BASIC SURGICAL SKILLS WITH

ANASTOMOSIS
Dr Tridip Dutta Baruah
Asst Prof, Deptt Of Surgery
MGMCRI
 OBJECTIVES
To learn basic surgical techniques
• –Surgical scrubbing
• –Gowning and gloving for surgery
• –Basic suturing techniques
• –Treatment of various wounds
• –Appropriate antibiotic use
 HAND WASHING
Hand washing: the single most important
measure for prevention of infection
• Plain soap and water is effective for removal
of visible contaminants
• Wash with vigorous mechanical action on all
hand surfaces for at least 40 seconds; washing
above wrists, removing jewellery
• Nails are areas of greatest contamination
• Rinse under poured or running water
HOW TO HAND WASH

To effectively reduce the

growth of germs on
hands, hand washing
must last 40–60 s and
should be performed by
following all of the
illustrated steps.
HOW TO HAND RUB

To effectively
reduce the growth
of germs on hands,
hand rubbing must
be performed by
following all of the
illustrated steps.
This takes only 20–
30 seconds
SCRUBBING
•Remove jewellery
•Use soap, brush, running
water to clean thoroughly
around nails
•Scrub hands, arms up to
elbows
•After scrubbing, hold up
arms to allow water to drip
off elbows
•Turn off tap with elbow
 SCRUBBING

After scrubbing hands:

•Dry with sterile towel, make sure towel does
not become contaminated
•Hold hands, forearms away from body and
higher than elbows until putting on sterile
gown and gloves
GOWNING
Place arms through
sleeves
•Have a non-
scrubbed assistant
pull gown over
shoulders so hands
go through sleeves
•Assistant will tie
back of gown
 GLOVING

• Surgical gloves prevent transmission of HIV

and other infections through contact with
blood, other body fluids
• Easiest to have someone who is already
gowned and gloved to assist
• Promptly change a glove punctured during
surgery, rinse hand with antiseptic or rescrub
GLOVING WITHOUT ASSISTANCE
•Open sealed package of sterile
gloves before scrubbing, gowning;
place inner package on sterile
surface
•Once gowned, take cuff of left
glove with right hand (1); make
sure thumb in correct position
•Slide glove onto left hand, wriggle
fingers slightly to help
•Only touch inside of glove, cuff
with bare hands
•Slide fingers of gloved left hand
into cuff of right glove (2)
GLOVING
•Pull glove onto right hand in
similar fashion to placing left
glove (3)
•Ensure that cuffs cover ends
of both gown sleeves (4)
 INSTRUMENTS

Many types of instruments

• Forceps, instruments for holding tissue
• Needle holders
• Scissors
• Retractors Which instrument to use?
• Choose shortest instrument that will comfortably
reach operative site
• If cutting suture or non-tissue material, avoid
using fine scissors
• If possible, choose instruments in good repair
 INSTRUMENTS
When holding instruments:
• Use three point control: have 3
points of contact between hand,
instrument to increase precision
• Extend index finger along
instrument to provide extra control,
stability
• Place only fingertips through
handle loops,
• rotation comes from wrist
• greater control
• quicker to pick up, put down
 INSTRUMENTS
• When using scalpel for
dissection,
• –use smaller knife
• –hold instrument like a pen:
thumb and third finger holding
knife, with index finger
controlling dissection Most
procedures are performed with
a #3 handle and
• –#10 blade for large incisions
• –#11 for stab incision
• –#15 for fine precision work
INSTRUMENT HANDLING
 SKIN PREPARATION

• Before operation, wash surgical site,

surrounding area with soap, water; particularly
wash debris from injuries
• Prepare skin with antiseptic solution; start in
centre, move to periphery
• Chlorhexidine gluconate and iodine preferable
to alcohol as less irritating to skin
• Solution should remain wet on skin for at least
two minutes
SKIN PREPARATION
•Prepare skin with antiseptic
solution, start in center,
move to periphery
•This area should be large
enough to include entire
incision, adjacent working
area
DRAPING
•Do not place drapes on
patient until scrubbed,
gowned, gloved
•Leave uncovered only
operative field (areas
that have been
prepped) and areas
necessary for
anaesthesia
•Secure drapes with
towel clips at each
corner
 WOUND MANAGEMENT

