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doi:10.1016/j.bpobgyn.2005.09.003 available online at http://www.sciencedirect.com
4 Basic surgical skills
David H. Oram*
Consultant 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 before any incision is made with consideration of the type of equipment needed and the incision to be used to ensure optimum access. Although the repertoire of tools available to the surgeon has increased, the attainment of safe and efﬁcient surgical technique still depends on a comprehensive knowledge of the basic surgical skills outlined in this chapter. These include proﬁciency in knot tying, 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 training shortens, the importance of teaching good surgical technique by example and direct supervision has never been greater Key words: basic surgical skills; gynaecological surgery; skills training; surgical haemostasis.
THEATRE ETIQUETTE Writing in the preface to the ninth edition of Bonney’s Gynaecological Surgery, the book’s editor, John Monaghan, advocates that ‘operations should ﬂow with a style and natural pace, rather like a well choreographed dance’. For this to be achieved, there must be an acknowledgement that the practice of successful surgery is the product of a team approach. As well as the lead surgeon, the team includes anaesthetists, surgical assistants, ODAs, theatre nurses, ward nurses and porters. The astute surgeon needs to engender such bonding as is required to ensure a belief in the common task. It is therefore axiomatic that there is a need to lead by example and to instil the correct working atmosphere in the operating theatre. Whilst there is a requirement to try to maintain the highest possible surgical standards, and in this respect for the surgeon to make his or her personal preferences known, it must be appreciated that individuals, instruments, equipment and even elevators are capable of malfunction. In such frustrating circumstances, shows of petulance are rarely productive and do nothing for team morale. If the problem is a recurring one, however, it is incumbent on the surgeon
* Corresponding author. Tel.: C44 20 7601 7179. E-mail address: email@example.com
1521-6934/$ - see front matter Q 2005 Elsevier Ltd. All rights reserved.
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to insist that it is rectiﬁed to ensure that the highest standards are indeed maintained at every operating list. Working every operating list with the same experienced scrub nurse/sister, who knows your surgical style and idiosyncrasies, is a rare event for many surgeons these days. It is, however, a privilege to work with someone who is poised, watching the surgery, armed with a selection of instruments, and who places the appropriate instrument ﬁrmly in your palm—sometimes without you needing to ask for it, and certainly without you having to look up from the operative ﬁeld. When surgery ﬂows with this sort of teamwork, it can be a truly beautiful—even emotional—thing to observe. The reality, however, is that different personnel are involved in different operating lists and the surgery is only able to ﬂow in an uninterrupted fashion if the surgeon plans ahead. It is always worth checking that instruments and sutures of choice are available before the operation starts. Intraoperatively, it is worth telling the scrub nurse a minute or two in advance what instruments/sutures/drains, etc. are to be needed imminently. It is only with this degree of forward planning that surgery will fulﬁl the 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 to teach, and teach constantly; this is more important now than ever. The concept of a consultant-based, rather than a consultant-led, service has inevitably led to doctors in training performing fewer operations themselves. This, combined with the fact that the duration of training is now shorter than it was, is a potential recipe for the production of undertrained inexperienced surgeons. Given that this is the case, clearly it is of equal importance 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 to be able to watch a variety of senior surgeons operate. There are enormous variations in style, technique and even demeanour that need to be appreciated. This provides the trainee surgeon with a great opportunity to pick up invaluable hints and tips and to select various aspects of surgical technique that can then be incorporated into their own surgical routines, which should be a composite of various learned skills and which is then open to further reﬁnement as experience develops. The attainment of safe, efﬁcient, reproducible surgical technique is predicated on a comprehensive knowledge of basic surgical skills, which this chapter is designed to address.
SURGICAL KNOTS A basic knowledge of surgical knot options and the acquirement of the dexterity necessary to tie them is a fundamental requisite at the start of surgical training. Knottying techniques by the two-handed method, the single-handed method and with the use of instruments, should be practised religiously until they can be performed both effectively and rapidly, with almost automatic ease. A wide variety of knot types is not required but the basic principles of tying a slip knot, a granny knot and a reef knot are essential, as is the knowledge of how to use variations and combinations of these knots in different surgical situations and with different suture materials. Catgut is no longer used as a suture material and with most modern suture materials there is a need to achieve the required knot placement and tension without any slippage after the ﬁrst throw. To achieve this, it is important that knots are set down as square knots. This requires the second half hitch to be made in the opposite direction to
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the ﬁrst. With synthetic suture materials, which do not have good ‘memory’, it is sometimes difﬁcult to hold the ﬁrst half hitch in position whilst making the second throw. This is overcome in one of two ways; either by holding one end taut whilst making 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 a bulky tissue pedicle, feel more comfortable tying such a double hitch with two hands before advancing the knot to its required position and thereafter securing it with a ﬁnal reef hitch, which locks the knot; this is known as a surgeon’s knot. One-handed tying of surgical knots is an essential skill. As a general principle, the purists would argue that the maximum economy of movement is achieved if a right-handed surgeon ties with the left hand and a left-handed surgeon ties with the right. Although this might require fewer hand changes of instruments, it is not essential and the surgeon should use whichever hand feels most comfortable, as this will generally be the safest.
