Basic surgical skills

Basic Surgical Skills

1. Basic Surgical Skills Dr Rajeev Kumar Pandit FCPS Resident ( Surgery) Manmohan Memorial Medical College, Swayambhu , Nepal

2. Learning Objectives TO UNDERSTAND:- The principles of patient positioning and operating room safety The Principles of skin and abdominal incision The Principles of wound closure The Principles of bowel and vascular anastomosis TO BE AWARE OF:- The principles of drain usages The principles of diathermy.

3. Introduction The successful outcomes in surgery depend upon the knowledge, skills and judgement. Along with technical, non technical skills like communication, empathy and teamwork are important.

4. PATIENT POSITIONING AND SAFETY ON THE OPERATING TABLE The safety of the patient in the operating theatre is paramount at all times, and is a key responsibility of the surgeon, regardless of grade, experience or seniority. For all cases it is the surgeon’s responsibility to make sure the patient is placed on the table to maximize exposure for the procedure itself and to ensure risks of injury are avoided.

5. TRANSFER TO AND FROM THE OPERATING TABLE The transfer of the anesthetized patient is a critical moment where there are significant risks of fall, injuries. Staff should all receive regular training in manual handling. Patients at additional risk include the obese, elderly and emaciated. These groups require additional care and specialized equipment.

6. POSITIONING ON THE TABLE Surgeons responsibility for Safety Adequate exposure for procedure Placement of diathermy Placement of operating lights These should be done before scrub

7. PATIENT PREPARATION Identification of patient History and physical examination of patient Hair of surgical site are better clipped or depilated than shaving and it should be done just prior to operation.

8. SURGICAL SCRUBBING Hand washing is important measure for infection prevention. Nails are area of greatest contamination Remove all jewelries Use soap, brush and running water Scrub hands, elbow up to arms Turn off tap with elbow Dry with sterile towels Hold hand and forearm away from body and above elbow until putting a sterile gown and glove

9. GOWNING AND GLOVING Place arms through sleeves Have non scrubbed assistant to tie gown back and then put on gloves

10. SKIN PREPARATION Before operation wash surgical site and surroundings with soap and water Prepare skin with antiseptic solution from centre to periphery in circular manner. Antiseptics- chlorhexidine , iodophores , alcohol Solution should remain wet on skin for atleast 2 minutes. The most important principle is progress from clean to dirty Areas of high microbial count like axilla , groin, vagina, perineum, anus are prepped last with separate sponge

11. DRAPPING Cover all part of body except the operative field and area necessary for anesthesia.

12. SKIN INCISION Skin incision to be made with scalpel with blade being placed vertical and down to skin and then drawn toward the area of desire direction. The incision is facilitated by tension being applied across the line of incision with fingers.

13. Different types of surgical blade

14. FACTORS CONSIDERED WHEN PLANNING A SKIN INCISION Skin tension line ( Langer’s line) represents dermal collagen orientation and results in better scar. Anatomical structures-avoid bony prominence, crossing skin creases, consider nerve and vessels Cosmetic factors- Adequate access for procedure-

15. ABDOMINAL INCISION It should be planned to access the relevant organs, surface landmarks , pain control and cosmetic outcomes. The incision should be carried deeper through the subcutaneous tissue. The muscle layers should be divided or split and peritoneum displayed. Peritoneum should be held with 2 forceps and gently incised to ensure there is no damage to the underlying organs. The length of suture material should be at least four times the length of wound to minimize risk of wound dehiscence and later incisional hernia.

16. Picture of skin incision

17. SUTURE MATERIALS Characters of suture materials Physical structures- Monofilament or Multifilament Strength- depends upon the constiuent materials, its thickness and how it handled in the tissue. Tensile strength-Elastic or Plastic Absorbability – absorbable or non absorbable Biological behavior- natural/synthetic Barbed sutures – novel suture materials, eradicate need for knot tying.

