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Surgical Principles

Reconstructive frameworks and universal operative technique. Organized into two groups: plastic surgery principles that govern when and why to reconstruct, and general surgical technique applicable to any surgical discipline. Domain-specific GU reconstruction principles (urethral, bladder, urinary diversion, upper tract, genital, fistula, prolapse) live with their respective sections in the Treatment Atlas.

See also: Perioperative Care. Surgical-skills training resources live under Resources → Websites & Online Tools and Resources → Surgical Video Atlases.

Plastic Surgery Principles​

The reconstructive-thinking layer. When to reconstruct, how tissue heals, which ladder rung applies, and the tissue-transfer toolkit common to any reconstructive surgeon.

  • Plastic Surgery PrinciplesCore plastic-surgery tenets — the reconstructive mindset, tissue handling, atraumatic technique, planning the scar, and the plastic-surgeon's approach to defect coverage.
  • Reconstructive LadderThe steps of reconstructive complexity, from healing by secondary intention to free tissue transfer, applied to GU defects.
  • Wound HealingPhases of healing, factors that impair healing (diabetes, steroids, radiation, nutrition), and what each phase means for suture strength-retention and timing of subsequent reconstruction.
  • Wound Healing AdjunctsTissue adhesives (Dermabond, Prineo), donor-site dressings, NPWT / wound VAC, closed-incision NPWT, skin substitutes and ADMs (Integra, AlloDerm, Apligraf), PRP and growth factors, hyperbaric oxygen.
  • Flaps in GU ReconstructionGracilis, VRAM, peritoneal, vastus lateralis, omental, and others — vascularized-tissue transfer for urinary diversion, fistula repair, perineal reconstruction, and prosthetic coverage.
  • Grafts in GU ReconstructionBuccal, lingual, oral-lip mucosa, intestinal segments, penile-preputial skin, saphenous vein, posterior auricular, STSG, FTSG, bladder mucosa — free grafts and vascularized intestinal tissue substitutes.[1]
  • Radiation & Tissue EffectsHow radiation changes pelvic tissue and what that means for any reconstruction in an irradiated field.
  • Hyperbaric Oxygen TherapyMechanism, randomized evidence in radiation cystitis and proctitis, observational data in Fournier's gangrene, fistulas and graft conditioning, and safety, contraindications and treatment delivery.

General Surgical Technique​

Universal operative technique applicable to any surgical discipline. Needles, sutures, incisions, closure patterns, bowel anastomosis, and the hand-economy that underpins them all.

  • Operative ExposureVaginal, perineal and abdominal exposure by target, including positioning, incisions and visceral mobilization.
  • Vascular Management & Damage ControlDamage-control resuscitation, packing, pelvic hemorrhage control, endovascular options, temporary shunts, and vessel-specific repair or ligation decisions.
  • Incisions & ClosureIncision selection, elective midline small-bites closure, hernia outcomes, selective prophylactic mesh, and port-site closure.
  • Laparoscopic AccessVeress, open, direct and optical entry; comparative evidence and its limits; site selection, placement checks, and vascular, bowel and gas-embolism complications.
  • NeedlesNeedle anatomy — cutting vs reverse-cutting vs taper vs blunt-taper vs taper-cut tips — and needle-size selection by tissue.
  • SuturesMaterials and selection — absorbable vs non-absorbable, monofilament vs multifilament, strength retention, knot security, and the suture sizes reported for each layer in GU reconstruction.
  • Barbed SuturesBarbed sutures: how they work, where they help and where they have caused problems.
  • Knot SecurityThrows needed by suture and position in the suture line, square and surgeon's knots, sliding knots and post switching, tying force and pulling direction.
  • Bowel AnastomosisHand-sewn and stapled anastomosis configurations (end-to-end, end-to-side, functional end-to-end / GIA-stapled), single- vs double-layer, and the anastomotic-leak-risk factors relevant to urinary diversion with bowel.
  • Intraoperative Bowel Handling & Injury ManagementAtraumatic handling, adhesiolysis, adhesion barriers, recognition of mechanical and thermal injuries, repair or resection, delayed diagnosis, and open-abdomen complications.
  • Surgical ErgonomicsTable height, monitors, loupes and posture to protect the surgeon's neck and back during long cases.

A handful of named, eponymous stitches (Heaney, Quilting, Parker-Kerr) live as standalone reference pages, linked from the operational pages where they are used.

References​

1. Faria EF, Maciel CVM, Melo PA, et al. "Mesentery-Sparing Technique: a New Intracorporeal Approach for Urinary Diversion in Robot-Assisted Radical Cystectomy." Int Braz J Urol. 2024;50(4):489-499. doi:10.1590/S1677-5538.IBJU.2024.0153