SURGICAL SUTURING A variety of suturing methods can be used in different clinical situations and in different anatomical locations. Simple interrupted sutures may be used for skin closure. They should be tied so as to achieve approximation of the tissue edges only and not so tightly that devascularisation and necrosis results. The advantage of interrupted sutures is that they allow drainage of any accumulated serous, sanguineous or purulent ﬂuid and may be removed individually in cases of infection without necessarily compromising the whole length of the incision. An alternative to the simple interrupted stitch is the vertical mattress suture, which again can be used for approximation of skin edges. The horizontal or crossed mattress suture 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 second layer of a bowel anastomosis and this technique is still useful to learn even though stapling devices are currently far more commonly employed. In different circumstances, continuous suturing techniques are useful. This is a more rapid method of suturing, and is strong because tension is evenly distributed along the entire length of the suture. They also leave less foreign material in the wound. They are effective not only in producing closure of tissue incisions and defects but also for providing for haemostasis. They can be used for closing the vaginal vault at the end of a hysterectomy, either in a simple running fashion or by converting them into a blanket or locked suture if extra haemostasis without shortening or puckering of tissue is required, such as closing a myomectomy incision in the uterus or closing the vaginal vault at the end of a colporrhaphy. Continuous sutures would also be employed to achieve closure of the rectus sheath and can be used in the form of a subcuticular stitch to achieve skin closure. For this purpose, either a curved or straight needle can be used. In principle, if a straight needle is used the surgeon should sew in a direction away from himself/herself; if a curved needle is used the surgeon should suture towards himself/herself. Subcuticular sutures generally produce an excellent cosmetic result but a disadvantage is that if a superﬁcial haematoma or infection of the subcutaneous tissues occurs 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 by transﬁxion sutures. In both circumstances, clamp placement is important. A curved or
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angled clamp is ideal and the points should be free to allow occlusion of the whole pedicle. A ligature may be placed around the pedicle either digitally or by mounting the suture end into the jaws of an artery forceps. If a pedicle is secured in this way, the ends of the tie should be cut and not held and the pedicle itself should not be put under tension. A transﬁxion suture provides greater security but runs the risk of vessel damage and should be undertaken with care in vascular pedicles. It can be achieved by a single pass of the needle through the tissue held in the clamp, the suture material being passed around the points and the back of the clamp before the knot is tied. Alternatively, the tissue can be doubly transﬁxed by suturing in front of the points of the clamp and again at the shoulder of the clamp; this is a particularly useful technique for securing the angles of the vaginal vault at the end of a hysterectomy. A transﬁxion suture performed in this way can then be left long and held in a small artery forceps, which would assist traction and improve exposure and access.
