Chapter 64 Basic Surgical Technique and Postoperative Care
Preoperative Planning and Preparation
Arrangement and Routine in the Operating Room
Seated opposite the surgeon, the assistant should view the operative field from 8 to 10 cm higher than the surgeon to allow a clear line of vision without having to bend forward and obstruct the surgeon’s view. Although mechanical hand holders are available, they are not as good as a motivated and well-trained assistant. It is especially helpful for the assistant to be familiar with each procedure. Usually, the primary duty of the assistant is to hold the patient’s hand stable, secure, and motionless, retracting the fingers to provide the surgeon with the best access to the operative field (Figs. 64-2 and 64-3).

FIGURE 64-3 Ideal position for assistant to stabilize patient’s hand as surgeon makes zigzag incision.
Choice of Anesthesia
TABLE 64-1 Maximal Doses of Local Anesthetics for Brachial Plexus Blocks*
ANESTHETIC | MAXIMAL RECOMMENDED DOSE |
---|---|
Bupivacaine | 2.5 mg/kg |
Bupivacaine with epinephrine | 3.0 mg/kg |
Levobupivacaine | 2.0 mg/kg |
Levobupivacaine with epinephrine | 3.0 mg/kg |
Ropivacaine | 2.0 mg/kg |
Ropivacaine with epinephrine | 3.0 mg/kg |
*These amounts should be used as a guideline only; practitioners should use their clinical judgment when administering local anesthetics.
Modified from Bruce BG, Green A, Blaine TA, Wesner LV: Brachial plexus blocks for upper extremity orthopaedic surgery, J AAOS 20:38, 2012.
Brachial Plexus Blocks
Digital Nerve Blocks
Digital nerve blocks provide excellent anesthesia for procedures on the fingers (Fig. 64-8). Usually, perineural injection around the digital nerves proximal to the finger web spaces is a safer technique than injection of the nerves at the base of the fingers. Because ischemia may develop after injection of an anesthetic agent in a circle around the base of the finger, this technique should be avoided. Digital blocks using a transthecal (flexor sheath) approach have shown no advantage compared with the traditional digital block technique (Fig. 64-9). We rarely use epinephrine in the local anesthetic agent in the digits, although it can be used safely.
Preparation and Draping for Elective Surgery
TABLE 64-2 Antiseptic Solutions
Alcohol | Good immediate skin disinfectant, but dries quickly and has less long-term effect |
95% alcohol better than 75% because of dilution by moist skin | |
Hexachlorophene (pHisoHex) | Forms a film that retains bacteriostatic properties |
Easily washed off | |
Requires multiple applications to be effective | |
May be toxic in infants | |
Effective against gram-positive organisms; less effective against gram-negative organisms | |
Iodine | Side effects |
Alcoholic (tincture) | Frequent skin irritation (can be lessened by adding iodine) |
Aqueous (Lugol’s solution) | True allergic reactions |
Iodophors (povidone-iodine [Betadine]) | Advantages over iodine |
Iodine and polyvinyl pyrrolidine or povidone | Slower release of iodine |
Fewer skin reactions | |
Effective against gram-negative and gram-positive organisms | |
Chlorhexidine (Hibiclens) 70% alcoholic solution | Some studies have shown it superior to Betadine and pHisoHex |
Repeated washings may have a cumulative effect |
Adapted from Green DP: General principles. In Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, editors: Green’s operative hand surgery, ed 6. Philadelphia, 2011, Elsevier.