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Basic Surgical Skill

Basic Surgical Skill

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Published by: Indah Fitria on Jan 10, 2013
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4Basic surgical skills
David H. Oram
FRCOGConsultant Gynaecological Oncologist
Department of Gynaecological Oncology, St Bartholomew’s Hospital, London EC1A 7BE, UK 
A team approach is essential to the practice of successful surgery. Good surgery begins beforeany incision is made with consideration of the type of equipment needed and the incision to beused to ensure optimum access. Although the repertoire of tools available to the surgeon hasincreased, the attainment of safe and efficient surgical technique still depends on a comprehensiveknowledge of the basic surgical skills outlined in this chapter. These include proficiency in knottying, instrument handling, suturing, haemostasis and tissue dissection. Surgery should ‘flow’,using the simplest and safest way to achieve the operative goal. As the duration of trainingshortens, the importance of teaching good surgical technique by example and direct supervisionhas never been greater
Key words:
basic surgical skills; gynaecological surgery; skills training; surgical haemostasis.
Writing in the preface to the ninth edition of 
Bonney’s Gynaecological Surgery 
, the book’seditor, John Monaghan, advocates that ‘operations should flow with a style and naturalpace, rather like awell choreographed dance’. For this to be achieved, there must be anacknowledgement that the practice of successful surgery is the product of a teamapproach. As well as the lead surgeon, the team includes anaesthetists, surgicalassistants, ODAs, theatre nurses, ward nurses and porters. The astute surgeon needsto engender such bonding as is required to ensure a belief in the common task. It istherefore axiomatic that there is a need to lead by example and to instil the correctworking atmosphere in the operating theatre. Whilst there is a requirement to try tomaintain the highest possible surgical standards, and in this respect for the surgeon tomake his or her personal preferences known, it must be appreciated that individuals,instruments, equipment and even elevators are capable of malfunction. In suchfrustrating circumstances, shows of petulance are rarely productive and do nothing forteam morale. If the problem is a recurring one, however, it is incumbent on the surgeon
Best Practice & Research Clinical Obstetrics and GynaecologyVol. 20, No. 1, pp. 61–71, 2006
doi:10.1016/j.bpobgyn.2005.09.003available online athttp://www.sciencedirect.com
1521-6934/$ - see front matter
2005 Elsevier Ltd. All rights reserved.
Corresponding author. Tel.:
44 20 7601 7179.
E-mail address
: davidoram@aol.com
to insist that it is rectified to ensure that the highest standards are indeed maintained atevery operating list.Working every operating list with the same experienced scrub nurse/sister, whoknows your surgical style and idiosyncrasies, is a rare event for many surgeons thesedays. It is, however, a privilege to work with someone who is poised, watching thesurgery, armed with a selection of instruments, and who places the appropriateinstrument firmly in your palm—sometimes without you needing to ask for it, andcertainly without you having to look up from the operative field. When surgery flowswith this sort of teamwork, it can be a truly beautiful—even emotional—thing toobserve. The reality, however, is that different personnel are involved in differentoperating lists and the surgery is only able to flow in an uninterrupted fashion if thesurgeon plans ahead. It is always worth checking that instruments and sutures of choiceare available before the operation starts. Intraoperatively, it is worth telling the scrubnurse a minute or two in advance what instruments/sutures/drains, etc. are to beneeded imminently. It is only with this degree of forward planning that surgery will fulfilthe choreographic requirements alluded to in the opening sentence of this chapter.An integral part of the senior surgeon’s responsibility in the operating theatre is toteach, and teach constantly; this is more important now than ever. The concept of aconsultant-based, rather than a consultant-led, service has inevitably led to doctors intraining performing fewer operations themselves. This, combined with the fact that theduration of training is now shorter than it was, is a potential recipe for the productionof undertrained inexperienced surgeons. Given that this is the case, clearly it is of equalimportance for doctors in training to avail themselves of every opportunity to watch,assist and operate under supervision. It is a great privilege during the training years tobe able to watch avariety of senior surgeons operate. There are enormous variations instyle, technique and even demeanour that need to be appreciated. This provides thetrainee surgeon with a great opportunity to pick up invaluable hints and tips and toselect various aspects of surgical technique that can then be incorporated into theirown surgical routines, which should be a composite of various learned skills and whichis then open to further refinement as experience develops.The attainment of safe, efficient, reproducible surgical technique is predicated on acomprehensive knowledge of basic surgical skills, which this chapter is designed toaddress.
