Tecnica cirurgica osh 3 pincas
A detailed guide to the 3-clamp ovariohysterectomy (OSH) surgical technique. Covers pedicle ligation, proper forceps placement, and steps for uterine body removal.
The Three-Clamp Ovariohysterectomy A Step-by-Step Surgical Guide ================================================================
For optimal tissue manipulation, initiate the maneuver by positioning two atraumatic grasping instruments at the 4 o'clock and 8 o'clock positions relative to the target structure. The third tool, preferably a DeBakey-style grasper, is then introduced superiorly to provide stable retraction. This specific geometric arrangement reduces tissue stress and establishes a triangulated field, clearing the path for precise dissection.
The primary grasping tool should apply steady caudal traction. The secondary instrument provides lateral counter-traction, which establishes a taut tissue plane and simplifies the separation of anatomical layers. The third, superiorly placed implement is not static. Its role is dynamic, adjusting its angle to reveal deeper structures as the dissection progresses. A frequent point of failure is the mismanagement of the counter-traction tool, which can result in tissue tearing or suboptimal exposure of the operative field.
This three-point fixation is particularly beneficial when applying energy sources. The stability created by the instrument triad prevents unintended thermal spread to adjacent structures. For more complex dissections, this configuration allows for a 'four-corners' expansion by introducing a suction-irrigator or an additional grasper through an accessory port. The action must be performed without disrupting the primary triangulation, maintaining the foundational tension while the fourth tool completes its specific task.
Instrument Setup and Patient Positioning for the 3-Forceps Technique
Position the patient in the prone jackknife (Kraske) configuration. Flex the hips at a 90-degree angle and separate the buttocks with adhesive tape to maximize surgical field exposure. Place a padded roll beneath the pelvis to elevate the perineum and another under the ankles to prevent pressure neuropathy. This arrangement provides direct access and visualization of the anorectal junction.
The primary instrument set includes three strong hemostatic holding instruments, such as Kocher or Allis clamps. These are applied to the apex of each primary hemorrhoidal complex, corresponding to the 3, 7, and 11 o’clock positions. The instrument tray must also contain a Fansler or Hirschman operating anoscope, a #15 scalpel blade for the initial incision, and Metzenbaum scissors for precise dissection of the hemorrhoidal tissue away from the internal sphincter muscle.
For ligation and closure, prepare a 2-0 or 3-0 absorbable suture, typically chromic catgut or polyglactin, on a tapered needle. A needle holder and suture scissors are also required. Prepare a local anesthetic, commonly 0.5% bupivacaine with epinephrine, in a 10 mL syringe with a 25-gauge needle for infiltration before excision. https://plazaroyal-casino-24.casino are used for blotting and maintaining a clear operative field.
Step-by-Step Guide to Forceps Placement and Tissue Manipulation
Isolate the ovarian pedicle by creating a window in the broad ligament caudal to the vascular complex. Place the first crushing clamp, such as a Rochester-Carmalt, deeply onto the pedicle, fully encompassing the ovarian artery and vein. Position a second hemostatic grasper approximately 5-8 millimeters distal to the first one, closer to the ovary. This second instrument prevents blood backflow from the ovarian tissues during transection.
Transect the pedicle with a number 10 or 15 scalpel blade on the ovarian side of the distal instrument. Secure the pedicle by placing a ligature of absorbable suture material directly into the tissue groove created by the proximal clamp. A surgeon's knot followed by two additional square throws provides secure hemostasis before the clamp is released.
Address the uterine body by placing two clamps across its full width, cranial to the cervix. Apply the first clamp, then position the second one immediately cranial to it. Pass a transfixing ligature through the avascular portion of the uterine wall, caudal to both instruments. Tie this ligature securely around the entire uterine stump. Excise the uterine tract by cutting between the two applied clamps.
Manipulate structures using the tips of the graspers to minimize iatrogenic trauma. Apply consistent, gentle traction on the proper ligament to exteriorize the ovary without avulsing the pedicle's vasculature. Maintain a clear operative field by using the non-dominant hand or a separate retractor to displace the intestines and bladder away from the targeted structures.
Managing Common Intraoperative Challenges and Post-Surgical Recovery Protocols
Address hemorrhage from a dropped ovarian pedicle by immediately elevating insufflation pressure to 14 mmHg to tamponade venous bleeding and improve visualization. Introduce an additional 5mm port if necessary to facilitate the use of a retrieval bag or to apply hemostatic clips. Avoid blind grasping; use controlled suction and irrigation to identify the vessel stump before securing it with a new ligature or clip. For minor oozing from the uterine stump, a brief application of bipolar cautery is sufficient.
Counteract poor exposure of the uterine horns in deep-chested or obese patients by placing the animal in a steep Trendelenburg position (25-30 degrees). This maneuver uses gravity to shift the intestines cranially. Use the shaft of a closed instrument, not the tip, to gently retract the bladder or colon, clearing the surgical field without causing tissue trauma. If the broad ligament is fatty and obscure, perform dissection closer to the uterine horn itself where the anatomy is more consistent.
Initiate post-procedural pain management with a multimodal approach before the patient recovers from anesthesia. Administer a long-acting local anesthetic, such as bupivacaine 0.5%, at each port site infiltration (1-2 mL per site). Continue with a scheduled non-steroidal anti-inflammatory drug (e.g., carprofen 4.4 mg/kg PO SID) and an opioid like buprenorphine (0.01-0.02 mg/kg IV or IM) for the initial 12-24 hours. Transition to an oral NSAID for 3-5 days post-discharge.
Enforce strict activity restriction for 14 days following the interventional sterilization. Permit only short, controlled leash walks for elimination. Prohibit all running, jumping, and interactions with other animals to prevent seroma formation or incisional herniation at the port sites. Instruct owners to inspect the three small incisions daily for any swelling, redness, or discharge. Skin staples or non-absorbable sutures are to be removed in 10-14 days; subcuticular closures require no removal.