OTHER HAEMOSTATIC METHODS Monopolar electrodiathermy forceps can be used to coagulate isolated superﬁcial bleeding points, both arterial and venous. For bleeding that is emanating from vessels that have retracted within the tissue, however, it is far less effective and in this situation haemostatic suturing, as outlined above, is the method of choice. In recent years some surgeons have favoured the use of monopolar hand-held cutting diathermy to incise tissues. Following an initial superﬁcial incision in the skin using a scalpel, the subcutaneous tissues and the rectus sheath can be incised with either a spatula or needle-point diathermy tip. The advantage claimed for this technique is that it provides concomitant haemostasis but there is no doubt that it is a slower process and care must be taken not to cause inadvertent burning of tissues. Metal surgical clips such as LIGA-CLIPS (Ethicon) may also be used to assist both haemostasis and lymphostasis. These are particularly useful in the retroperitoneal space, where they add conﬁdence to dissection. However, they must always be used judiciously and only to occlude speciﬁc identiﬁable vessels. They should not be used indiscriminately in an attempt to control diffuse bleeding, not only because they are usually unsuccessful in this context but also because, once they are placed in the tissues, they impede the identiﬁcation and subsequent suturing of the bleeding vessel. They are also useful in marking out position of tumour deposits as they can be identiﬁed on subsequent imaging. LIGA-SURE (Tyco HealthCare) is a relatively new concept that was initially designed for use in laparoscopic surgery but can be used perfectly acceptably in open surgery. It is a form of electrosurgery that produces a permanent seal to veins, arteries and tissue bundles up to 7 mm in diameter. The system identiﬁes the type of tissue in the instrument jaws and delivers the appropriate amount of energy needed to seal it effectively. The mechanism uses the body’s collagen to change the nature of the vessel walls and obliterate the lumen. The collagen and elastin within the tissue melt and, when combined with mechanical pressure, create the sealed zone, which can then be transected using the same instrument. A variety of coagulation-promoting products are available and can be used to help control diffuse oozing that is not amenable to conventional suturing. Sponges such as Sterispon or a haemostatic cellulose mesh such as Surgicel (Ethicon) can be applied to raw oozing surfaces. When in contact with blood, these products assist in
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the formation of a clot and thereby serve as a haemostatic adjunct. More recently, haemostatic sealant preparations, such as Flo-Seal and Diseel, have been developed. The former is a combination of a thrombin solution and a gelatine matrix. The preparation is held in place against the bleeding surface by a moist gauze sponge, which is applied for approximately 2 minutes. On removing the sponge a coagulum should have developed, which is designed to seal off the bleeding area.
GIVE NATURE A CHANCE With increasing experience and maturity, the wise surgeon becomes increasingly aware of this maxim and does well to be aware that nature, for the most part, is on one’s side and should be allowed to help. In this context there is nothing that ﬁlls one with more foreboding about what is to come than to watch a surgeon make the initial hesitant incision, barely severing the skin, and then put the knife down and immediately reach for the diathermy forceps. The next few minutes of the operation are spent fruitlessly dealing with minor capillary bleeding points before the knife is retrieved. A tentative incision is made into the subcutaneous fat and the diathermy procedure is repeated! Many of these tiny superﬁcial bleeders will stop spontaneously if allowed to do so. Vessels will go into spasm and clots will form provided time is given and the tissues are left relatively undisturbed. In real terms, what this means is that the tissues should not be rubbed by having swabs dragged across them. Swabs should be used to dab only, and then removed gently. The same is true for diffuse oozing from a tumour bed or peritoneal surfaces where an ovarian cyst might have been adherent, or the raw surface in the pelvis following a hysterectomy. In these circumstances, beware the bored but helpful SHO wielding the sucker! Injudicious use of the sucker is to be discouraged every bit as much as dragging swabs. Diffuse bleeding can often be controlled by direct and sustained pressure using an abdominal pack (2 minutes on the clock). During this time, the assistant should arm him- or herself with a swab and a stick and a Robert’s forceps. The pack should then be removed slowly, gently and progressively. Any persisting bleeding points can then be identiﬁed, secured and controlled with the assistant’s help. Suction should be used in a purposeful and directed manner to reveal a speciﬁc bleeding point, or points, which can then be ligated or cauterised; it should not be wiggled haphazardly over raw surfaces, thereby disturbing the natural clotting process.
BASIC SURGICAL PRINCIPLES The KISS principle Overelaboration in surgery should be avoided: it inevitably leads to an increase in overall operating time and this should be eschewed. The KISS principle—‘keep it simple stupid’—is important and is an axiom to which the astute surgeon adheres. Some of the best surgeons have utilised video recordings to analyse their technique and they are inevitably surprised by the number of unnecessary hand movements and time-wasting manoeuvres that they make. Ligatures need only be held in certain deﬁned instances. Do not develop three pedicles when two will sufﬁce, as this runs the risk of increased tissue damage and often clutters up the operating ﬁeld with extra instruments.
