Basic surgical skills final

Basic Surgical

SkillsDr. Amira BadawyLecturer OB/GYNFaculty of Medicine – Alexandria University

1 May 2023

PART-I

PART-II

PART-III

• Patients.• Procedures.

• Gowning.• Gloving.

• Skin Incisions.

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PART-IV

PART-V

PART-VI

• Needles.• Suture Materials.

• Instruments• Suturing techniques.

• Wound healing.• Wound Closure.

Theatre Preparation• Patient & Procedure

• Hand washing

• Gowning & Gloving

• Universal precautions

Patient & Procedure

A. Patient & Procedure• Patient• Permission• Preparation• Position • Procedure• Post procedure• Prescription

Hair removal• “ If ” hair must be removed,

clipping & depilatory creams are better than shaving with a razor (as shaving damage the skin's defences & risk of wound infection).

• Hair removal is better to be accomplished immediately prior to surgery & outside the OR.

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Surgical positions

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Surgical positions• Supine• Prone• Fowler’s.• Trendlenberg’s.• Lateral (Sim’s).• Lithotomy.• Knee-chest.• Squating.

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Skin Disinfection

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ALCOHOL

• Has immediate & broad activity against gram+ve & gram-ve bact., many fungi & viruses & myco-bacteria, (although not sporicidal).

• Kills faster than chlorhexidine gluconate or povidone iodine, but has little residual effect.

• { 1-minute scrub with alcohol = 4-7 minute scrub with other antiseptics}.

• Not to be used on mucous membranes.

• 70% solution is most commonly used. Ethanol, normal propyl, & isopropyl are all effective.

• Highly flammable, (must be dried completely where electro-cautery or laser will be used).

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IODOPHORES

• The povidone carrier releases its iodine slowly.

• Iodophors are highly effective.

• Their anti-microbial action declines rapidly upon drying, (does not have a residual effect).

• Iodine is in-activated by organic material so should be applied only to clean skin.

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CHLORHEXIDINE GLUCONATE

• more effective against gram +ve than gram -ve bacteria, with less activity against viruses & fungi.

• It binds to the top layer of the skin extended effectiveness, (chemical activity for about 5 hours).

• It does not become inactivated in the presence of organic materials.

• It is also available as an alcohol-based hand-rinse, combining the rapid & effective action of alcohol with the long action of chlorhexidine gluconate.

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Duration is not fully

established, better to

be ~ 5 minutes.

Duration is not fully

established, better to

be ~ 5 minutes.

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Surgical scrubbing&Gloving

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Skin disinfection technique

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• The prep solution & paint shouldn't be allowed to pool or accumulate under, or adjacent to the patient (to prevent chemical burns & decrease the risk of electrosurgical or laser burn).

• Sterile towels should be placed at the periphery of the skin prep boundaries to prevent accumulation of the agents.

• ECG leads, grounding pad, & tourniquet (if in the area of the skin prep region), should be covered by an adhesive clear plastic drape to prevent accumulation of prep fluids & prevent chemical burns.

• Do not wipe off prepping solution. Allow it to DRY COMPLETELY prior to draping.

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• Skin prep is begun at the incision site to the periphery, using circular motion.

• The most important principle is to progress from clean to dirty area.

• Areas of high microbial counts, (axilla, groin, perineal region, anus & vagina are prepped last with a separate sponge.

• Umbilicus is an exception. It is prepped first. This prevents debris from umbilicus from splashing onto the prepped abdomen.

• In abdomino-perineal & abdomino-vaginal procedures, separate skin preps are used starting with perineal & vaginal areas.

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Abdominal preparation

• Included area is from nipple line to upper 1/3 of thighs; table level left to table level right.

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Perineal & Vaginal preparation

• Do not use Chlorhexidine or alcohol solutions.

• Place drip towel or drape under buttocks to prevent prep solution from pooling under the patient’s coccyx.

• Ensure towel or impervious drape is removed following completion of the prep.

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A. Prep pelvis, labia, perineum, & thighs:– Start at the pubis to iliac crest (back & forth

strokes).– Prep L. majora & perineum (downward strokes).– Use fresh sponge to prep inner thigh of first leg

starting at labia majora then laterally (back & forth strokes). Then discard sponge when periphery reached.

– Use fresh sponge to prep inner thigh of second leg starting at labia majora & moving laterally using back & forth strokes. Discard sponge when periphery reached.

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B. Vaginal prep: use a separate sponge mounted on a forceps.

C. Prep anus last.

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Draping

Aseptic technique for draping

1) Handle drapes as little as possible.

2) Never reach across the operating table to drape the opposite side, go around the table.

