Basic General Surgery Skills

2. BASIC SURGICAL SKILLS
DR.ADEEL RIAZ
PGR GENERAL SURGERY CPTH,
LHR.

3. OBJECTIVES
TO UNDERSTAND
• Surgical approaches, incisions and the use of
appropriate instruments in surgery in general
• Indications for alternative techniques(glues &
staples)
TO KNOW
• Materials & methods used for surgical wound
closure and anastomosis (sutures, knots &
needles)
• The technique for skin closure, artery & bowel
anastomosis

4. OBJECTIVES
TO BE AWARE OF
• The whole operative surgical team and the
responsibility of each member in the care of
sharp and peri-operative care of instruments

5. INCISION OF SKIN
• Skin and tissue incisions are made using scalpels
with disposable blades.
• All sharp instruments pose a needle-stick type
injury and need to be passed within kidney dish.
• Attaching a blade to scalpel handle should always
be done using a hemostat, and not using fingers.
• The blade shape & size is chosen by its purpose.
• Blades for skin incisions usually have curved
margin, those used to make a passage for drain or
for an arteriotomy, have a sharp tip.

6. INCISION OF SKIN
• When making an incision thru skin and deeper
layers, the knife should be pressed firmly at
right angles to the skin & then draw against it.
• Skin should not be incised obliquely as it can
cause necrosis of the undercut edge.
• Diathermy, Laser & harmonic scalpels can be
used when opening deeper structures to reduce
blood loss and save operating time and may
reduce post-operative pain.

7. BLADES

8. SUTURE OF SKIN
• Wound should be closed with a minimum of
tension.
• Edges of skin should be gapped to allow swelling
as inflammation of healing occurs in few days.
• If a wound is closed tightly, necrosis of wound
edges occurs and adds exogenous infection.
• Needles are inserted at right angles using
supination/pronation movements of the wrist.
• Entry & Exit points should be approximated at
same distance from the wound edges.

9. SUTURE OF SKIN
• When a suture is tightened, the knot should be
drawn to one side to facilitate suture removal.
• The ends of the knots should be left long enough
to easy to grasp when they are removed later.
• As a general rule, each suture should be
separated by a gap twice the thickness of the
skin.
• If a wound has curves & zigzags, stay sutures at
the tip of each corner make sure that the wound
edges come close together to avoid Dog-Ears.

10. CLOSURE OF WOUNDS
• Wound edges should be left slightly gaping to
allow swelling.
• Edges should be everted.
• The knot should be placed to one side of the
wound
• Knots must be secured with the ends long
enough to grasp when removing the suture.

11. TYPES OF SKIN CLOSURE
• Skin closure may be interupted, continuous, or
simple mattress or subcuticular.
• Interrupted sutures have the advantage that
they can be removed individually if a
hematoma or infection forms locally, to help
drain blood or pus later without disrupting
suture line.
• Mattress sutures appose skin edges tidily,
ensure eversion and help to close the dead
space in the subcutaneous fat layer.

12. TYPES OF SKIN CLOSURE
• Subcuticular sutures are cosmetically appealing
but ar edifficult to place in a curved wound.
• Nevertheless, subcuticular closure is most
widely practiced skin closure in virtually all
specialities, although skin clips have their
advocates.
• Non-absorbable suture are removed when the
wound has healed to avoid scarring, infection &
irritation.

13. SKIN CLOSURE

14. TIME OF REMOVAL OF SUTURES
• Face 2-3 days
• Scalp 5 days
• Upper limb 7 days
• Groin 7 days
• Abdomen 7 days
• Dorsum 10-14 days
• Lower Trunk 10-14 days

15. NO-TOUCH TECHNIQUE
• Suturing should be done with this technique
whenever possible
• Needle holders should be suitable for the needle
• Avoids the risk of needle-stick injuries
• Short-handled holders are used for skin closure, and
long-handled holders are used for suturing deep
inside the body.
• The needle should be held in the tip of the holder
and placed about 2/3rd of the way back from its tip.
• Needles can be placed in holders both forehand &
backhand for appropriate use.

16. SUTURE MATERIALS
• There is evidence that traumatic and surgical wounds were
closed in 3000 BC by the Egyptians using thorns and needles.
• By 1000 BC, Indian surgeons were using horsehair, cotton and
leather sutures.
• In Roman times, linen and silk and metal clips called fibulae
were commonly used to close gladiatorial wounds.
• By the end of the nineteenth century, developments in the
textile industry lead to major advances, and both silk and catgut
became popular as suture materials.
• Lister believed that catgut soaked in chromic acid (a form of
tanning) prevented early dissolution in body fluids and tissues.
• Moynihan felt that chromic catgut was ideal as it could be
sterilized, was non-irritant to tissues, kept its strength until its
work was done and then disappeared.

