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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 ladder of reconstructive complexity — secondary intention → primary closure → skin graft → local flap → regional flap → 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, labial mucosa, intestinal segments, penile-preputial skin, saphenous vein, posterior auricular, STSG, FTSG, bladder mucosa — non-vascularized tissue transfer.
  • Radiation & Tissue EffectsAcute vs chronic radiation changes, the altered biology of the irradiated pelvis, and the implications for fistula repair, urethroplasty, reimplant, and any reconstruction in previously radiated tissue.
  • Hyperbaric Oxygen TherapyMechanism (hyperoxia-driven neovascularization, leukocyte oxidative-burst restoration, antimicrobial synergy), evidence base across hemorrhagic radiation cystitis, radiation-induced fistulas, and Fournier's-gangrene salvage, and the protocol parameters that determine response.

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 — positioning, incisions, tissue-plane dissection, Kocher / Mattox / Cattell–Braasch visceral rotations, transmesenteric approaches, and the zone-based retroperitoneal algorithm in trauma.
  • Vascular Management & Damage ControlThe three-phase DCS paradigm and damage-control resuscitation. Vaginal / perineal packing, the pelvic-hemorrhage algorithm (binder → PPP → angioembolization → IIAL), REBOA zones, proximal aortic control, temporary intravascular shunts, and vessel-by-vessel repair-vs-ligation decisions.
  • Incisions & ClosureThe incision atlas (midline, Pfannenstiel, Gibson, flank, Chevron, thoracoabdominal, dorsal lumbotomy, perineal), fascial closure, layered vs mass closure, and modern evidence on small-bites fascial technique.
  • Laparoscopic AccessPeritoneal entry for minimally invasive GU reconstruction — Veress, Hasson, and direct / optical trocar techniques with comparative safety data (Cochrane, 2025 network meta-analysis); Veress-placement confirmation; entry sites (umbilicus, Palmer's point, supraumbilical, subxiphoid); entry-related complications (great-vessel, inferior-epigastric, bowel, gas embolism, trocar-site hernia); and entry strategy in obesity, the hostile abdomen, and portal hypertension.
  • 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 a procedure-by-procedure selection table for GU reconstruction.
  • Barbed SuturesDedicated deep-dive — V-Loc, Quill, Stratafix, MONOFIX biomechanics; the upper-tract pyeloplasty controversy (Liatsikos 83% / Radford 40% failure); overtightening-to-avoid technique; SBO risk from exposed tails; clinical decision framework.
  • 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 ManagementAdhesion / enterotomy prevention (sharp adhesiolysis, atraumatic graspers, bipolar vs monopolar, intestinal isolation bag, Seprafilm, viscera retainer at closure) and iatrogenic-injury management (primary repair vs diversion in small bowel and colon, thermal-injury resection rule, missed-injury recognition, damage control, EAF prevention).
  • Surgical ErgonomicsOR-table height, monitor placement, loupes, foot-pedal workflow, and the posture economics that determine whether a 6-hour case leaves the surgeon with a functioning neck and back.

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