18. SIZES OF SUTURE MATERIALS 2— Thick. For pedicle ligation. 1— 1—zero. 2—zero. For bowel suturing. 3—zero. 4—zero. 5—zero. For vascular anastomosis. 6—zero. ” 7—zero. 8—zero. 9—zero. For ophthalmic surgery

19. TYPES OF SUTURE MATERIALS According to source Natural – catgut, silk Synthetic – vicryl , prolene According to absorbability Absorbable – catgut, vicryl Non absorbable- prolene , silk According to number of filament Monofilament – prolene , silk Multifilament/Braided – catgut, vicryl According to relation with needle Atraumatic –eyeless needle Traumatic-needle with eye

20. NEEDLE Needles can be atraumatic or traumatic with eye It has main three parts Shank Body Point It should be hold approximately one third to one half of the way back from the rear of needle.

21. KNOTTING TECHNIQUE The knot must be tied firmly, but without strangulating the tissues. The knot must be unable to slip or unravel. The knot must be as small as possible to minimise the amount of foreign material. The knot must be tightened without exerting any tension or pressure on the tissues being ligated, i.e. the knot should be bedded down carefully, only exerting pressure against counter-pressure from the index finger or thumb. During tying, the suture material must not be ‘sawed’ as this weakens the thread. The suture material must be laid square during tying, otherwise tension applied during tightening may cause breakage or fracture of the thread. When tying an instrument knot, the thread should only be grasped at the free end, as gripping the thread with artery forceps or needle holders can damage the material and again result in breakage or fracture.

22. TYPES OF KNOT

23. SUTURE TECHNIQUE 1. Continuous suturing 2. Interrupted simple suturing 3. Mattress suturing Vertical Horizontal 4. Subcuticular suturing

24. Alternative to sutures Skin adhesive strip - Tegaderm or Bioclusive Tissue glue - n -butyl-2-cyanoacrylate monomer solution Staples

25. WOUND CLOSURE Types of wound healing Primary intention Clean wound Secondary intention Healthy granulation tissue Overexuberant granulation tissue Infected sloughy wound Black eschar Tertiary intention Delayed closure Skin grafting

26. PRINCIPLE OF ANASTOMOSIS Intestinal anastomoses Ensure good blood supply to both bowel ends before and after formation of anastomosis Ensure the anastomosis is under no tension Avoid risk to mesenteric vessels by clamps or sutures Use atraumatic bowel clamps to minimize contamination Interrupted and continuous single-layer suture techniques are adequate and safe Stapling devices are an alternative when speed is required or access is a major factor

27. Vascular anastomosis Non-absorbable monofilament suture material should be used, e.g. polypropylene A smooth intimal suture line is essential Knots require multiple throws in order to ensure security The suture must pass from within outwards on the downflow aspect of the anastomosis

28. DRAINS Drains are inserted to allow fluid or air that might collect at an operation site or in a wound to drain freely to the surface. Three basic principles apply in the use of drains: 1 Open drains that utilize the principle of gravity 2 Semi-open drains that work on the principle of the capillary effect 3 Closed drain systems that utilize suction.

29. PRINCIPLE OF DRAIN REMOVAL Drains put in to cover perioperative bleeding may usually be removed after 24 hours, e.g. thyroidectomy. Drains put in to drain serous collections usually can be removed after 5 days, e.g. mastectomy. Drains put in because of infection should be left until the infection is subsiding or the drainage is minimal. Drains put in to cover colorectal anastomoses should be removed at about 5–7 days. However, it should be stressed that in no way does a drain prevent any intestinal leakage, but merely may assist any such leakage to drain externally rather than to produce life-threatening peritonitis.

30. THE PRINCIPLE OF DIATHERMY: ELECTROCAUTERY When an electrical current passes through a conductor, some of its energy appears as heat. The heat produced depends on: the intensity of the current; the wave form of the current; the electrical property of the tissues through which the current passes; the relative sizes of the two electrodes. There are two basic types of diathermy system in use, monopolar diathermy and bipolar diathermy

31. EFFECT OF CAUTERY Diathermy can be used for three purposes: 1 Coagulation: the sealing of blood vessels. 2 Fulguration: the destructive coagulation of tissues with charring. 3 Cutting: used to divide tissues during bloodless surgery .

32. COMPLICATION OF DIATHERMY Electrocution Explosion Burn Channeling Interference with pacemaker

33. Reference :- Bailey and love’s short practice of surgery 27 th edition Farquharson’s textbook of operative surgery SRB surgical operation textbook. Thank you