Fundamentals of Dissection

  • Neal S. McCall
  • Harish LavuEmail author


Appropriate surgical technique requires a mastery of the basic skills of surgical dissection. This chapter provides a brief overview of considerations of lighting, positioning, and preoperative imaging as they relate to surgical dissection. It discusses basic aspects of dissection, such as the differences between sharp and blunt dissection techniques and their applications, as well as the use of proper traction and counter-traction during dissection. More advanced, instrumental methods of dissection, encompassing electrosurgery and water dissection, are reviewed. Approaches to dissection of more challenging tissue planes, including those of neoplastic and inflamed tissues, are explored as well. Finally, the chapter ends with a discussion of cognitive biases, how they can relate to surgical dissection, and the importance of a surgeon’s awareness of them.


Dissection Surgery Cognitive bias 

Suggested Readings

  1. Kirk R. Basic surgical techniques. Edinburgh: Elsevier; 2010.Google Scholar
  2. Karakousis CP. Principles of surgical dissection. J Surg Oncol. 1982;21:205–6.CrossRefPubMedGoogle Scholar
  3. Way LW, et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg. 2003;237:460–9.PubMedPubMedCentralGoogle Scholar


  1. 1.
    AlJamal YN, Zendejas B, Gas BL, Ali SM, Heller SF, Kendrick ML, et al. Annual surgeon volume and patient outcomes following laparoscopic totally extraperitoneal inguinal hernia repairs. J Laparoendosc Adv Surg Tech A. 2016;26(2):92–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Al-Sahaf M, Lim E. The association between surgical volume, survival and quality of care. J Thorac Dis. 2015;7(Suppl 2):S152–5.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Amato L, Colais P, Davoli M, Ferroni E, Fusco D, Minozzi S, et al. [Volume and health outcomes: evidence from systematic reviews and from evaluation of Italian hospital data]. Epidemiol Prev. 2013;37(2-3 Suppl 2):1–100.Google Scholar
  4. 4.
    Sosa JA, Bowman HM, Gordon TA, Bass EB, Yeo CJ, Lillemoe KD, et al. Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg. 1998;228(3):429–38.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Bell RH, Biester TW, Tabuenca A, Rhodes RS, Cofer JB, Britt LD, et al. Operative experience of residents in US general surgery programs: a gap between expectation and experience. Ann Surg. 2009;249(5):719–24.CrossRefPubMedGoogle Scholar
  6. 6.
    Khuri SF, Henderson WG, Daley J, Jonasson O, Jones RS, Campbell DA, et al. Successful implementation of the Department of Veterans Affairs’ National Surgical Quality Improvement Program in the private sector: the patient safety in surgery study. Ann Surg. 2008;248(2):329–36.CrossRefPubMedGoogle Scholar
  7. 7.
    Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.CrossRefPubMedGoogle Scholar
  8. 8.
    Fabri PJ, Zayas-Castro JL. Human error, not communication and systems, underlies surgical complications. Surgery. 2008;144(4):557–63; discussion 563.CrossRefPubMedGoogle Scholar
  9. 9.
    Regenbogen SE, Greenberg CC, Studdert DM, Lipsitz SR, Zinner MJ, Gawande AA. Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients. Ann Surg. 2007;246(5):705–11.CrossRefPubMedGoogle Scholar
  10. 10.
    Rogers SO, Gawande AA, Kwaan M, Puopolo AL, Yoon C, Brennan TA, et al. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery. 2006;140(1):25–33.CrossRefPubMedGoogle Scholar
  11. 11.
    Singh K, Ohri A. Anatomic landmarks: their usefulness in safe laparoscopic cholecystectomy. Surg Endosc. 2006;20(11):1754–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Buchwald H. Three helpful techniques for facilitating abdominal procedures, in particular for surgery in the obese. Am J Surg. 1998;175(1):63–4.CrossRefPubMedGoogle Scholar
  13. 13.
    Poulin E, et al. Chap. 25: Splenectomy. In: ACS surgery: principles & practice. 6th ed. New York: WebMD; 2010.Google Scholar
  14. 14.
    Anema JG, Morey AF, McAninch JW, Mario LA, Wessells H. Complications related to the high lithotomy position during urethral reconstruction. J Urol. 2000;164(2):360–3.CrossRefPubMedGoogle Scholar
  15. 15.
    Frezza EE. The lithotomy versus the supine position for laparoscopic advanced surgeries: a historical review. J Laparoendosc Adv Surg Tech A. 2005;15(2):140–4.CrossRefPubMedGoogle Scholar
  16. 16.
    Knulst AJ, Mooijweer R, Jansen FW, Stassen LPS, Dankelman J. Indicating shortcomings in surgical lighting systems. Minim Invasive Ther Allied Technol. 2011;20(5):267–75.CrossRefPubMedGoogle Scholar
  17. 17.
    Moriyama S, Kawasuji M. [Lighting and surgical exposure with head lamp and optical loupes]. Kyobu Geka. 2009;62(8 Suppl):633–7.Google Scholar
  18. 18.
    Browne D. A headlight for general surgery. Lancet. 1956;270(6909):191.CrossRefPubMedGoogle Scholar
  19. 19.
    Tosun A, Hancerliogullari KO, Serifoglu I, Capan Y, Ozkaya E. Role of preoperative sonography in predicting conversion from laparoscopic cholecystectomy to open surgery. Eur J Radiol. 2015;84(3):346–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Jacobson FL. Chap. 3. Chest imaging: role of CT, PET/CT, and MRI. In: Sugarbaker DJ, Bueno R, Krasna MJ, Mentzer SJ, Zellos L, editors. Adult chest surgery. New York: McGraw-Hill; 2009.Google Scholar