A basic knowledge of surgical knot options and the acquirement of the dexteritynecessary to tie them is a fundamental requisite at the start of surgical training. Knot-tying techniques by the two-handed method, the single-handed method and with theuse of instruments, should be practised religiously until they can be performed botheffectively and rapidly, with almost automatic ease. A wide variety of knot types is notrequired but the basic principles of tying a slip knot, a granny knot and a reef knot areessential, as is the knowledge of how to use variations and combinations of these knotsin different surgical situations and with different suture materials.Catgut is no longer used as a suture material and with most modern suture materialsthereis a need to achieve the required knot placement and tension without any slippageafter the first throw. To achieve this, it is important that knots are set down as squareknots. This requires the second half hitch to be made in the opposite direction to
62 D. H. Oram
the first. With synthetic suture materials, which do not have good ‘memory’, it issometimes difficult to hold the first half hitch in position whilst making the secondthrow. This is overcome in one of two ways; either by holding one end taut whilstmaking the second throw, or else by making two turns about the suture on the first half hitch. Some surgeons, particularly when tying deep in the pelvis or when securing abulky tissue pedicle, feel more comfortable tying such a double hitch with two handsbefore advancing the knot to its required position and thereafter securing it with a finalreef hitch, which locks the knot; this is known as a surgeon’s knot.One-handedtyingofsurgicalknotsisanessentialskill.Asageneralprinciple,thepuristswould argue that the maximum economy of movement is achieved if a right-handedsurgeontieswith the lefthandanda left-handedsurgeon tieswiththe right.Although thismightrequirefewerhandchangesofinstruments,itisnotessentialandthesurgeonshoulduse whichever hand feels most comfortable, as this will generally be the safest.
A variety of suturing methods can be used in different clinical situations and in differentanatomical locations. Simple interrupted sutures may be used for skin closure. Theyshould be tied so as to achieve approximation of the tissue edges only and not so tightlythat devascularisation and necrosis results. The advantage of interrupted sutures is thatthey allow drainage of any accumulated serous, sanguineous or purulent fluid and maybe removed individually in cases of infection without necessarily compromising thewhole length of the incision.An alternative to the simple interrupted stitch is the vertical mattress suture, whichagain can be used for approximation of skin edges. The horizontal or crossed mattresssuture is an excellent haemostatic stitch and can be used with great effect: for example,if there is oozing from the vaginal vault or its angles at the end of a hysterectomy.Lembert sutures are another form of interrupted suture that can be used in a secondlayer of a bowel anastomosis and this technique is still useful to learn even thoughstapling devices are currently far more commonly employed.In different circumstances, continuous suturing techniques are useful. This is a morerapid method of suturing, and is strong because tension is evenly distributed along theentire length of the suture. They also leave less foreign material in the wound. They areeffective not only in producing closure of tissue incisions and defects but also forproviding for haemostasis. They can be used for closing the vaginal vault at the end of ahysterectomy, either in a simple running fashion or by converting them into a blanket orlocked suture if extra haemostasis without shortening or puckering of tissue isrequired, such as closing a myomectomy incision in the uterus or closing the vaginalvault at the end of a colporrhaphy. Continuous sutures would also be employed toachieve closure of the rectus sheath and can be used in the form of a subcuticular stitchto achieve skin closure. For this purpose, either a curvedor straight needle can be used.In principle, if a straight needle is used the surgeon should sew in a direction away fromhimself/herself; if a curved needle is used the surgeon should suture towardshimself/herself. Subcuticular sutures generally produce an excellent cosmetic result buta disadvantage is that if asuperficial haematoma or infection of the subcutaneous tissuesoccurs then the whole suture will need to be removed to allow drainage.Pedicles can be secured and haemostasis achieved either by the use of ligatures or bytransfixion sutures. In both circumstances, clamp placement is important. A curved or
Basic surgical skills 63

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