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The surgeon should constantly strive to discover the simplest and safest way to achieve the operative goal, and these two factors are frequently not mutually exclusive. Instrument handling Instrument handling should above all be safe, but should also be performed in a way that unnecessary manoeuvres can be avoided. A knife should be held with the handle in the palm of the hand and steadied by the index ﬁnger and thumb. For more precise incisions it may also be held like a pen. It must be passed handle ﬁrst with the blade facing downwards or, alternatively, in a kidney dish. Scissors should be held between the distal phalanges of the thumb and ring ﬁnger, and steadied by the middle ﬁnger in proximity to the ring ﬁnger. Further stability is achieved with the distal phalanx of the index ﬁnger resting on the fulcrum or pivotal portion of the shaft. Haemostats and other tissue clamps should be opened gently and slowly using the thumb and ring ﬁnger and preferably under direct vision, although this is not always possible when operating deep in the pelvis. Instrument choice The selection of instruments available to the pelvic surgeon is described in Chapter 3. The choice of the appropriate instrument for a particular surgical task is, of course, important but it is also idiosyncratic, and it is unwise to be too proscriptive or judgemental. Tissue clamps Tissue clamps can be straight, semi-curved, fully curved or angled and any, or all, can be successfully employed in an operation such as hysterectomy. Because of the size of the pedicles formed in this operation, and the nature of the tissues to be secured, the clamps selected should be of the ‘heavy’ variety, preferably with longitudinal grooves in the jaws to prevent tissue slippage. In this context, the author, whilst admitting to being judgemental, would contend that there is no place in gynaecological surgery for Kocher’s forceps, because they are too light and spring open too easily. Every bit as important as clamp selection is clamp placement. Thought should be given to releasing the tips of the clamp to aid subsequent transﬁxion and clamps should be positioned in such a way that when they are released they facilitate the placement of the next set of clamps and the development of the next pedicle. In the context with a hysterectomy, the initial tissue clamp should be placed alongside the uterus with the points aimed for the translucent avascular area, which can be transluminated and viewed through the back of the broad ligament. The clamps securing the uterine vessels should be placed horizontally and as low as possible after mobilisation and deﬂection of the bladder. Such thoughtful clamp placement facilitates the placement of the vaginal clamps and usually obviates the need to create an extra paracervical pedicle. Dissecting scissors Dissecting scissors can be used to splay tissues to aid the development of tissue planes by spreading the points. They can be used to mobilise tissues by ‘milking’ or ‘stroking’ with the points or the back of the blades, but only once the correct tissue plane has been entered. Above all else, however, scissors are designed for cutting or cutting and pushing,
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and good tissue dissection requires the conﬁdence to practise this skill. ‘Nibbling’ with dissection scissors is to be discouraged. Not only does this signify uncertainty in the surgeon but it also often leads to a failure to enter the correct tissue plane.
TISSUE PLANES Surgery is all about tissue planes. Gaining access to them usually requires a degree of boldness. The inexperienced surgeon—quite correctly—will be cautious and with this inevitably comes a degree of timidity. Such a tentative technique might lead to attempts at blunt dissection with ﬁngers or gauze before the correct tissue plane is entered, and the result is often increased bleeding and occasionally organ damage. This is never more evident than when opening the uterovesicle fold of peritoneum to mobilise the bladder at hysterectomy. Timidity leads to this incision being made too high, and the bladder being pushed down digitally or with a swab before the correct tissue plane has been identiﬁed and entered. Bleeding from the plexus of bladder veins, and sometime damage to the organ itself, are the consequence. Over-conﬁdence in surgery is to be discouraged as much as timidity; the outcome— of haemorrhage and organ damage—is usually identical. The surgeon should aspire to a conﬁdence in dissection that displays not only knowledge of anatomy but permits boldness and also an awareness of the pitfalls inherent in cavalier technique.
CUT UNDER TENSION Linked to the points made above, and those that follow below, is the concept of cutting tissues when they are put under tension. This facilitates entry into the correct surgical plane and requires help from the surgical assistant to achieve the desired results.
ORGANISE ASSISTANTS Surgery is learned in three phases: learning to assist, learning to perform the operative procedure, and learning to organise the assistants. There is a tendency to under-utilise assistants and a regular sight in an operating theatre is to watch a surgeon struggling— trying to retract and dissect at the same time while the assistant stands idly by. The experienced surgeon recognises the importance of working as a team and involves the assistants not only to retract and cut ligatures but also to pick up tissues to facilitate cutting under tension and thereby aiding dissection. In longer surgical procedures, assistants can be deployed to carry out routine phases of the operation while the lead surgeon assists and relaxes for a short period.
