College of medicine ‫كليه الطب فرع الجراحه‬

Surgical department
Dr.Thulfiqar Baiae
General surgeon ‫جراح عام‬
Jan.2021
2021‫كانون ثاني‬

Basic surgical skills ‫مهارات جراحيه اساسيه‬

and anastomoses ‫وتوصيالت‬
Courtesy https://imamhussain.org/islamicarts/24250
Basic surgical skills and anastomoses
INTRODUCTION

Successful outcomes in surgery depend on

knowledge, skills and judgement.

Technical skill is important for the

surgeon also important the non-technical
skills, such as communication, empathy
and teamwork.
PATIENT POSITIONING AND
SAFETY ON THE OPERATING TABLE

It is a key responsibility of the

surgeon.
PATIENT POSITIONING AND
SAFETY ON THE OPERATING TABLE

This is used :
to maximise exposure for the procedure
and
to ensure risks of injury are avoided.
PATIENT POSITIONING AND
SAFETY ON THE OPERATING TABLE
These are categorised as:

●Transfer to and from the operating table

● Positioning on the table,
● Pressure areas,
● Nerve injury,
● Compartment syndrome, and
● Considerations for laparoscopic surgery
PATIENT POSITIONING AND
SAFETY ON THE OPERATING TABLE
These are categorised as:
● Considerations for laparoscopic surgery

During laparoscopic surgery,steep angles of tilt to the

side, or Trendelenberg (head down) and reverse-
Trendelenberg(head up) positions are required to move
the abdominal viscera, such as small bowel, away from
the operative field.

There is significant danger that the patient can slide, or

in some cases, fall off the operating table and be injured.

What devices are used to secure position?

PATIENT POSITIONING AND
SAFETY ON THE OPERATING TABLE
These are categorised as:
● Considerations for laparoscopic surgery

What devices are used to secure position?

● Suction bean bags and

● Antislip mats can be used to help secure placement
of the patient.
● A lateral position to expose the target organ, e.g. kidney or
spleen, with the aid of gravity.
The ‘side boards’ or arm restraints are best avoided as they can
interfere with the laparoscopic instruments.
SKIN INCISIONS
Skin incisions to be made by a scalpel at right
angles to the skin to create a clean incision.

The skin not to be incised obliquely , it can lead to

necrosis of the undercut edge.

A scalpel, with the blade to be handled firmly as

any slip may result in a self-inflicted injury.
Skin incisions
Arteriotomy
Drain-site insertion
Skin incisions Arteriotomy
Drain-site insertion
Skin incisions
Diathermy,
Laser,
Harmonic scalpels and
Combination devices.
They can be used for deeper
tissues, as they can reduce

■ Blood loss

■ Save operating time,

■ Reduce postoperative pain.

SKIN INCISIONS
Factors should be considered when
planning a skin incision:

● Skin tension lines (Langer’s lines).

● Anatomical structure.
● Cosmetic factors.
● Adequate access for the procedure.
Langer’s lines
Dealing with a ‘dog ear’
http://www.skinandsculpt.com/index.php/en/skinbiopsis.html
An elliptical incision.

Courtesy Farquharson's Textbook of Operative General Surgery

http://www.skindermatologists.com/bowen-disease.html
Skin incisions /Abdominal incisions
Abdominal incisions

Transverse incisions tend to be associated with

fewer respiratory complications and a better
cosmetic outcome and less postoperative
complications.
Abdominal incisions

The closure technique:

● The layers appropriately delineated(multiple layers closure).

● Mass closure by using large bites and short steps in the closure
technique.
Abdominal incisions

Suture material used:

●Non-absorbable (e.g. nylon or polypropylene)

● Very slowly absorbable suture material (e.g. polydioxanone

suture (PDS)).

● The length of the suture material should be at least four times

the length of the wound to be closed.
Abdominal incisions

Major complications:

● Abdominal dehiscence.

●Incisional hernia.
Surgery
Open

Laparoscopic

Hand assisted

Natural orifices
Laparoscopic surgery

The benefits of laparoscopic surgery

●● Less postoperative pain
●● Better cosmesis
●● Earlier return of normal physiological function
●● Shorter hospital stay
●● Earlier resumption of normal activities
Laparoscopic surgery

Access is of equal importance to open surgery

and laparoscopic surgery.

