basic surgical skills and operating protocols

Basical Surgical skills

1. Basic Surgical Skills

2. Contents Principles of Wound Management Types of incision Types of flap Suturing techniques Types of Knots Wound management Bleeding management Triage Dissection types Decide- Conscious sedation, LA or GA? GA medications

3. Principles of wound management Assessment of wound Haemostasis Analgesia Skin preparation and wound toilet Closure Dressing Infection prevention Follow-up

4. Assessment of wound Mode of injury: blunt, penetrating, blast Time of injury Type of wound: puncture, laceration, incision, crush, burst, bite. (Consider removing rings from injured fingers before oedema starts.) Location: proximity to major vessels (potential damage to blood supply for healing), nerves and organs. Shape: linear, curved, stellate, Y-shaped, inverted V, etc. Depth and direction: risk to underlying tissues, skin tension lines. Potential foreign body: suggestive history - whether it will be radio-opaque or require ultrasound scan location. Potential underlying structural injury: bone fracture, tendon rupture, organ perforation.

5. Haemostasis Either spontaneous Or requires Pressure Torniquet Clamp/Suture (for arterial bleeders)

6. Analgesia Topical: tetracaine-lidocaine combinations can be used to good effect on wounds in children Infiltrative: most often lidocaine (up to 3 mg/kg.  NB : a 1% solution contains 10 mg/mL) However, it is vital not to inject epinephrine around the ears, the tip of the nose The immediate closure of animal and human bites is not recommended, and these wounds should be left open as this can lead to florid infection.

7. Skin preparation and wound toilet Disinfect the skin around the wound with antiseptic, but do not put antiseptic inside the wound. Also consider debridement of ragged, non-viable skin edges. If necessary you can trim hair; however, avoid shaving. Simple ointment can be used to flatten any remaining hair away from the wound. Remove foreign bodies but make sure personnel and equipment to control any increase in bleeding are at hand. Irrigation is more important where there is high risk of infection. The aim is to remove foreign matter and bacteria. Normal saline, drinking-quality water, or cooled boiled water can be used. For lacerations that are not visibly contaminated, low-pressure irrigation using a syringe is sufficient. If high pressure is required, use 50-100 mL/cm liquid under pressure from a syringe with a 25G needle. 

8. Wound closure Timing Primary closure: immediate closure for simple wounds <12 hours old (24 hours on the face), with opposable edges. Delayed primary closure: if there is high risk of infection, give prophylactic antibiotics and close after approximately four days if there is no infection. Secondary closure: allow the wound to close by itself if a bite (except on the face) or it has separated edges or infection. This may result in increased scarring

9. Options Take account of the location and severity of the wound and the age, comorbidities and preferences of the wounded person. Suturing (with local anaesthetic ) is preferred for wounds longer than 5 cm, or those 5 cm or shorter when: There is likely to be excessive flexing of the wound and tension ( eg , over joints or thick dermis), or wetting. Deep dermal sutures are required, to allow low-tension apposition of the wound edges.

10. Suturing (with local anaesthetic ) is preferred for wounds longer than 5 cm, or those 5 cm or shorter when: There is likely to be excessive flexing of the wound and tension ( eg , over joints or thick dermis), or wetting. Deep dermal sutures are required, to allow low-tension apposition of the wound edges. Tissue adhesives or adhesive strips may be used to close wounds 5 cm or shorter where the risk to infection is low  and  the wound edges are easily apposed without leaving any dead space,  and  the wound is not subject to excessive flexing, tension, or wetting

11. Technique tips: Generally use interrupted sutures; mattress sutures may be required for larger wounds. First oppose midpoint if linear, or corners if jagged wound. There are special tricks for when there has been skin loss or complex-shaped lacerations. Ensure good bite of tissue taken with needle entering and leaving vertically.. Space sutures about 2-5 mm apar

12. Staples: In a case where you have a linear laceration located on the scalp or extremities, it is a reasonable alternative to use staples. The advantage is that they can be placed quickly. This is immensely useful in situations where there is brisk bleeding and in mass casualty. Sutures: absorbable and non-absorbable. Non resorbable: great tensile strength, not dissolved by body’s chemical, superficial wounds Resorbable: double layer closure for deeper wounds , help decrease the tension and better approximate the wound edges choice of suture and technique depends on the type of wound, depth, degree of tension, and desired cosmetic results.

13. Adhesives n percutaneous wounds or simple pediatric cases

14. Suggested sizes and durations [ 5 ,  8 ,  9 ,  10 ] Child's face: 6'0 monofilament nylon; remove after 3-5 days. Adult's face: 5'0 monofilament nylon; remove after five days. Adult scalp: 4'0 nylon/silk; remove after 3-5 days. Adult arm/trunk/abdomen: 3'0 nylon/silk; remove after 7-10 days.

