scalpel is narrower and smaller and the curved tip is the primary cutting surface
  • It is utilized for shorter or angled incisions
  • It is best held as a pencil

  

• 11 blade
  • This blade has an angled, pointed tip. It is primarily used to make a stab-type incision and can also be used in a sawing fashion. It is best held as a pencil.

  

Surgical Instrumentation: Scissors

• Metzenbaum or tenotomy: These scissors are primarily used for both blunt and sharp dissection. Techniques include spreading the tips for blunt dissection (“push and spread”) and closing the tips for sharp dissection.

  

• Mayo: These scissors have a broader blade and wider spread. They may be curved or straight. Techniques are similar to those described above.

  

Surgical Instrumentation: Forceps

In general, forceps should be used as extensions of the index finger and thumb (like holding a pencil or fork), to permit optimal grasp and control.

• Adson: Small fine forceps, with or without teeth, for handling skin edges or fragile structures

• DeBakey: Longer but still fine forceps without teeth. Used for handling structures such as vessels or nerves

• Forceps with teeth: Long or short, used for handling fascia, muscle, etc.

Techniques of Expert Dissection

• Five operating techniques of expert dissection are:
  1. Grasp and Tent
     • Operator elevates the tissue to be incised away from vital structures such as ureter, artery, vein, bowel, bladder and nerves
     • Aids in thinning out grasped tissue to improve visualization
  2. Push and Spread
     • Also known as “Poke and Open”
     • Further thins out connective tissue and releases scarring
     • Is aided by “Traction Countertraction” and “Grasp and Tent” techniques
     
     

     Images courtesy of Oz Harmanli, MD, Department of Obstetrics-Gynecology, Baystate Medical Center.

  3. Traction Countertraction
     • A gentle pulling technique which separates vital structures in the surgical field and allows for evolution of the surgical plane
     • Typically performed by a surgeon with the assistance of another member of the surgical team
       
       

       Images courtesy of Oz Harmanli, MD, Department of Obstetrics-Gynecology, Baystate Medical Center.

  4. Gentle Wiping and Teasing
     • Proceed gently, millimeter by millimeter
     • Further thins out connective tissue
     • Use this technique only when the tissue plane is clearly identified
     • Avoid blunt, quick strokes, which may cause unwanted damage to viscus or vessels
     • May use scissors, a peanut, sponge or simply fingers
     • A peanut or sponge may also help clear blood from the field
       
       

       Image courtesy of Oz Harmanli, MD, Department of Obstetrics-Gynecology, Baystate Medical Center.

  5. Hydrodissection
     1. Is the injection of sterile fluid into the surgical field to tent and thin out the connective tissue fibers
     2. Is helpful for opening potential spaces such as pararectal and paravesical spaces
     3. With a suction-irrigation device is useful during laparoscopic surgery along the pelvic sidewall
     4. May also facilitate vaginal dissection
        
        

        Example of hydrodissection. Image courtesy of Oz Harmanli, MD, Department of ObstetricsGynecology, Baystate Medical Center.

Skeletonizing

• A combination of dissection techniques
• The thinning out of visceral connective tissues enveloping structures, such as blood vessels, via ‘push and spread’ and ‘gentle wipe/tease’ techniques, to render these structures clearly identifiable
• A technique done in which the operator
  • Holds the scissor tips slightly open
  • Gently brushes the tissue
  • Uses care to not cut unintentionally
• The technique is:
  • Typically performed with Metzenbaum scissors
  • Ideal for separating adhesions, broad ligament dissection, and cleaning connective tissue

One example of skeletonizing is the clearing the tissue overlying vessels such as when the uterine artery is dissected during a hysterectomy.

Additional Surgical Pearls

• Optimize visualization
  • Appropriate incision and port site selection
  • Lighting
  • Loupes
  • Adequate retraction
  • Irrigation
• Proceed from easy to difficult dissection
  • “Path of least resistance”
• Proceed from normal to abnormal anatomy
• Do not rush
• Heed warning signs:
  • Bleeding indicates wrong plane
  • Assess the sight and feel of correct plane
• Maintain flexibility
  • Be prepared to change the technique, the tools and the direction of dissection
  • Think outside the box

Proper Dissection Technique

Less blood loss + Less trauma to tissues and surrounding structures = Better surgical outcomes 

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References

1. Birkmeyer JD, Finks JF, O'Reilly A, Oerline M, Carlin AM, Nunn AR, et al. Surgical skill and complication rates after bariatric surgery. Michigan Bariatric Surgery Collaborative. N Engl J Med 2013;369:1434-42.
2. Rogers RM Jr, Taylor RH. The core of a competent surgeon: a working knowledge of surgical anatomy and safe dissection techniques. Obstet Gynecol Clin North Am 2011;38:777-88.

Contributing Authors

• Jeffrey Cornella, MD, Mayo Clinic - Scottsdale, Arizona
• Marlene Corton, MD, Professor of Obstetrics and Gynecology, University of Texas Southwestern Medical Center
• Rajiv Gala, MD, Ochsner Health System
• Oz Harmanli, MD, Professor of Obstetrics and Gynecology, Tufts University School of Medicine
• Jamie Bashore Long, MD, Director, Center for Pelvic Health and Chief of Urogynecology, Reading Health System - Pennsylvania
• Doug Miyazaki, MD, Novant Health - North Carolina
• Michael Moen, MD,| Professor of Obstetrics and Gynecology, Chicago Medical School/Rosalind Franklin University
• Mikio Nihira, MD | Professor, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center
• Amy O’Boyle, MD, Captain, USN, MC, Fellowship Director Female Pelvic Medicine and Reconstructive Surgery, Walter Reed National Military Medical Center
• John Riggs, MD, Associate Professor, Department of Obstetrics, Gynecology and Reproductive Sciences, The University of Texas Health Science Center at Houston (UTHealth)
• Robert Rogers, MD, Kalispell Regional Medical Center
• Montana Carmen Sultana, MD, Professor of Clinical Obstetrics and Gynecology, Weill Cornell Medical College

Developed in association with the Society of Gynecologic Surgeons.