REMEMBER TO USE YOUR FEET Operating in the pelvis with the patient in the Trendelenberg position can be uncomfortable and physically demanding. It is important to move one’s body not only to relieve discomfort but also to optimise access and view. It is also important to stand
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back once in a while and visually take in an overall picture of the regional anatomy so that it prevails in the mind’s eye. It is a mistake for the surgeon to remain crouched over the incision with eyes focused exclusively on the points of the dissection scissors. Such a practice is analogous to driving a car with eyes focused on the rear bumper of the car in front, oblivious to the overall pattern and behaviour of the trafﬁc ﬂow.
ENSURE ADEQUATE EXPOSURE Inadequate exposure of the operative ﬁeld will inevitably cause the surgeon to struggle. On being called to assist a junior colleague in difﬁculty, a consistent ﬁrst move by the more experienced surgeon is to enlarge the incision and thereby improve both exposure and access. A lower midline incision can be enlarged by extending it around the umbilicus if necessary, while improved access through a transverse incision can be gained by dividing the rectus abdominus muscle on one or both sides and if necessary ligating the inferior epigastric artery.
PLAN THE APPROPRIATE INCISION—IN ADVANCE To avoid falling into the trap of inadequate exposure and impaired access, careful thought needs to be given to the type and size of the incision required prior to the operative procedure. Factors that would inﬂuence this decision include the nature of the pathology, the size of the patient, and the mobility and size of the tissue to be removed. In contrast to what has already been said, in a thin patient with benign pathology and mobile tissues there is no need to make too large an incision, a small transverse suprapubic approach will often sufﬁce. With smaller incisions, perioperative morbidity is less, recovery time is quicker and, furthermore, cosmetic awareness is important. However, this ceases to be a priority consideration in cases of malignancy or even suspected malignancy, or when large or relatively ﬁxed masses are to be dealt with, when a vertical incision is mandatory. It is worth remembering that even in grossly obese patients, the most efﬁcient way to gain access to the peritoneal cavity might be by a transverse incision below the pannus, where the abdominal wall is at its thinnest. This is a situation not infrequently encountered in endometrial cancer patients. Two basic incisions are employed in routine gynaecological practice, the vertical lower midline and the transverse suprapubic. Paramedian incisions are no longer used and are only considered if a previous such incision exists. The vertical incision The lower midline incision is a simple technique. It can be performed rapidly and is ﬂexible because, as mentioned above, it can easily and extensively be enlarged if necessary. The skin and subcutaneous tissues are cut with a scalpel from below the umbilicus to 1 cm above the symphysis pubis. The fascia is then opened longitudinally with the same knife. It is important at this point to avoid traction by the surgeon or the assistant on the wound edges as this distorts the position of the midline. The fascia should ideally be opened between the two rectus muscles, which can then be separated bloodlessly by blunt dissection to expose the underlying peritoneum. This process is extended throughout the whole length of the incision. The peritoneum can then be
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grasped and elevated in the upper part of the incision using artery forceps and, when ‘tented’ in this fashion, incised carefully with a scalpel. The peritoneal incision thus made is then extended superiorly and inferiorly under direct vision using dissecting scissors. The transverse incision This incision has the advantage of being very strong, with a low postoperative hernia incidence; it is also cosmetically acceptable. The skin incision needs to be planned carefully. It needs to be symmetrical and placed not too high or too low. Generally, it is better to cut a straight line rather than to attempt a ‘smile’. Once the skin incision has been made, several variations to the method described by Johannes Pfannenstiel exist. Some, such as the Maylard or Cherney, involve muscle division to enhance exposure. However, the KISS principle (see above) should prevail in the majority of instances and the method of entry into the abdominal cavity described by Cohen is an excellent example of this. The rectus sheath is incised for approximately 3 cm on either side of the midline, two ﬁngers are hooked under the superior part of the incision to elevate it and place the underlying tissues under tension. The tented median raphe is then boldly incised just above pyramidalis muscle without putting down the knife, thereby exposing the underlying peritoneum in the midline. The rectus muscles are separated by digital splitting in a cephalad—caudal direction and the peritoneal cavity is entered in the upper part of the incision to avoid damage to the bladder. The incision is enlarged by lateral stretching. This is a simple, quick, rapid and reproducible technique, which is also relatively bloodless and which completely obviates the need for extensive incision and undercutting of the rectus sheath.