  21. 21.
    Gross SD. In: Lee HC, editor. A system of surgery: pathological, diagnostic, therapeutic, and operative. 5th ed. Philadelphia: H.C. Lea; 1872.Google Scholar
  22. 22.
    Kirk R. Basic surgical techniques. Edinburgh: Elsevier; 2010.Google Scholar
  23. 23.
    Karakousis CP. Principles of surgical dissection. J Surg Oncol. 1982;21(4):205–6.CrossRefPubMedGoogle Scholar
  24. 24.
    Karakousis CP. The technique of popliteal lymph node dissection. Surg Gynecol Obstet. 1980;151(3):420–3.PubMedGoogle Scholar
  25. 25.
    Vollmer CM, Dixon E, Sahajpal A, Cattral MS, Grant DR, Gallinger S, et al. Water-jet dissection for parenchymal division during hepatectomy. HPB (Oxford). 2006;8(5):377–85.CrossRefGoogle Scholar
  26. 26.
    Naude GP, Morris E, Bongard FS. Laparoscopic cholecystectomy facilitated by hydrodissection. J Laparoendosc Adv Surg Tech A. 1998;8(4):215–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Araki Y, Noake T, Kanazawa M, Yamada K, Momosaki K, Nozoe Y, et al. Clipless hand-assisted laparoscopic total colectomy using Ligasure Atlas. Kurume Med J. 2004;51(2):105–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Targarona EM, Balague C, Marin J, Neto RB, Martinez C, Garriga J, et al. Energy sources for laparoscopic colectomy: a prospective randomized comparison of conventional electrosurgery, bipolar computer-controlled electrosurgery and ultrasonic dissection. Operative outcome and costs analysis. Surg Innov. 2005;12(4):339–44.CrossRefPubMedGoogle Scholar
  29. 29.
    McCarus SD. Physiologic mechanism of the ultrasonically activated scalpel. J Am Assoc Gynecol Laparosc. 1996;3(4):601–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Bubenik LJ, Hosgood G, Vasanjee SC. Bursting tension of medium and large canine arteries sealed with ultrasonic energy or suture ligation. Vet Surg. 2005;34(3):289–93.CrossRefPubMedGoogle Scholar
  31. 31.
    Steele PRC, Curran JF, Mountain RE. Current and future practices in surgical retraction. Surgeon. 2013;11(6):330–7.CrossRefPubMedGoogle Scholar
  32. 32.
    Rossidis G. Chap. 1: Laparoscopic cholecystectomy. In: Operative techniques in surgery. 1st ed. Philadelphia: Lippincott Williams & Wilkins; 2015. p. 475–84.Google Scholar
  33. 33.
    Friedberg JS. Chap. 65. Segmentectomy. In: Sugarbaker DJ, Bueno R, Krasna MJ, Mentzer SJ, Zellos L, editors. Adult chest surgery. New York: McGraw-Hill; 2009.Google Scholar
  34. 34.
    Jones DR, Stiles BM, Denlinger CE, Antippa P, Daniel TM. Pulmonary segmentectomy: results and complications. Ann Thorac Surg. 2003;76(2):343–8; discussion 348.CrossRefPubMedGoogle Scholar
  35. 35.
    Fell SC. Segmental resection. Chest Surg Clin N Am. 1995;5(2):205–21.PubMedGoogle Scholar
  36. 36.
    Abcarian H. Is the holy plane the last word? Dis Colon Rectum. 2016;59(2):160–1.CrossRefPubMedGoogle Scholar
  37. 37.
    Su Y-R, Shih I-L, Tai H-C, Wei S-C, Lin B-R, Yu H-J, et al. Surgical management in enterovesical fistula in Crohn disease at a single medical center. Int Surg. 2014;99(2):120–5.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Brown T, Shah AH, Bregy A, Shah NH, Thambuswamy M, Barbarite E, et al. Awake craniotomy for brain tumor resection: the rule rather than the exception? J Neurosurg Anesthesiol. 2013;25(3):240–7.CrossRefPubMedGoogle Scholar
  39. 39.
    Brucker SY, Hahn M, Kraemer D, Taran FA, Isaacson KB, Krämer B. Laparoscopic radiofrequency volumetric thermal ablation of fibroids versus laparoscopic myomectomy. Int J Gynaecol Obstet. 2014;125(3):261–5.CrossRefPubMedGoogle Scholar
  40. 40.
    Yule S, Flin R, Paterson-Brown S, Maran N. Non-technical skills for surgeons in the operating room: a review of the literature. Surgery. 2006;139(2):140–9.CrossRefPubMedGoogle Scholar
  41. 41.
    Reason J. Safety in the operating theatre - part 2: human error and organisational failure. Qual Saf Health Care. 2005;14(1):56–60.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Way LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg. 2003;237(4):460–9.PubMedPubMedCentralGoogle Scholar
  43. 43.
    Arora S, Miskovic D, Hull L, Moorthy K, Aggarwal R, Johannsson H, et al. Self vs expert assessment of technical and non-technical skills in high fidelity simulation. Am J Surg. 2011;202(4):500–6.CrossRefPubMedGoogle Scholar
  44. 44.
    Kaye AD, Fox CJ III, Urman RD. Operating room leadership and management. Cambridge: Cambridge University Press; 2012.CrossRefGoogle Scholar
  45. 45.
    Thiels CA, Lal TM, Nienow JM, Pasupathy KS, Blocker RC, Aho JM, et al. Surgical never events and contributing human factors. Surgery. 2015;158(2):515–21.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of SurgerySidney Kimmel Medical College, Thomas Jefferson UniversityPhiladelphiaUSA
  2. 2.Jefferson Pancreas, Biliary and Related Cancer, Center and the Department of SurgeryThomas Jefferson UniversityPhiladelphiaUSA
  3. 3.Sidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaUSA

Personalised recommendations