Surgical wound classification:

• Clean
• Clean Contaminated: normal but colonized
tissue
• Contaminated: contains foreign or infected
material
• Infected: obvious pus present
 WOUND MANAGEMENT

• Clean wounds: close immediately to allow

healing by primary intention
• Contaminated or infected wounds: never close,
leave open to heal by secondary intention
• Clean Contaminated: surgical toilet, leave open,
then close 48 hours later - delayed primary
closure
• Careless closure of a contaminated wound will
promote infection and delay healing
 WOUND MANAGEMENT

Primary repair:
• Primary closure requires clean tissue to be
approximated without tension
• Leave skin sutures in place for an average 7 days;
longer if healing expected to be slow due to blood
supply of particular location (back or legs) or
patient’s condition
• Close deep wounds in layers; absorbable sutures for
deep layers
 WOUND MANAGEMENT

Delayed Primary Closure:

• Irrigate clean contaminated wounds, then pack open
with damp saline gauze
• Close wounds with sutures at 2 days
Secondary healing:
• Perform wound toilet, surgical debridement without
closure; may need skin graft
 WOUND TOILET AND DEBRIDEMENT

• Thoroughly clean the wound with normal saline or sterile

water.

• It is important to use a large volume of fluid and pressure

to remove all visible dirt and debris from a wound

• Use a large syringe for irrigation. Attach a 16 or 19 gauge

needle or soft IV catheter to generate pressure
 WOUND TOILET AND DEBRIDEMENT

• Gentle handling of tissues to minimize bleeding, additional

trauma

• Control residual bleeding with compression, ligation, cautery

• Dead or devitalized muscle is dark in color, soft, easily damaged;

does not contract when pinched

• Dead tissue does not bleed when cut

WOUND TOILET AND DEBRIDEMENT
• Wash wound with large
quantities of soap and boiled
water for 10 minutes, then
irrigate with saline; prep skin
with antiseptic (A)
• Debride wound meticulously
to remove loose foreign
material, use surgical
techniques to cut away
damaged, dead tissue
• Excise only very thin margin
of skin from wound edge (B)
DEBRIDEMENT
• Systematically perform
wound toilet, surgical
debridement; initially to
superficial tissue layers,
subsequently deeper layers
(C and D)
• With scalpel or dissecting
scissors, remove all adherent
foreign material along with a
thin margin of underlying
tissue, irrigate
• Continue cycle of surgical
debridement, saline
irrigation until wound is
completely clean
 WOUND TOILET AND DEBRIDEMENT

• Leave wound open after debridement to allow

for healing by secondary intention
• Pack lightly with damp saline gauze, cover
packed wound with dry dressing
• Change packing, dressing daily - more often if
outer dressing becomes damp with blood, other
body fluids
• Large defects will require closure with flaps or
skin grafts but may be initially be managed with
saline packing
 PREVENTION OF INFECTIONS

• Restore breathing, blood circulation as soon as

possible after injury
• Warm victim; at earliest opportunity provide high-
energy nutrition, pain relief
• Perform wound toilet, debridement as soon as
possible (within 8 hours if possible)
• Respect universal precautions
• Antibiotic prophylaxis for deep or penetrating
wounds (dirty stick, knife) and wounds older than 12
hours
 PREVENTION OF INFECTIONS
• Cleaning wound: most important factor
• Antibiotics usually not necessary unless:
-Wound older than 12 hours
-Deep penetrating wounds (dirty stick, knife)

• Wound closure
-Less than 24 hours from injury, cleaned properly: primary closure
-Greater than 24 hours, contaminated or animal bite: do not close
-Wounds not closed primarily should be packed lightly with damp
gauze
-If clean after 48 hours, delayed primary closure
-If wound infected, pack lightly, heal by secondary intention
 PREVENTION OF INFECTIONS
TETANUS VACCINATION

• Patient vaccinated: give booster if needed

• Patient not vaccinated: give antitetanus serum and start dose

of tetanus toxoid vaccine (separate syringes, separate sites)