3) Hold the drapes high enough to avoid touching non-sterile areas (take care of the overhead light).

4) Hold the drape high until it is directly over the proper area, then drop it. NEVER adjust any drape. If the drape is incorrectly placed, leave it & place another drape over it.

5) Protect the gloved hands by cuffing the end of the sheet over them. Do not let the gloved hand touch the skin of the patient.

6) A drape should be carefully unfolded & allowed to fall gently into position by gravity.

7) The low portion of the sheet that falls below the safe working level shouldn’t be raised or lifted back onto the sterile area.

8) Drape the incisional area first, then the periphery.

9) Use non-perforating towel clamps.

10)When sterility of a drape is questionable, consider it contaminated.

Gowning & Gloving

• The only way to learn is to go to theatre.

• Duration is not fully established, better to be ~ 5 minutes.

• Prepare the gown & gloves before you wash.

• Put the mask & cap on BEFORE gowning up.

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Gloving, & Gowning, Instrument handling, Knots

Gloving

Universal

Precautions

include:

Washing hands

Double Gloves

Goggles

Masks

CapsFace shields

Boots

Disposal of sharps

into sharp’s

bins

Reporting of needle

stick injuries

Skin incisions

The incision should be accomplished with the least possible tissue damage.

A scalpel should be used, & the fewest possible strokes will limit tissue damage.

Electro-cautery tends to produce much larger zones of damage & increases infection rates.

Haemostasis can be obtained with well-directed cautery & fine ligatures.

Transverse Abdominal Incisions

• Advantages (compared to midline inc.):– 30 xs stronger.– Less painful, less interference with post op.

respirations.– Less wound eviscerations & hernias.

• Disadvantages (compared to midline inc.):– More time consuming.– More haemorrhage.– More nerves are divided.– More possibility for formation of potential

spaces & haematoma formation.– Less exposure of the upper abdomen.

A.Pfannenstiel incision:• Transverse incision, slightly curved

(curvi-linear fashion).• Usually 10-15 cm long.• At any level suitable for the surgeon,

about approximately 2–3 cm above the pubic symphysis.

• No dissection of the SC fat from the ant rectus fascia ( as in Kustner’s incision).

• Fascial incision should not extend beyond the ext oblique fascia.

• No need to suture the sub cutaneous tissue.

Pfannensteil Incision

Pfannensteil Incision

B.Joel-Cohen incision:• A transverse incision. • Made in a linear fashion approximately

2–3 cm above the traditional placement of the Pfannenstiel incision.

A. Pfannenstiel incision.B. Joel-Cohen incision.C. Midline vertical incision.

C.Küstner incision:• Wrongly named (modified Pfannenstiel).• A slightly curved transverse skin incision.• From below the level of the ASIS, extends

below the pubic hair line.• Superficial inferior epigastric vessels are

ligated.• The external oblique fascia is incised vertically

(as in midline incision) after separation of the SC tissue till the umbilicus at the midline.

• More time consuming (than Pfannenstiel & low midline incisions) due to more bleeding.

• A SC drain is strongly recommended.• Has no advantage & of very limited use.

Küstner Incision

D.Cherney incision:• It entails freeing of the recti (& pyramidalis)

from their tendinous insertion into the SP.• Bleeding is negligable at this area., no need to

ligate the inferior epigastric vessels.• It gives 25% more length compared to mid line

incision.• Provides excellent access to the space of

Retzius.• Provides excellent access to the pelvic side

walls.• Nerve injury is more encountered (especially

the Femoral nerve when using a self retaining retractor.

• To avoid osteomyelitis, the rectus should be sutured to the lower flap of the muscle, not the SP.

Cherney Incision

Cherney Incision

D.Maylard incision:• A true muscle cutting-incision, all layers of the

abd wall are incised transversely.• Provides excellent pelvic exposure.• The skin incision is to be made 3-8 cm above

the SP.• After fascial incision (till lateral to the outer

edges of the Recti), gently identify & ligate the inferior epigastric vessels (with permenant sutures).

• After cutting the Recti , better to suture the muscle to the overlying fascia (to avoid their retraction).

• The peritoneum is opened transversely.

Maylard Incision

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Maylard Incision

Incisions Pfannenstiel Cherney Maylard Vertical

Pelvic exposure ++ +++ ++++ +++

Upper abdomen exposure

+ ++ ++++

Potential blood loss ++ ++ +++ +

Potential hernia + + ++ +++

Evisceration risk + ++ +++

Speed ++ +++ + ++++

Techniques of abdominal

wall closureA. Layered closure.