17. SUTURE MATERIALS
• All the natural sutures, silk, cotton, linen and catgut,
are being replaced by polymeric synthetic materials
that cause minimal inflammatory reactions, are of
predictable strength and absorb at an appropriate
rate.
• They can be manufactured as monofilaments or
braids, and can be coated with wax, silicone or
polybutyrate to allow them to run smoothly through
tissues and to knot securely.
• The absorbables cause a minimal tissue reaction as
they are resorbed. To aid in the prevention of
postoperative infection, particularly after prosthetic
surgery

18. Suture
Types
Raw
material
Tensile
strength
Absorption
rate
Tissue
reaction
Contraindic
ations
Frequent
uses
Silk Natural
protein
from
silkworm
Loses 20%
when wet
50% lost by
6 months
Absorbed
slowly over
1-2 years
Moderate
to high
Not for use
with
vascular
prosthesis
Ligation &
suturing for
prolong
support
Polyglycona
te
Copolymer
of glycolic
acid
70% in 2 wk
55% in 3 wk
Absorbed in
180 days
mild Not Prolong
support
Gut
anastomosi
s
Polypropyle
ne
Polymer of
propylene
Infinite > 1
year
Remains
encapsulate
d in body
tissues
low none Cardiovascu
lar, plastic
& general
surgery
Catgut Collagen
from sheep
or cattle
Lost in 7-10
days
Phagocytosi
s within
7-10 days
high Not for
tissues
which heal
slowly
Ligate
vessels &
suture s/c
tissues
Chromic
Catgut
Catgut e
tanned
chromium
Lost in
21-28 days
Degrades in
90 days
moderate Same as
catgut
Same as
catgut
Polydioxano Polyester 70% in 2 wk Complete mild Heart Used as

19. METAL SUTURES,CLIPS & STAPLES
• Mechanical stapling devices were first used successfully
by Hümer Hültl, in Hungary, to close the stomach after
resection.
• There is now a wide choice of linear, side-by-side and
end-to-end stapling devices that give strong predictable
suture lines, with minimal tissue necrosis.
• Metal clips for skin allow quick, accurate closure.
• Metal clips save operating time & are easy to remove
• Steristrips can be used to buttress a skin closure and can
prevent ‘spreading’ of a scar. This can be useful, for
example after a wide lump excision of the breast.
• Adhesive polyurethane films,such as Opsite, Tegaderm
or Bioclusive, may have a similar property.
• Transparent dressings also allow wound inspection and
may protect against cross-infection.

20. NEEDLES
• The choice of surgical needle is as important as the choice of
suture. The needle holder chosen also needs to be appropriate;
a large needle holder damages a small needle, and a large
needle is unmanageable in a small needle holder.
• The appropriate size and shape of cutting, or round-bodied
atraumatic needle, needs to be chosen for the least traumatic
passage through tissue.
• Shaped needles allow easier access for suturing. Examples are
the J-shaped needle useful in low-approach femoral hernia
repair, or the compound curve needle used in ophthalmic
surgery.
• Hand needles should be avoided because of the risk of needle-
stick injury.
• The tips of laparotomy closure needles are deliberately blunted
by some of the manufacturers to reduce the risk of needle-stick
injury.

21. NEEDLES

22. TISSUE GLUES
Cyanoacrylates
• The use of tissue glues is not widespread despite
much published work.
• The cyanoacrylates have been used for skin
closure but require near perfect haemostasis if
they are to work well.
• Some specific uses have been described such as
the use in closure of a laceration on the forehead
of a fractious child in Accident and Emergency
(thereby dispensing with local anaesthetic and
sutures).
• They are relatively expensive but quick to use, do
not delay wound healing and are associated with
an allegedly low infection rate

23. TISSUE GLUES
Fibrin tissue glues
• Tissue glues, involving fibrin, work on the conversion of
fibrinogen by thrombin to fibrin with cross-linking by factor XIII;
the addition of aprotinin retards break-up of the fibrin network
by plasmin.
• The fibrinous network produced has good adhesive properties
and has been used for haemostasis in the liver and spleen.
• It has also been used in neurosurgery for dural tears; in ear,
nose and throat (ENT) and ophthalmic surgery; to attach skin
grafts and prevent haemoserous collections under flaps; and in
cardiac and general surgery for the prevention of postoperative
adhesions in the pericardium and the peritoneum.
• Fibrin glues have been used to control gastrointestinal
haemorrhage, using endoscopic injection, but do not work
when bleeding is brisk.
• They are more effective in haemostasis when combined with
collagen.

24. KNOT TYING
• Secure knots are crucial in operative surgery. Most should be
performed using an instrument such as a needle holder, with
care being taken not to damage the suture material
incorporated into the knot.
• Surgeons in training should practice these on the jigs devised
for use in basic skill courses.
• All knots should be square, but the two-throw reef (surgeon’s)
knot does not slip.
• A granny knot is a two-throw knot using the same type of
throw; its ability to slip is useful in producing the right tension
prior to ensuring security with a third, double-throw knot.
• The Aberdeen knot can be used with a continuous suture to
make a final knot. The free end of the suture is pulled through
the final loop several times before being pulled through a final
time prior to cutting.

25. TYPES OF KNOTS

26. KNOT TYING
• When knots are cut short, the free ends or ‘ears’
should be left at least 1–2 mm long. This is
particularly important with monofilament non-
absorbables.
• However, if the ends are left too long, they can
cause wound irritation and add to the
complications of wound pain and wound sinuses.
• Ligatures can be tied using instruments or by
hand when tissues are divided between forceps.
• The security of a ligature depends on good
communication between surgeon and assistant as
the tissue forceps is released and tissue tied
without slippage.
• This needs practice.

27. KNOT TYING
• Secure wound closure is crucial. Technical
wound failure follows knots slipping, tissues
tearing or breakage of sutures.
• When this occurs after laparotomy closure,
the result is a burst abdomen, a disaster for
the patient and a technical failure for the
surgeon.
• This complication is avoided by the use of an
appropriate material, polypropylene (Prolene)
or polydioxanone suture (PDS), secure knots
and appropriate tissue bites.

28. SECURE WOUND CLOSURE
• Correct suture material
• Appropriate bites of tissue and suture spacing
• Secure knots