Basic Surgical Skills

Indonesia 2021
 Aims
• To learn one safe way to do a surgical
procedure.
• It is not the only method of performing a
surgical procedure, but we endeavour to teach
one safe way
• The course should be not only instructive and
educational but also enjoyable
• Acquire good habits earlier – it is difficult to
unlearn bad habits
Theatre etiquette

•Mr R.K.Tandon
 The night before theatre

• Read up the operation

• Cut nails and clean them
• No long nails
• No artificial nails
• MRSA is harboured under the nails
• No Fake eyelashes
 Shower at home on the
morning of the operation list
 Entering theatre

• Leave phones etc. with receptionist

• Lockers
• Remove everything except pants and bra
• Change to theatre clothes
• TUCK SHIRT IN
 Headgear

Various forms of caps, hoods etc.

COVER ALL HAIR
 Masks

• Over the nose and not on lip

• Talk, cough and sneeze into the wound
• Don’t turn head away
 Eye protection

Spectacles,visors etc.
 Cuts

• Cover them with waterproof dressing

 Jewellery

• Earrings, necklaces, rings must be removed

Surgical Attire
(dressing)
Surgical Attire (dressing for hijab)

Wear clean hijab only for the OR. Don’t mix it from outside
Surgical Attire (dressing for hijab)

Wear clean hijab only for the OR. Don’t mix it from outside
Theatre suite has 3 doors

• Anaesthetic room
• Scrub room
• Patient exit
• Enter through scrub room door
Scrub room

Equipment
Mirror
Clock
Scrubbing
• Follow hospital policy
• Use elbow to adjust water and collect antiseptic
solution
• Avoid splashing water
• Do not mix two solutions
• Duration of contact and not how hard you scrub
• Take 5 to 10 ml of solution
• Wash from hands towards elbow
• Must not come back to wash part again
• 2 minutes above elbow,1 minute below elbow and 2
minutes above wrist
• Keep hands up
• Rinse by rotation of forearms
• Nail brush only for nails and
hand creases

• Down strokes only

Drying hands and elbow
• Do not open paper
towel
• Sponge, do not rub
• Keep towel folded for
better absorbency
Gowning
 Opening the pack

• If scrubbed touch inside

• If not scrubbed touch outside
• Hold by pinch grip
• Do not shake
• Slip hand to sleeve
• Keep hands in
 Gloving

• Closed technique
• Rarely open
• Half size larger underneath for double gloving
• Always clean to clean if walking in theatre, dirty
to dirty
• Hands folded between nipple and umbilicus
 Removing the gown
(St Andrew’s cross)

• Grip left shoulder with right hand

• Grip right shoulder with left hand
• Don’t let go
• Straighten your elbows first and then cross
and remove so that the contaminated exterior
is inside and the clean interior is outside
 Removal of gloves

• “Dirty to dirty”
• Pinch the outside of one glove with the other gloved
hand
• Remove the glove and grasp it in the palm of the
gloved hand
• Put one finger of the ungloved hand under the cuff of
the glove and remove it so that only the interior of the
glove can be seen, with the other glove inside
 Walking in the theatre
• Clean to clean- Front to front
• Dirty to dirty- Back to back
 Skin Preparation

• video
 Draping

• video
 Drapping
in other parts of body

Genital Perineal
Genital
Genital
 Drapping
in other parts of body

Abdominal Upper Extremity

Instruments Handling
 SAFETY FIRST !
• NEVER DIRECTLY HANDLE SHARPS WITH YOUR
FINGERS (i.e. blades or needles)
• Pass sharps in a kidney dish to your assistant /
nurse
• Safety of all is responsibility of operating surgeon
• Always dispose of sharps in a sharps bin
− not on patient or operating table!
• In case of injury
• assess the injury
• assess patient status
 Handling Instruments
Basic Principles:

• Safety
• Economy of movement
• Relaxed handling
• Avoidance of awkward movement
 Handling Instruments (cont.)
Cutting Instruments:
• Scalpel
- attachment
- detachment
- holding - like a table knife
- like a pen
- cutting
- passing the scalpel in a kidney dish

• Scissors (2 types) - holding

- cutting
 Handling Instruments (cont.)
Holding Instruments:

• Forceps (toothed and non-toothed) - holding

• Artery Forceps

• Needle Holders
Knot Tying
 Knots
• Knot-tying is a fundamental technique in
surgery, and is often performed badly

• Take time to perfect your knotting technique

• Uses of knots:
− Tying sutures
− Ligation (tying vessels)
 General Principles of Knot-Tying
• Firm and unable to slip
• Small, to minimise foreign material and
foreign body reaction
• Don’t ‘saw’ the material – it will weaken the
thread
• Don’t damage it by grasping with instruments
except at the free end
 General Principles of Knot-Tying
• Avoid excessive tension
• Avoid tearing tissue
• Apply tension horizontally