WOUND CLOSURE A competent technique for closing wounds is an essential requirement for all surgical procedures. The aim is to produce a well-healed, strong incision, with an acceptable cosmetic scar. Closure of the parietal peritoneum is not necessary to achieve integrity of the incision. It has been advocated in the past on the basis that it restores normal anatomy, reduces adhesion formation and reduces the risk of infection, herniation or dehiscence. Against this are data from animal experiments that demonstrate that peritoneal suturing might cause tissue ischaemia, necrosis, inﬂammation and foreign body reactions, which will slow the healing process and actually predispose to adhesion formation. Peritoneum is a mesothelial organ. In contrast to epidermal repair, where healing occurs gradually from wound borders, peritoneum heals simultaneously throughout the wound because the mesothelial cells initiate multiple sites of repair. If the peritoneum is left open, experimental studies have shown that a spontaneous reperitonealisation will appear within 48–72 hours, with complete healing after 5– 6 days. Data from randomised clinical trials now exist to demonstrate that non-closure of the peritoneum reduces operating time, has no effect on wound healing, and results in a smaller number of postoperative complications. Closure of a transverse incision It seems logical to close a transverse incision in layers and the layer that confers the overall strength to the incision is the fascia of the rectus sheath. This may be closed
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transversely using a running or continuous suture and a suture material such as polyglactin (No. 1 vicryl) is acceptable. This is a suture material that has good knot security and predictable resorption, complete absorption occurring within 60–90 days. The decision whether to employ the use of a suction drain beneath the rectus sheath is the choice of the individual surgeon. Transverse incisions are relatively vascular, which aids the healing process but can also make them more prone to the development of haematomas. If suction drainage is used, the drain should be brought out through a separate stab incision and not through the wound itself and in the majority of instances the drain can be removed the following day or most certainly when the drainage decreases to less than 50 ml over a 24-hour period. There is no need to suture the subcutaneous tissues. Proponents might argue that closing the subcutaneous fat reduces ‘dead space’ and decreases the opportunity for serous oozing. However, it also increases operative time and can cause puckering of the skin and providing meticulous haemostasis has been achieved is an unnecessary part of wound closure. The skin incision can be closed with interrupted sutures, although this is rarely performed. The choice is largely between a continuous subcuticular suture of either an absorbable material such as monocryl or a non-absorbable suture such as prolene, which can be removed on the ﬁfth postoperative day, and surgical staples, which also produce a perfectly acceptable cosmetic result and again can be removed on the ﬁfth postoperative day. Closure of a vertical incision Based on currently available evidence there is wide agreement that vertical incisions should be sutured using a mass closure technique. This produces a stronger incision than that which is obtained by layered closure. A running continuous suture is faster and is as effective and safe as interrupted sutures. It should be drawn tight enough to approximate the tissues but not so tight as to cause tissue ischaemia and necrosis. The suture should be placed approximately 2 cm from the fascial edge and should incorporate the anterior fascia, the rectus muscle, the posterior sheath (if present) and the peritoneum. Each bite should be 1.5 cm further along the incision and a ratio of the suture length to the wound length overall should be approximately 4:1. Continuous sutures have the theoretical advantage of distributing tension across the suture line more evenly than interrupted sutures. The choice of suture material should lie between a permanent monoﬁlament such as nylon or a delayed absorbing synthetic suture such as polydioxsane (PDS). Two sutures are sometimes required, one starting from the top of the wound, and the other from bottom, the knot being tied at the point where they meet. Knot integrity is essential with running continuous closures and the surgeon must understand the suture material being used and its characteristics. In the case of nylon, it must be appreciated that knots may slip and many throws are needed for knot integrity. The advantage of using nylon, however, is that it is strong and degrades at about 15–20% per year. If PDS is used there is complete absorption by 180 days. The use of a non-absorbable suture is associated with the development of sinus tracts and occasionally in thin patients the knot can be uncomfortably palpable underneath the skin. Multiﬁlament sutures should not be used in this context as they have been shown to have a higher incidence of wound infection because bacteria can exist within the braids, where they are protected from phagocytosis. The skin incision may be closed using interrupted sutures, subcuticular sutures or surgical staples as mentioned above.
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1. 2. 3. 4. Monaghan JM (ed.) Bonney’s Gynaecological Surgery, 9th edn. London: Bailliere-Tindall, 1986. Nelson JH & Morgan L (eds.) Manual of Basic Pelvic Surgery. New York: McGraw–Hill, 1994. Maxwell DJ (ed.) Surgical Techniques in Obstetrics and Gynaecology. Edinburgh: Churchill Livingstone, 2004. Royal College of Obstetrics and Gynaecology (RCOG) peritoneal closure. RCOG guideline no. 15. RCOG, London 2002.
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