Correct port site placement and closure are

crucial to the success of the operative procedure
Laparoscopic surgery
The principles of safe laparoscopic surgery

●● The umbilicus is preferred for primary trocar insertion

●● An open or semi-open technique is preferred by most
surgeons
●● Open insertion away from the umbilicus is safer if
there is a midline scar
●● Secondary trocars should be inserted and removed
under direct vision
●● All trocars should be placed perpendicular to the
abdominal wall
●● All trocar sites above 5 mm in length should undergo
closure of the fascial layer
Laparoscopic surgery
Insufflation

Closed(Veress needle )

Open(Hasson )

Modified open

**Iraqi
Laparoscopic surgery
Technique for laparoscopic primary
trocar insertion:
A semi-open technique
Laparoscopic surgery
Laparoscopic surgery
Laparoscopic surgery
Laparoscopic surgery
Laparoscopic surgery
Laparoscopic surgery
WOUND CLOSURE

The suturing of any incision or wound depend upon the

site and tissues involved and the technique for
closure to be chosen accordingly.

There is no ideal wound closure technique for all

situations.

The ideal suture to be made in future!

The desired characteristics are next.

WOUND CLOSURE
Suture material: desired characteristsics
●● Easy to handle
●● Predictable behaviour in tissues
●● Predictable tensile strength
●● Sterile
●● Glides through tissues easily
●● Secure knotting ability
●● Inexpensive
●● Minimal tissue reaction
●● Non-capillary
●● Non-allergenic
●● Non-carcinogenic
●● Non-electrolytic
●● Non-shrinkage
WOUND CLOSURE

The correct choice of suture technique and suture

material is vital and important.

For the wound to heal well, there must be a good

blood supply and no tension on the closure.
WOUND CLOSURE
Types of wound healing
●● Primary intention
Clean wound

●● Secondary intention
Healthy granulation tissue
Overexuberant granulation tissue
Infected sloughy wound
Black eschar

●● Tertiary intention
Delayed closure
Skin grafting
Clean wound heals by primary intention.(primary
closure)

Courtesy http://www.endotherapeutics.com.au/insorbgo
Secondary closure of wound
WOUND CLOSURE

Clean uninfected wounds with a good blood supply heal by

primary intention.(primary closure)

When a wound is left open, it heals by secondary intention

through the formation of granulation tissue.(no closure)

Delayed primary closure, or tertiary intention, is utilised when

there is a high probability of the wound being infected. The wound
is left open for a few days and, provided any infective process has
resolved, the wound is closed to heal by primary intention. Skin
grafting is another form of tertiary intention healing.
WOUND CLOSURE
Examples

When choosing suture materials, there are

certain specific requirements depending on the
tissues to be sutured;

For example, vascular anastomoses require

smooth, non-absorbable , non-elastic material,
WOUND CLOSURE
Examples

The biliary anastomoses require an

absorbable material that will not promote tissue
reaction or stone formation.
WOUND CLOSURE

Using absorbable material, the wound support is

required.
Example muscular aponeuroses need longer support
compared with subcutaneous tissues.

It is important to select the suture material and suture

technique that will achieve the objective for each wound
closure or anastomosis.
WOUND CLOSURE

Courtesy https://www.mountnittany.org/articles/healthsheets/37280
Courtesyhttps://pixabay.com/photos/wrist-cut-zombie-wound-stitches-598441/
WOUND CLOSURE

Courtesy https://www.clinicaladvisor.com/home/the-waiting-room/try-absorbable-sutures-for-facial-lacerations/
Courtesy https://notyouraverageholidaystory.weebly.com/blog/scar-progress-shots
 Suture techniques

Courtesy https://i1.wp.com/lacerationrepair.com/wp-content/uploads/2017/10/basic-suturing-cover-pic.png?ssl=1
 Mattress suture techniques

Courtesy https://www.consultant360.com/content/suturing-and-wound-closure-part-3-wound-repair-special-areas
WOUND CLOSURE

Courtesy https://www.wisegeek.com/what-are-absorbable-sutures.htm
 steri-strips techniques

Courtesyhttps://www.thefirstaidshopau.com.au/product/wound-closure-strips-3mm-x-75mm-pack-5/
Courtesy https://en.wikipedia.org/wiki/Cyanoacrylate#/media/File:Incision_wound_on_child's_arm,_closed_with_Dermabond.jpg
WOUND CLOSURE

Courtesy https://www.shutterstock.com/es/image-photo/closure-abdominal-skin-wound-stapler-device-756001093
WOUND CLOSURE

Courtesy https://scarsandspots.com/wound-stapled-stitched-or-glued-heres-the-type-of-scar-you-can-expect/
Courtesyhttps://www.shutterstock.com/image-photo/cut-my-wrist-
1070908952?irgwc=1&utm_medium=Affiliate&utm_campaign=Pixabay+GmbH&utm_source=44814&utm_term=https%3A%2F%2Fpixabay.com%2Fphotos%2Fwrist-cut-
zombie-wound-stitches-598441%2F
Courtesy https://medcaretips.com/different-types-of-wounds/ https://www.handsurgeryresource.com/laceration
WOUND CLOSURE
Suture materials(next lecture)
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