B. Modified Smead-Jones closure.

C. Mass closure.

D. Retention suture.

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Needles & Suture

Materials

NEEDLES

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Selection of appropriate needle:

• The choice of needle to be used depends on several factors such as:

1. requirements of the procedure; 2. nature of the tissue being sutured; 3. accessibility of the operative area; 4. gauge of suture material being used;

and 5. surgeon's preference.

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Components Surgical needles have three basic components: the point, the body & the swage.

The Point depends on the needle type (round or cutting).

The Body has flattened section where the needle can be grasped by the needle holder. Some needles have longitudinal ribs on the surface which reduce rotational movement.

The majority of surgical needles are Eyeless (already swaged to the suture material).

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Components

Point

Swage

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Needle Curve

• Straight needle just becomes embedded in normal tissues, unless they can be held up. (as skin edges).

• 3/8 curve is the most common shape. • 1/2 or 5/8 curve needle are useful in small

spaces. • 1/4 curve or a straight needle is adequate if

there is no shortage of space. (as skin edges). • Compound shapes include a J needle for

confined spaces (as for femoral hernia repair).

• Most surgical needles are curved. • Few are straight. • The curve allows the needle to pass down

into the tissues & to come out again along a curved track.

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Needle Material

•Needles are made from stainless steel alloys, selected to hold a very sharp point for one use only.

•They are designed to bend, rather than to break, when over stressed.

• The strength of the needle is designed to match the use to which it is put.

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Needle measurements

Needle length, not chord length (bite

width), is the measurement supplied

on suture packages

Chord length: the linear distance from the point of the curved needle to the swage (bite width).

Needle length: The distance measured along the needle from the point to the swage.

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Needle measurementsRadius: This is the distance from the body of

the needle to the centre of the circle along which the needle curves (bite depth).

Diameter: The gauge or thickness of the needle wire.

The needle should be long enough to: Pass through the tissue. Show at the far side of

the wound to be grasped by the needle holder or dissecting forceps.

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Needle Size• Size originally scaled from 0-3. • As technology advanced & sutures became

smaller, extra 0’s were added.• Scale now ranges from 3 (largest) to 12/0

(smallest)Size Uses7/0 and smaller Ophthalmology, microsurgery

6/0 Face, blood vessels5/0 Face, neck, blood vessels

4/0 Mucosa, neck, hands, limbs, tendons, blood vessels

3/0 Limbs, trunk, gut blood vessels2/0 Trunk, fascia, viscera, blood vessels

0 and larger Abdominal wall, fascia, drain sites, arterial lines, orthopaedics

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Needle Cross Section(1) Round-bodied needles • Designed to separate tissue fibers rather than

cut them.

• Used either for soft tissue or in situations where easy splitting of tissue fibers is possible.

• After the passage of the needle, the tissue closes tightly round the suture material, thereby forming a leak-proof suture line which is particularly vital in intestinal & cardiovascular surgery.

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(1) Round-bodied needles Needle

type Description Typical application

Intestinal

The hole made by this needle isno larger than the diameter of the needle. The hole is then filled by the material, which reduces the risk of leakage.

Gastrointestinal tract; biliary tract; dura; peritoneum; urogenital tract; vessels; nerve.

HeavyIn some situations where particularly strong needles are required, a heavy wire diameter needle would be appropriate.

Muscle; subcutaneous fat; fascia; pedicles.

Blunt Taper-point

Where needle-stick injury is a major concern, particularly in the presence of blood borne viruses, the blunt taper-point needle virtually eliminates accidental glove puncture.

Uterus; pedicles; muscle; fascia.

Blunt-pointThis needle has been designed forsuturing extremely friable vasculartissue.

Liver; spleen; kidney; incompetent uterine cx.

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Needle Cross Section(2) Cutting needles

• They are required where tough or dense tissue needs to be sutured.

(3) In addition, there are surgical needles for special areas, such as microsurgery, opthalmics & endoscopic surgery.

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(2) Cutting needles Needle

type Description Typical application

Tapercut™

This needle combines the initial penetration of a cutting needle with the minimized trauma of a round-bodied needle. The cutting tip is limited to the point of the needle, which then tapers out to merge smoothly into a round cross-section.

Fascia; ligament; uterus; scar tissue.

Cutting

This needle has a triangular cross- section with the apex on the inside of the needle curvature. The effective cutting edges are restricted to the front section of the needle.

Skin; ligament; nasal cavity; tendon; oral.

Reverse cutting

The body of this needle is triangular in cross-section with the apex on the outside of the needle curvature.

Skin; fascia; ligament; tendon; oral; nasal cavity.

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Tapered Needle• Gradually taper to the point & cross-section

reveals a round, smooth shaft.• Used for tissue that is easily penetrated (as

bowel or blood vessels).

