Basic Surgical Skills

Indonesia 2018
 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
Knots
 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
- two hands
- instrument tie
• Surgeon’s Knot - one hand
- two hands
- instrument tie
• Slip Knot - must always be followed by a
reef knot
Square ( Reef ) Knot
 Secure Knot

Secure knot
Standard > 3 throw for
knot tying multifilaments
> 6 throws for
monofilaments
Surgeon’s knot
SUTURING
 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.
 Interrupted Suture

x (tissue thickness)

x 2x

•-same distance apart

and same distance
from edge
 Interrupted Suture

x
x

x
Interrupted Suture
Long wound : half – half

Ellipse : start from either end

Ellipse

≥3X
 Ellipse

•X
•≥3X
Linear Incision Closure

3 2 3 1 3 2 3
Closure of Ellipse
 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
Lidocaine Composition
 Forming Sutures
• Interrupted
• Mattress - horizontal
- vertical
• Continuous
• Subcuticular - absorbable
- non-absorbable
Subcuticular Suture

USING ABSORBABLE SUTURE

Subcuticular Suture

Using Non-Absorbable Suture

 Handling Sutures (cont.)

• NO suture should be tied under too much

tension
• Go through one edge at a time in most cases
• Ellipse - length is 3x width
- suture either end
• Long wound : half and half
• Cut 0.5 cm from knot
• Removal : flush to skin
Types of Suture Material
Sutures:
Absorbable Non-absorbable
Biological Synthetic
Monofilament Multifilament
(twisted, braided)
Needles:
Curved Eye
J-shaped Body
Straight Tip
Types of Suture Material (cont.)
Needles:
Curved Eye
J-shaped Body
Straight Tip
Round Body
Taper - blunt
- cutting (forward /reverse)
 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 2 mm away from the first stitch.
c. Serosa meet serosa (inverted)
5. No leakage & no stenosis.
 Bowel Anastomosis
End to end anastomosis extra mucosal layer, Interrupted suture
technique
 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 Vein Patch Graft
Vein Patch Graft
 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