• Antitetanus serum for adults and children

Tetanus immunoglobulin (human) 250 units IM, increased to
500 units if any of the following conditions apply:
-wound older than 12 hours
-presence or risk of heavy contamination
-patient weight more than 90 kg
 PREVENTION OF INFECTIONS
TETANUS IMMUNIZATION

• ADULTS and CHILDREN over 7 years:

tetanus toxoid (TT) or tetanus and diphtheria vaccine (Td)

• CHILDREN under 7 years:

Diphtheria and tetanus vaccine (DT). Higher diphtheria toxoid content

Dose of TT or Td When to give Expected duration of protection

1 As early as possible None
2 At least 4 weeks after TT 1 1-3 years
3 At least 6 months after TT 2 At least 5 years
4 At least 1 year after TT 3 At least 10 years
5 At least 1 year after TT 4 Booster every 10 Y
 PREVENTION OF INFECTIONS
ANTIBIOTIC PROPHYLAXIS

Indicated for wounds at high risk for infection:

• Contaminated wounds
• Penetrating wounds
• Abdominal trauma
• Compound fractures
• Lacerations greater than 5 cm
• Wounds with devitalized tissue
• High risk anatomical sites—hand, foot
 SUTURE MATERIALS
Sutures are made of variety of materials with variety of
properties
•Non-absorbable
–Use when possible
–Braided suture not ideal for contaminated wounds
–May sterilize polyester thread or nylon line when
commercial suture unavailable
•Absorbable
–Degrades, loses tensile strength within 60 days
–Option when not possible for patient to return or for
children for whom suture removal may be difficult
 SKIN SUTURE PRINCIPLE

• EPITEL TO EPITEL
• ALL SURFACE MUST
• RIGHT MATERIAL

• NOT TENSION
NO • NO EVERSI
• NO INVERSI
• NO DEAD SPACE
 SUTURE TECHNIQUES

• Aim of all suturing techniques: approximate wound

edges without gaps or tension
• Size of suture “bite” and interval between bites
should be equal in length, proportional to thickness
of tissue being approximated
• Suture is foreign body: use minimal size, amount of
suture necessary to close wound
 SUTURE TECHNIQUES
• Use tip of needle driver to hold
needle between half - two thirds
way along needle
• Hold needle driver so that fingers
are just within rings so possible to
rotate wrist
• Pass needle tip through skin at 90o
• Use curve of needle by turning
needle through tissue
• Close deep wounds in layers with
either absorbable or monofilament
non-absorbable sutures
• Diag- ?
SUTURE TECHNIQUES
SUTURE TECHNIQUES
 ABSCESS DRAINAGE

Introduce tip of artery Explore cavity with finger to Extend incision, if

forceps into cavity, open break down all septae necessary, for complete
jaws drainage
DRAINAGE OF BREAST ABSCESS