Cutting• Triangular tip with the apex forming a

cutting edge.• Used for tough tissues, (as skin)(NB: use of a tapered needle with skin causes excess trauma because of difficulty in penetration).

Reverse cutting needle• Similar to conventional cutting needle except

the cutting edge faces down instead of up.• This may decrease the likelihood of sutures

pulling through soft tissue.

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Round-bodied needle

Cutting needle

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W9890 needle

• Thread (suture material):• 75 cm thread length, • 3/0 thread diameter (size).• Coated Vicryl (polyglactin , braided,

absorbable, synthetic). • Needle =

• Cutting (reverse cutting).• 30 mm long, • 3/8 circle

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Code J345

• Thread (suture material):• 90 cm thread length, • 2/0 thread diameter (size).• Coated Vicryl (polyglactin , braided,

absorbable, synthetic. • Needle =

• Rounded (taper end).• 36 mm long, • half circle

SUTURE MATERIALS

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Ideal Suture MaterialsThe ideal suture has the following criteria

:1. Sterile2. All-purpose (composed of material that

can be used in any surgical procedure).3. Causes minimal tissue injury or tissue

reaction (ie, non-electrolytic, non-capillary, non-allergenic, non-carcinogenic).

4. Easy to handle.5. Holds securely when knotted (ie, no

fraying or cutting).6. High tensile strength.7. Favourable absorption profile.8. Resistant to infection.

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Characteristics of suture material

• Absorbable - Progressive loss of mass and/or volume of suture material; does not correlate with initial tensile strength.

• Breaking strength - Limit of tensile strength at which suture failure occurs.

• Capillarity - Extent to which absorbed fluid is transferred along the suture.

• Elasticity - Measure of the ability of the material to regain its original form and length after deformation.

• Fluid absorption - Ability to take up fluid after immersion.

• Knot-pull tensile strength - Breaking strength of knotted suture material (10-40% weaker after deformation by knot placement).

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• Knot strength - Amount of force necessary to cause a knot to slip (related to the coefficient of static friction and plasticity of a given material).

• Memory - Inherent capability of suture to return to or maintain its original gross shape (related to elasticity, plasticity, and diameter).

• Non-absorbable - Surgical suture material that is relatively unaffected by the biological activities of the body tissues and is therefore permanent unless removed.

• Plasticity - Measure of the ability to deform without breaking and to maintain a new form after relief of the deforming force.

• Pliability - Ease of handling of suture material; ability to adjust knot tension and to secure knots (related to suture material, filament type, and diameter).

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• Straight-pull tensile strength - Linear breaking strength of suture material.

• Suture pullout value - The application of force to a loop of suture located where tissue failure occurs, which measures the strength of a particular tissue; variable depending on anatomic site and histological composition (fat, 0.2 kg; muscle, 1.27 kg; skin, 1.82 kg; fascia, 3.77 kg).

• Tensile strength - Measure of a material or tissue's ability to resist deformation and breakage.

• Wound breaking strength - Limit of tensile strength of a healing wound at which separation of the wound edges occurs.

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Types of suture materials• Absorbable sutures or Non-absorbable sutures.

• Monofilament sutures or Multifilament sutures.

• Of Biological (natural) source or Man-made (synthetic) source.

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Absorbable sutures: • Offer temporary wound support, then are gradually

absorbed.• Composed of biodegradable materials which can be:

Naturally occurring (degraded enzymatically).1. Catgut• Consists of processed collagen from animal intestines.• Broken down after 7 ds.

2. Chromic catgut• Consists of intestinal collagen treated with chromium.• Loses tensile strength after 2-3 ws & is broken down after

3 ms.

Synthetic• Degraded (non-enzymatically) by hydrolysis when water penetrates the suture filaments & attacks the polymer chain.

• Tend to evoke less tissue reaction.•Sub-classified according to degradation time.The ideal suture should disappear immediately after its work is complete, but such a suture does not yet exist.

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Non-absorbable sutures

• Do not absorb, but some, especially those of biological origin, lose strength without any change in the mass of the suture material.

• Others gradually fragment over time. • Other non-absorbables, especially those of

synthetic origin, never lose tensile strength or change in mass.

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M ersilk

N atur al

N urolonEthibond

Braided

EthilonPr olene

M onofi lament

S ynthet ic

N on- absor bable

Catgut

N atural

Vicryl rapide

S ynthetic

S hor t term

Braided vicryl

Braided

M onocryl

M onofi lament

M edium term

Panacryl

Braided

PDS I I

M onofi lament

Long term

A bsorbable

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Types of suture materialsMonofilament suture (Ethilon or Prolene)• Made of a single smooth strand. • Less traumatic as they glide through tissues with less

friction.• May be associated with lower rates of infection (resists

harbouring micro-organisms). • Ties down smoothly, but more likely to slip (should be

secured with 5 or 6 ‘throws’ in contrast to 3 throws with multifilament)

• Preferred for skin closure because they provide a better cosmetic result.