15. Risk factors for delayed healing [ 5 ] Size, location and motion of wound. Age. Genetics. Race. Marfan's syndrome, connective tissue disorders. Nutrition; deficiencies in protein, vitamins A, C, E, B1 (thiamine), other B vitamins, and zinc have been shown to retard healing. However, supplements to non-deficient patients probably have little or no benefit. Local infection. Ischaemia. Glucocorticoid therapy. Diabetes mellitus. Smoking. Foreign bodies.

16. Wound dressings The first layer in contact with the wound surface should be non-adherent - eg , a lightly lubricated gauze with interstices. Occlusive dressings can lead to maceration with retained fluid. If there is a large amount of exudate, the next layer should be absorbent material such as alginate or foam. Finally, soft gauze rolls tape can be used to secure the initial materials in place. Dressings may not be necessary if the wound is dry and extra protection is not required.

17. Dressing For a wound to heal well Wound must be cleansed and kept clean Divided tissues must be adjusted and retained in position Parts must be kept at rest All effused fluids must be able to escape (but the primary blood clot), Wound must be protected by some dressing material

18. The cleansing of wound Thoroughness of washing more important than fluid employed If infected, use: iodine 2%, a 1-40 carbolic lotion, perchloride of mercury of the strength of about 1-2000,or hot peroxide of hydrogen Foreign bodies to be removed from ordinary wounds 10cc tetanus antitoxin IMl

19. The adjustment and closure of the wound Closure in layers Deep/ buried sutures

20. Wound infection Signs and symptoms Increasing local inflammation - rubor , dolour , calor and tumour . Discharge/collection of pus. Systemic signs - fever. Risk factors Delayed presentation (>12 hours). Foreign bodies. Heavily soiled wounds. Bites (especially human, cats). Puncture wounds (especially on the foot). Intra-oral wounds. Open fractures/exposed tendons. Crush wounds.

21. Antibiotic usage in wound management This is advisable for high-risk wounds or if there are already signs of infection. Take a swab of the wound before starting antibiotic treatment. If the wound is contaminated with high-risk material ( eg , soil, faeces , saliva, or purulent exudates), treat with co-amoxiclav. If the person is allergic to penicillin, treat with erythromycin or clarithromycin combined with metronidazole. If the wound is clean, treat with flucloxacillin. If the person is allergic to penicillin, treat with erythromycin or clarithromycin. Mode of delivery is usually oral, unless there are systemic signs or rapid spread. Topical antibiotic ointment is an option.

22. Complications Immediate: hematoma formation due to poor hemostatic control Human bites and some animal bites, particularly felines, have a very high chance of getting infecting early on Late complications : scar formation due to improper technique . . H ypertrophic scars and keloid formation

23. post-closure assessment includes: Assess for presence, type, and amount of exudate:Serous , serosanguineous, sanguineous, or purulent Minimal, light, moderate, or heavy Access surrounding skin tissue Assess wound margins for tunneling, rolled, undermining, fibrotic changes, and if unattached Evaluate for signs and symptoms of infect - warm, pain, odor, delayed healing Assess pain

24. Scrubbing, Gowning and Gloving Technique

25. Surgical handscrub a systematic washing and scrubbing of the hands and forearms with an effective antibacterial cleaning solution to render the skin of hands and arms as free from bacteria as possible Transient Organisms Resident Organisms Hand scrub therefore needs to be repeated between procedures

26. Solutions used: Hibiscrub —( Cholorhexidine 4%) Betadine scrub—(Povidone iodine 7.5%) Soap

27. Scrub up technqiue Time method Scrub solutions: 2 minutes Soap: 5 minutes Brush stroke method a prescribed number of brush strokes are applied lengthwise for each surface of fingers hands and arms

28. Gowning

29. Gloving

30. Knot tying techniques for approximation of tissues or for ligation of blood vessels. Multifilament sutures are easier to tie .

31. Safe Principals of Knot Tying firm to avoid slipping. as small as possible friction between strands must be avoided avoid excessive tension Extra ties do not add to the strength

32. Methods of Knot Tying Hand tied knot Instrument tied knot Endoscopic knot tying

33. Hand tied knots: 1. Granny knot 2. Square knot or reef knot 3. Surgeon’s knot 4. Reverse surgeon’s knot 5. Double-double knot

34. Endo Knotting - extracorporeal A Roeder’s knot Indications for Loop Application 1. For ligation of pedicles. 2. In case of a wider cystic duct when appropriate size clip is not applicable. 3. For control of bleeding vessels.

35. Wound closure techniques

36. Primary wound closure 1. Brings wound edges together neatly and evenly 2. Stops bleeding 3. Preserves function of the tissue 4. Prevents infection 5. Restores cosmetic appearance 6. Promotes rapid healing 7. Decreases patient discomfort

37. Wounds should be closed within 18 hours to avoid wound infection except for wounds of face and scalp where a delay of up to 72 hrs is acceptable.