Incise Break down loculations

Spread Drain
ANASTOMOSIS
 PRINCIPLES OF ANASTOMOSIS
A. Access and exposure :
Intestinal anastomosis become difficult if access and exposure are
unsatisfactory as may result from :
- Inadequate anaesthesia and muscle relaxation
- Poor assistance
- Inappropriate incision
- Imperfect illumination
- Inadequate mobilization of viscera especially fixed and deeply
placed viscera like oesophagus, colon and rectum.
 PRINCIPLES OF ANASTOMOSIS
B. Blood supply :
Poor blood supply is inimical to the healing of all anastomosis. Causes
of poor blood supply are:
- Undue tension on suture line
- From inadequate mobilization
- Devascularization during mobilization of bowel
- Strangulation of the tissues by tightly knotted sutures
- Excessive use of diathermy
- Tight clamp application to bowel mesentery. In oesophagus no
clamps are applied by some surgeons because blood supply is
through intramural blood flow.
 PRINCIPLES OF ANASTOMOSIS
C. Suture technique :
Basic principles of intestinal sutures were established 100 years ago
and have undergone little modification.
• Secure healing is dependent on accurate apposition of the serosal
surface and is achieved by the use of a inverting suture of cut edges.
• Ravitch et al (1967) claimed that everting technique of suture gave
better results in animals study2 however clinical study of anastomosis
have proved that everting technique results in higher incidence of
anastomotic dehiscence.
• One aspect of the technique of intestinal suture which has remained
the subject of some controversy is use of one or two layers of sutures
in anastomosis.
• Two layers inverting suture technique devised by Czerny is the method
used by surgeons. Halsted and Cushing recommended use of single
layer of sutures in anastomosis.
 PRINCIPLES OF ANASTOMOSIS
A. Single layer technique -
• Less ischaemia and tissue necrosis.
• Less narrowing of the intestinal lumen. Single layer technique is used in Colon and
Rectum.
B. Two layer technique -
• Narrowing of lumen is hardly a problem
• No evidence of single layer as better anastomosis over two layers.
• Excellent results of single layer obtained by some surgeons are probably because of
expertise of surgeon rather than the technique3.Two layer technique is used in
Oesophagus, Stomach, Duodenum and Small Intestine
• Studies have shown that single layer technique is better in extraperitoneal rectum
so recommended for very low rectal anastomosis.
• It has been shown that single layer interrupted sutures are reliable for all
gastrointestinal anastomoses.
 PRINCIPLES OF ANASTOMOSIS
D. Suture material :
• Two -layer anastomoses are made with an inner layer of absorbable suture and
outer layer of non-absorbable sutures. Single layer anastomoses are usually made
with non-absorbable materials.
• Polyglycolic acid and Polyglactin most popular absorable suture material.
• Non-absorbable sutures on the mucosal aspect of gut provoke a significant foreign
body reaction and granuloma formation. This is of little practical significance in
small and large intestinal anastomoses but in gastric mucosa may result in
ulceration and clinical symptoms. Theoretically monofilament sutures like nylon or
polypropylene may cause less tissue reaction than braided sutures , but the
difference in the intestine appears to be relatively minor 5 and the monofilament
sutures have inferior handling qualities. Most surgeons prefer braided silk because
of good handling.
• The size of the gauge used for anastomoses is not standard but mostly surgeons
use 2-0/3-0 sutures in adult surgery as the finer sizes will have tendency to cut
through.
 PRINCIPLES OF ANASTOMOSIS
E. Factors affecting the healing of anastomoses
Dehiscence is chiefly a problem in anastomoses in oesophagus, colon and rectum.
Local factors :
i. Sepsis: Peritoneal sepsis has adverse effect on healing of anastomoses especially in large
intestine7. Anastomotic dehiscence is significant in carcinoma and traumatic injuries of the
colon. Faecal soiling of peritoneum during surgery should be avoided.
ii. Mechanical state of the bowel: This is a factor which determines the failure or success of
anastomoses in the left colon or rectum. This is major factor for dehiscence which follows
primary anastosis of left colon in acute obstruction.Bowel preparation and prophylactic
antimicrobial therapy especially systemic is more effective in prevention of postoperative
sepsis in colonic surgery8
iii. Drains: Peritoneal drains are put for the purpose of removing any blood or serum after
operations involving dissection or mobilization of viscera and in cases having faecal
contamination. The drains are not deliberately placed in the vicinity of anastomoses and
removed after 48 hrs. Protagonists of use of drain claim that they safeguard the patient by
permitting enterocutaneous fistula when anastomotic dehiscence occurs rather than
causing faecal peritonitis
iv. Faecal diversion:A proximal loop colostomy may be used for temporary protection of high
risk anastomoses such as very low colorectal anastomoses or anastomoses in the presence
of unfavourable local conditions. Septic complications will be less severe if diversion has
been done in case of dehiscence rather than preventing the dehiscence10.
 PRINCIPLES OF ANASTOMOSIS
Systemic factors :
i. Advanced malignancy
ii Malnutrition- reduced collagen synthesis
impaired healing
iii Extensive intraoperative blood loss-
Hypovolaemia and tissue hypoxia & Sepsis
iv Old age
v Preoperative irradiation
vi Anaemia
 THE ANASTOMOSIS
Anastomoses may be made end to end,end to side,side to side, but the method used is
fairly standard.
A. End To End Anastomosis
1. Small bowel anastomoses :
Insertion of posterior outer layer of suture- Non-absorbable silk interrupted submucosal
sutures are placed. Inner layer of sutures- (a) A continuous chromic catgut over –and-
over suture technique starting from antimesenteric border through all the layers. (b)
Mesenteric corner invagination by Connell suture technique (fig 2). (c) Anterior aspect
of the inner layer by over-and-over suture technique but a continuous Connell suture
technique is generally preferred. (d) Mucosa and edges of bowel on antimesenteric
aspect are invaginated as last Connell suture is pulled tight and tied with starting
suture. Insertion of anterior outer layer- Non-absorbable interrupted submucosal silk
sutures. Alternatively, Anastomosis beginning with inner layer of sutures: Inner layer,
Outer layer on anterior aspect and then outer layer on posterior aspect after rotating
the anastomosis.
2. Ileocolic anastomoses :
Correction for unequal ends of the bowel: This is required in cases of right
hemicolectomy or small bowel obstruction.
(a). Widening the orifice of smaller lumen. Outer layer of submucosal sutures is inserted
obliquely on the antimesenteric border.
(b). The open end of the bowel is widened by cutting along the antimesenteric border.
 THE ANASTOMOSIS
3. Gastroduodenal anastomosis:
Billroth I gastroduodenal anastomosis- (a). Meticulous haemostasis to be achieved to prevent
serious postoperative bleeding from suture line because stomach has rich blood supply. (b).
Connell suture technique is not haemostatic so ’Loop on the serosa’ technique to be used.
This provides effective haemostasis and adequate inversion.