Multifilament suture (Mersilk or Mersilene)• Consists of several filaments twisted together. • Gives good handling and tying qualities.

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Types of suture materialsbased on the origin of the raw material; suture material is either: Biological or natural source (Mersilk, cotton &

steel)• They tend to create greater tissue reaction than man-made

sutures; • Result can be localised irritation or even rejection. • Factors present in the patient (as infection & general

health) can affect the rate at which enzymes attack & break down absorbable natural sutures.

Man-made or synthetic source (Prolene, Ethilon, Nurolon)

• Very predictable and elicit minimal tissue reaction.

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Types of suture

materials

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Name Ab Filament. So.

Gut Mono N Silk Braided N Cotton Braided N Steel Mono N Monocryl (poliglecaprone) Mono S Maxon (polyglycolide-trimethylene carbonate) Mono S

PDS (polydioxanone) Mono S Vicryl (polyglactin) Braided SDexon (polyglycolic acid) Braided S Prolene (polypropylene) Mono S Novafil (polybutester) Mono S PTFE (polytetrafluoroethylene) Mono S

Nylon Mono or Braided S

Steel Mono or Braided S

Polyester Braided S

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Sutures

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INSTRUMENTS

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Instruments• Needle Holder• Forceps• Blade / Scalpel• Scissors• Other instruments

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Needle Holder• Notice the Ratchet.• Notice the course

inner tip.• How to manipulate it:

– Thumb – to unlock– 3rd finger (middle

finger)– 1st finger (index)

• Use distal phalanges.

T3

1

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Needle Holder (HOW)• Open ′suture packet with one tear to reveal

′needle.• Grasp ′needle with ′needle holder at ′ junction of

′upper 1/3 & ′lower 2/3 (two-thirds ′distance from its pointed end).

• Avoid grasping ′needle at its proximal or distal ends.

• Correct movement is supination of ′wrist.• Suture needle size & material vary in size

dependant on properties & usage.

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Forceps• Use ′non dominant hand,• Hold in ′first three fingers (similar way to

a pen holding)• Notice ′tip:

– Toothed – Non Toothed

Toothed forceps

Non-toothed forceps

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Tissue Forceps

Russian forceps

Singley forceps

Micro-surgery forceps (micro-forceps)

Bipolar / Diathermy

forceps

Adson forceps

DeBakey forceps

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Scalpel

• Use needle holder to insert the blade & slide it on the handle

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Scalpel

No. 22

No. 11

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Scalpel• For small No. Scalpel (as No. 11):

hold like a pencil.• The tripod grip:

three parts of ′tripod are:′side of ′middle finger, & ′tips of ′index & thumb.

• The tripod grip enables ′surgeon to:

1. Flex & extend ′digits, so that ′scalpel moves in & out during delicate dissections.

2. Rotate ′handle of ′scalpel with ′thumb, so ′scalpel can cut small diameter curves.

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Scalpel• For larger No. Scalpel (as No.

22):hold like a table knife.

• ′handle rests in ′ palm of ′ hand.• ′digits & hand are largely on top of

′scalpel (unlike with ′pen grip). This means that ′scalpel can be held close to ′surface of ′tissues when cutting, without ′digits & ′hand getting in ′way as in ′pencil grip.

• This allows ′curved part of ′blade to cut ′skin, rather than ′point of ′blade tending to just scratch ′skin (with the tripod grip).

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ScalpelThe grip is quite gentle.

1. For tough tissues, (such as skin on ′back), grip more firmly & place your index finger on ′top of ′handle rather than on ′side This will increase ′downward pressure of ′blade on ′tissue.

2. For more delicate tissues, hold ′handle between ′thumb on one side & ′four fingertips on ′other. 1 2

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Scalpel (DO NOT)•DO NOT hold ′scalpel in ′fist or like a dagger.

•DO NOT dissect with ′handle of ′scalpel. (You will be concentrating on ′site of dissection & may accidentally cut your assistant) .

•DO NOT hold ′scalpel in your hand while using another instrument (You may accidentally cut ′patient as you concentrate on ′dissection area).

X

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Scalpel (DO NOT)•ALWAYS pass ′scalpel to someone else handle first.

•PREFERABLY, place ′scalpel in a dish for ′scrub nurse to pick out.