38. Increased Risk of Infection Diabetes mellitus Obesity Malnourishment Immune suppressed state Patient on steroids or chemotherapeutic agents Crush injuries leading to devitalized tissue Contaminated wounds with foreign bodies

39. Wound Closure Techniques Sutures Tissue adhesives Staples Surgical tapes

40. Steps of Laceration Suturing Wound Assessment Time of injury. After four hours , wound should be scrubbed to remove the protein coagulum. Mechanism of injury Ask about tetanus immunization status. 4. Test for distal sensory and motor function to rule out nerve and tendon injuries 5. Consider imaging studies

41. Wound Preparation Wound cleaning is done either by direct scrubbing or irrigation of the tissue continuous or pulsatile irrigation. Normal saline is the irrigation solution of choice because it does not damage tissue 100cc of saline is used for each cm of wound

42. If using plain lignocaine for local anesthesia it should be buffered by adding 1 ml of sodium bicarbonate to 9 ml of lignocaine to reduce pain of injection. Inject slowly, subdermally , beginning inside the cut margin of the wound. Avoid piercing intact skin.

43. Wound Suturing Face Use 4-0 or 5-0 monofilament suture on a cutting needle simple interrupted or sub-cuticular Sutures are removed in 5 days . Scalp 2-0 or 3-0 non-absorbable monofilament suture 10 days

44. Lip Deeper layers: 4-0 or 5-0 synthetic absorbable suture superficial layer: 3-0 synthetic monofilament Simple interrupted Oral cavity 4-0 absorbable

45. Types of Sutures Simple Interrupted Suture If sutures are tied too tightly they will cause ischemia, delay healing and increase scarring.

46. Vertical Mattress Suture: if there is excess skin or loose subcutaneous fat Horizontal mattress: eversion or inversion of a wound edge

47. Subcuticular suturing fine and neat scar no support to the underlying tissue

48. Post suturing management Cover sutured wounds for 1-2 days Topical application of antibiotic ointment Prophylactic antibiotics not indicated for simple laceration

49. Suture removal

50. Other methods of wound closure Tissue adhesives = formaldehyde + cyanoacrylate React with oh- ions in water and blood Not to be applied over areas of high tension Can be removed with acetone, petroleum jelly or antibacterial ointment.

51. Staples 1. fast application 2. lower rate of foreign body 3. decreased infection rate Surgical or adhesive tapes ( steristrips ) placed after suture removal and may decrease skin tension.

52. Instrument handling Instruments for Cutting 1. Scissors 2. Scalpel Instruments for Grasping 1. Thumb forceps (toothed/non-toothed) 2. Artery forceps 3. Babcock forceps 4. Ellis forceps Instrument for Suturing 1. Needle holders

53. The scalpel Handle 3 – blade #10-15 Handle 4 – blade #18-24 Larger blades- #10 blade- larger incisions #11 blade- stab incisions #15 blade- precision work

54. The scissors 1. Tissue dissection. 2. Undermining skin or raising skin flaps 3. Dividing tissue. 4. Cutting sutures. 5. Cutting gauze, meshes or other surgical materials. 6. Opening tissue planes. 7. Assisting the surgeon in the palpation of tissues. 8. Probing cavities

55. Types of Scissor Dissecting scissors with a blunt tip. Cutting scissors with a sharp tip Mayo Cutting scissors Metzenbaum

56. Tissue forceps Used to retract, stabilize or grasp tissue Artery forceps for holding bleeding vessels before they are occluded by a ligature or cauterized for dissection

57. Needle holder

58. Retractors Traction and counter traction Superficial retractors Deep retractors Self retaining retractors

59. Superficial retractors Langenbeck’s retractor: to retract fascia or aponeurosis. Czerny’s retractor Deep Retractors Morris retractor Deaver’s retractor Doyen’s retractor

60. Austin retractor - to retract soft tissue flaps after incision away from the tooth - tendency to cause bleeding in friable tissues

61. Dingman retractor - self retaining - cleft palate and other intraoral surgeries - can’t be used to visualize deep structures

62. Soft palate retractors - pull the soft palate superiorly to expose the nasopharynx - tonsillectomy and adenoidectomy Latrobe retractor adenoidectomy, tonsillectomy, and extracting tonsilloliths Needs constant retraction

63. References Pye’s Surgical Handicraft Basic Surgical Skills and Techniques by by David L stoker and Sudhir K Jain Wound Management and Suturing Assessment , Dressing, and Closure Last updated by  Dr Laurence Knott   Peer reviewed by  Dr Colin Tidy Azmat CE, Council M. Wound Closure Techniques. [Updated 2023 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.  Available from: https://www.ncbi.nlm.nih.gov/books/NBK470598/

64. Thank you