4.Colorectal anastomosis:

Two layer Method: Modified two layer technique is used in extraperitoneal rectal
anastomosis. In low colorectal anastomosis where access is restricted, outer layer of
submucosal horizontal mattress sutures is inserted. In extraperitoneal rectum these sutures
are at right angle to the longitudinal muscle fibres and thus causing less cutting through. A
similar technique is recommended for in two layer oesophageal anastomoses.
Single layer Method: This is simple and more satisfactory method for low rectal
anastomoses. Mesenteric and antimesenteric silk sutures through all the layers of the bowel
wall are inserted. The posterior layer of all the through-and-through sutures are passed and
tied at the end. The interval between these sutures should be very small otherwise there is
tendency for the eversion of mucosa. Anterior layer is again through all the layers , knotted
on the mucosa. A small gap in the last is closed by horizontal submucosal suture. An
alternative method of suturing anterior layer is submucosal horizontal mattress sutures.
 THE ANASTOMOSIS
B.End-to-side Anastomosis

This is mostly used in oesophagus and stomach surgery.

Technique involves closure of end of bowel: This is required in cases of right hemicolectomy
and subtotal hemicolectomy when end to side anastomosis is performed. Two layer inverting
suture technique is used. First layer of continuous horizontal mattress suture. Then
continuous over-and-over stitch incorporating all the layers. Finally interrupted submucosal
sutures of silk invaginating the ends of bowel.
1. Ileocolic anastomosis:
In right hemicolectomy, end of colon is closed and end of ileum is anastomosed to side of
colon, using standard two layer technique.
Baker used similar technique in colorectal anastomoses. Side of colon is anastomosed to end
of rectal stump.
2. Oesophagogastric and oesophago-jejunal anastomosis
In operation for oesophagogastrectomy, the proximal end of the gastric remanant is closed
and end of oesophagus is sutured to front of stomach using two layer technique with outer
layer of horizontal mattress. After total gastrectomy, the end of oesophagus is anastomosed
to the side of jejunum using two layer technique. A defunctioned loop or Roux-en-y loop of
jejunum is used.
 THE ANASTOMOSIS
3. Gastrojejunal anastomosis:
In partial gastrectomy, gastric remanant is anastomosed end-to-side to
jejunum using two layer technique. Double layer of catgut sutures are
applied in view of rich blood supply. Loop on serosa sutures are applied for
good haemostasis. Connell sutures can also be applied if haemostasis have
been controlled by individually securing the vessels.
C. Side-to –Side Anastomosis:
This method is used in gastric surgery to provide drainage of the stomach
after vagotomy or to relieve gastric outlet obstruction. Elsewhere as
palliative measure in malignant disease. Gastro-jejunostomy in
malignancy of distal stomach, Ileocolic in malignancy of right colon and
cholecysto-jejunostomy in bile duct malignancy.
Thank you