•DO NOT throw ′scalpel down on ′bench (or on ′patient).

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Scalpel (HOW)• ′part of ′blade that does ′cutting is ′curve (& not

′tip).• Scratching with ′tip of ′blade is a beginner's error.

• Go slowly & gently at first with repeated strokes in ′same place, until you see how much ′blade is cutting ′tissue.

• Press harder at ′beginnings & ends of ′incision.• Blade should be perpendicular to ′tissues to avoid slicing; Slicing will de-vascularise ′thinner side of ′incision.

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Scissors• Two (main) types (dissecting &

suture cutting).

• Thumb & ring finger into rings.

• Index to stabilise from top.

• Use tips of phalanges.

• Use other hand / fingers to stabilise.

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Scissors

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Scissors

Mayo

Metzenbaum

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Haemostats• Haemostats / Artery Forceps

– Use to clamp blood vessels– Jaws may be curved or straight.

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Clamps

Kelly Clamp

Mosquito Clamp

Kocher Clamp

Allis Clamp

Babcock Clamp

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Retractors

• Retractors– An instrument used to retract deep

tissues in abdomen or chest cavity– Lip may be curved or smooth

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Retractors

DeaverBalfour

Doyen

Kelly

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Retractors

Army-Navy

Brisky-Navratil

Rt-angle retractor

Auvard

Richardson

Suction tips

Frazier

Yankauauer

Poole

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Exercise 1 – Reversing needle

• Practice handling instruments.

• Be comfortable with needle holder & forceps.

• Transfer needle from one to the other.

• Practice reversing the needle.

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Standard position on needle in needleholder

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Exercise 2 – Making an incision

• Make a 5 cm incision into the skin model.

• Make a clean cut.

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Exercise 3 – Interrupted Suture

• Watch the video

• Practice tying interrupted sutures.

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Simple interrupted stitch: Steps 1&2

• Grasp the skin edge with the forceps and slightly evert the skin edge

• Then pronate the needle-holder so that the needle will pierce the skin at 90o

• Ensure the trailing suture material is out of the way to avoid tangling

Drive the needle through the full thickness of the skin by supinating the needle-holder

Keeping the shaft of the needle perpendicular to the skin allows the curvature of the needle to traverse the skin as atraumatically as possible


• Release the needle and pronate the needle-holder

• Regrasp the needle proximal to its pointed end

• Maintain tension with the forceps to prevent the needle from retracting

• Again, supinate the needle-holder to rotate the needle upwards and through the tissue


• Regrasp the needle in order to rearm the needle-holder (due to HIV risks it is better to use the forceps to do this)

Grasp and slightly evert the opposing skin edge with the forceps

Pronate the needle-holder


• Again, supinate the needle-holder to rotate the needle through the skin, keeping the shaft 90° to the skin surface

• After releasing the needle, pronate the needle-holder before regrasping the needle…


• …and again supinate the needle-holder to rotate the needle through the skin

Pull the suture material through the skin until 2-3 cm is left protruding

Discard the forceps and use your free hand to grasp the long end in preparation for an instrument tie

Place the needle-holder between the strands


• Wrap the long strand around the needle-holder to form the loop for the first throw of a square knot

• Rotate the needle-holder away yourself and grasp the short end of the suture


• Now draw the short end back through the loop towards yourself

• Now tighten the first throw


• The throw should be tightened just enough to approximate the skin edges but not enough to strangulate the tissue

• To begin the second throw of the square knot, wrap the long strand around the needle-holder by bringing the long strand towards yourself


• Rotate the needle-holder towards yourself to retrieve the short end

• Grasp the short end and draw it through the loop by pulling it away from yourself

Simple interrupted stitch: Step 19&20

• Finally, tighten the second throw securely against the first

• Ensure the knot is to one side of the wound to avoid involvement in the clot

In one hand hold the scissors With the other hand maintain

tension on the suture material Slide the tips of the scissors

down the strands to the point where they will be cut

Cut the suture material leaving 4-5mm tails (important for removal of external non-absorbable sutures)

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Exercise 4 – Continuous Suture

• Watch the video.• Practice tying Continuous sutures.• Tie Knot at one end.• Cut only one strand.• Continue suturing along wound.• Secure suture at other end with

reef knot.

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Exercise 5 - Mattress Suture• Mattress sutures are either:

Vertical, or Horizontal.

• They can evert or invert wound edges.

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Suture removal• Sutures should be removed:

Face: 3-4 days Scalp:5 days Trunk: 7 days Limb: 7-10 days Foot: 10-14 days

• Steps involved in removal:– Reassure patient that ′procedure is not painful.– Clean ′skin with hydrogen peroxide.– Grasp one of ′suture ‘tails’ with forceps & elevate.– Slip ′tip of ′scissors under ′suture & cut close to ′skin

edge (to minimise ′the length of contaminated suture that will be pulled through ′wound).