The standard knot used in surgery is the

reef or square knot, with a third throw for security.
- Alternate tying ‘index finger’ knots and ‘middle
finger’ knots at the same time as the hands
cross over for each throw
 Types of Knots
• Reef / Square Knot - one hand
- instrument tie
• Surgeon’s / Half Surgeon’s Knot
- one hand
- two hands
- instrument tie
• Tying in Depth
 Secure Knot

Secure knot
Standard ≥ 3 throw for
knot tying multifilaments
≥ 6 throws for
monofilaments
Square ( Reef ) Knot
Surgeon’s knot
Half Surgeon’s knot
SUTURING
Types of Suture Material

Sutures:
Absorbable Non-absorbable
Biological Synthetic
Monofilament Multifilament
(twisted, braided)
Types of Suture Material (cont.)
Needles:
Curved Eye
J-shaped Body
Straight Tip
Round Body
Taper - blunt
- cutting (forward /reverse)
 Handling Sutures
• Tension – attempt to remove all elements of
tension from any anastomosis
• Insert needle at right angles to the tissue and
gently advance through the tissue, avoiding
shearing forces
• As a rough rule of thumb, the distance from the
edge of the wound should correspond to the
thickness of the tissue
• Successive sutures should be placed at twice
this distance apart, i.e. double the depth of
tissue sutured.
 Types of Suture
1. Interrupted suture
2. Interrupted mattress suture
• Vertical – used to evert the edges of a wound
• Horizontal – used mainly to control bleeding from
wound edge (useful for, e.g., suturing the scalp)
3. Continuous sutures.
4. Subcuticular sutures – commonly used to seal a
wound. One can use absorbable or non-absorbable
material. When absorbable material is used the knot
lies inside the tissue; when non-absorbable material is
used the knot lies outside.
 Handling Sutures (cont.)
• All sutures should be placed at right angles to
the line of the wound at the same distance from
wound edge and same distance apart in order
for tension to be equal down the wound length

wound
edge parallel, same distance
apart, same distance
from edge
 Handling Sutures (cont.)

• NO suture should be tied under too much

tension
• Go through one edge at a time in most case
• Long wound : half and half
• Cut 0.5 cm from knot
• Removal : flush to skin
 Interrupted Suture

x
x

x
Interrupted Suture
Interrupted Vertical Mattress
Suture
 Continuous Sutures

Simple continuous Continuous Interlocking

Subcuticular Suture

USING ABSORBABLE SUTURE

Subcuticular Suture

Using Non-Absorbable Suture

Linear Incision Closure

3 2 3 1 3 2 3
 Skin Lession
and
Local Anestesia
Lidocaine Composition
 Ellipse
- length is 3x width
- suture from either end

≥3X
Closure of Ellipse
Tendon Repair
 Tendon Repair
Kessler technique: Step 1

Handle tendon with needle tip

Trim to clean edges

 Tendon Repair
Kessler technique: Step 2
Pass midway through tendon

Exit at 1.5cm from cut end

(or, x2 widths of tendon)
 Tendon Repair
Kessler technique: Step 3
 Tendon Repair
Kessler technique: Step 4

Running 4-0 nylon

Debridement
 Debridement Technique

• Wound toilet and irrigation

• Inspection of the wound
• Deep palpation of the wound
• Excision of dead or contaminated tissue
• Establishment of adequate drainage
• Dressing of the wound for later inspection
 Leave Contaminated Wound
Open
• Infected discharge can escape
• Painless change of surface dressing
• Pressure on bleeding point
• Delayed primary suture
• Secondary suture
• Skin grafting
Abdominal Wall Incision &
Closure
Layer of Abdominal Wall
Design of Incision
umbilicus

Symphisis pubis
 Aberdeen Knot

video
Bowel Anastomosis
 Bowel Anastomosis

1. No Tension.
2. Good Blood Supply.
3. Adequate and Accurate Apposition
4. Immaculate and Accurate suture technique :
a. Extra-mucosal
b. Distance of stitch 5 mm away from the first stitch.
c. Serosa meet serosa (inverted)
5. No leakage & no stenosis.
End to end anastomosis extra mucosal layer
Interrupted suture technique
Vascular (Vein) Patch
 Vascular Anastomosis

The essential for vascular anastomosis are :

1. Gentle vessel handling.

2. Non – absorbable monofilament suture.
3. Careful knot technique
4. Smooth internal suture line.
5. 1 to 2 mm suturing technique
Vascular Wall Anatomy

Intimal flap
Vein Patch Graft
Vascular Vein Patch Graft