– Gently pull ′knot with ′forceps & reinforce ′wound Proxi-Strips if required.

Suturing techniques

Knotting techniques

WOUND HEALING

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CDC wound classification1)Clean.2)Clean, contaminated.3)Contaminated.4)Infected.

1) Clean:• Uninfected operative wound in which no

inflammation is encountered & NO systemic tracts are entered (resp., GIT)

• Closed by primary intention & is usually not drained.

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CDC wound classification2) Clean, contaminated:• Operative wound in which systemic tract (s) are

entered under controlled conditions and without contamination.

3) Contaminated: Includes:• Open traumatic wounds (open fractures,

penetrating wounds)• Operative procedures involving:

Spillage from the GI, GU or biliary tracts. A break in aseptic technique (open cardiac

massage).−Microorganisms multiply rapidly that a

contaminated wound can become infected within 6 hours.

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CDC wound classification4) Infectedo Heavily contaminated/infected wound prior to

operation.o Includes:

• Perforated viscera.• Abscesses.• Wounds with undetected foreign

body/necrotic tissue.

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Types of wound healing

1.Primary intention.2.Second (secondary)

intention.3.Delayed primary

closure.

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1) Primary intention

•Involves closure of a wound within hours of its creation.

• It is the optimum closure; the wound heals in minimum time with no separation of its edges & minimal scar formation.

•Thus, a wound closed surgically with sutures or by other means heals soon after creation .

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2) Secondary intention• Occurs when the wound fails to heal by primary

intention due to:– Infection– Excessive trauma– Tissue loss.

• More complicated & prolonged than healing by primary intention.

• ↑↑ formation of granulation tissue :– Contains myo-fibroblasts which lead to gradual

but marked wound contraction.– May protrude above the wound surface,

prevent epithelialisation & thus require treatment.

– Imprecise approximation of tissue (leaving dead space).

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3) Delayed primary closure• Used in management of contaminated &

infected wounds with extensive tissue loss & high risk of infection (eg. trauma following RTA, penetrating injury).

• Steps taken include:– Debridement of non-viable tissues (usually

under sedation).– Leaving wound open with gauze packing

inserted.– Wound approximation within 3-5 days if no

infection is evident.– If infection is present, the wound is allowed

to heal by secondary intention.

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Phases of wound healing

There are 3 phases for wound healing:

1. Inflammatory phase.

2. Proliferative phase.

3. Remodeling phase.

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Phases of wound healing1. Inflammatory:

•Begins immediately & completed by Day 3-7.

• Initially, haemostasis occurs, •Then the wound is prepared for repair by:» Extra-vasation of tissue fluid, cells &

fibroblasts.» Increasing blood supply to the wound.» Debridement of tissue debris by

proteolytic enzymes.

• No increase in tensile strength of tissue & wound healing is dependent on approximation of edges by closure material.

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Phases of wound healing2.Proliferative:

• Starts from Day 3 onwards.• Fibroblasts form a collagen matrix (granulation

tissue).• This collagen matrix:

Determines the tensile strength & pliability of the healing wound.

Becomes vascular, supplying the nutrients & oxygen necessary for wound healing.

• Tensile strength increases until wound is able to withstand normal stress.

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Phases of wound healing• Wound contraction also occurs:

– Wound edges pull together in order to close the wound,

– If successful, it results in a smaller wound with less need for repair by scar formation.

– Beneficial in areas such as the buttocks or trochanter.

– Harmful in areas such as the hand, neck & face (can cause disfigurement & excessive scarring).

– Skin grafting reduces contraction in undesirable locations.

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Phases of wound healing3. Remodelling:

• May continue for a year or longer

• Following completion of collagen deposition, vascularity decreases & any surface scar becomes paler.

• Resulting scar size is dependent upon the initial volume of granulation tissue. The percentage recovery of the tensile strength of the wound is:– About 20% after 2 weeks– About 50% after 5 weeks– About 80% after 10 weeks

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Time for wound healingThe timetable for wound healing is quite

variable, eg:

Chronic wounds can stall in the inflammatory phase because of poor perfusion, poor nutrition, or a numerous other factors causing excessive build-up of exudates at the wound base. These wounds tend to remain unhealed unless active and aggressive means are undertaken to correct the cause while providing proper wound care.

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Time for wound healing

Healing may become exaggerated in Keloids & hypertrophic scar formation. Excessive type III collagen formation in the proliferative phase causes overgrowth of scar tissue in these wounds. Individuals with darkly pigmented skin are genetically prone to keloid formation. Certain body areas, as the sternum & shoulder, are more prone to hypertrophic scar formation.

Phases can also be blunted as in the foetus, which has a decreased inflammatory phase & heals without scar.

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N.B.: Collagen types & locations are as follows:

Type I Located in all connective tissue except hyaline cartilage & basement membranes

Type II Located in hyaline cartilage

Type III Located in distensible connective tissue (blood vessels)

Type IV Located in basement membranes

Type V Located in all tissues

Type VI Located in all tissues

Type VII Located in the dermal-epidermal junction

Type VIII Located in the Descemet membrane

Type IX Located in hyaline cartilage

Type X Located in hypertrophic cartilage & hyaline cartilage

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Wound Optimization• Creating conditions that allow for proper

wound healing can make all the difference in various wounds (from an unnoticeable wound after plastic surgery to an amputation or even death in a patient with severe vascular disease or burn).

1. Perfusion: Tissues cannot heal without the cells, oxygen, & nutrients. This is particularly important in wound healing of patients with diabetes or paraplegia, patients who smoke, & patients who have been exposed to radiation.

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Wound Optimization2. Infection: Infection is defined as: having

quantitative bacterial counts of 105 colony forming units per gram of tissue. Infected wounds do not heal because of decreased epithelialization and increased collagen breakdown.

3. Nutrition: Albumin is a good marker of overall long-term nutritional status over the last month;, it should be > 3.5 g/dL to optimize wound healing. Pre-albumin offers a more recent nutritional status picture & should be maintained > 17 g/dL. Caloric needs of severely injured patient can exceed 35 kcal/kg/d & 0.8-2 g/kg/d of protein, & should be continually assessed & adjusted.

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Wound Optimization4. Steroids: Corticosteroids can blunt the

response of macrophages, the most essential cell in wound healing. Vit. A, IGF, & oxandrolone (anabolic steroid) can be given to reverse the effects of corticosteroids on wound healing.

5. Dressing: The wound should be kept moist (but not wet). Desiccated (dead) tissue must be sharply debrided. There is no substitute for frequent dressing changes in a grossly contaminated or recently debrided infected wound. With the advent of negative pressure wound dressing, wound healing for even chronic wounds can be greatly increased.

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WOUND CLOSURE

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Wound closure technologiesRecently, many new technologies are available for sealing tissues that supplement or replace traditional methods of wound closure.

Alternative technologies include (for ex.): Taping systems, Synthetic super glues, Energy-based modalities capable of melding tissues together.

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((A)) SUTURES:• Absorbable sutures : wound heals

quickly & needs minimal temporary support. (They alleviate tension on wound edges).

• Non-absorbable sutures: offer longer mechanical support.

• Mono-filaments have less drag through the tissues & less tendency for infection.

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Disadvantages :

Additional injuries to the tissue & the

Introduction of foreign material, (which may interact with tissue & slow down the wound healing process).

Furthermore, sutures are not watertight.

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((B)) ADHESIVES:1. Cyano-acrylate:

• An acrylic resin which rapidly polymerises in the presence of water forming long, strong chains.

• It can induce inflammatory reaction if implanted subcutaneously, thus, placement of SC suture aids in everting skin edges & chances of deposition of cyanoacrylate into the SC tissues.

• 2-octyl cyanoacrylate is the only FDA approved cyano-acrylate. (In addition, in Jan. 2001 FDA granted approval for its use as a barrier against common bacterial microbes including certain staphylococci, pseudomonads, & E. coli.)

• SurgiSeal, Octylseal, FloraSeal, Dermabond, Surgi-Lock & Nexaband, LiquiBand.

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2. Fibrin-based tissue adhesives: • These are biological sealants based on natural adhesion

promoters like pooled blood or autologous sources (as fibrin, platelet gels, modified collagen, and recombinant proteins).

• Used for haemostasis & can seal tissues. • Although they do not have adequate tensile strength to

close skin, they can be used to fixate skin grafts or seal CSF leaks.

• Baxter (Tisseel) & Haemacure (Hemaseel) are FDA-approved fibrin tissue adhesives made from pooled blood sources.

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((C)) STABLES:• Provide a fast method for wound closure.

• Associated with decreased wound infection rates.

• Composed of stainless steel, which are less reactive than traditional suturing material.

• They are more expensive than traditional sutures.

• Require great care in placement, especially in ensuring the eversion of wound edges.

• However, with proper placement, resultant scar formation is cosmetically equivalent to that of other techniques.

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((D)) ADHESIVE TAPES & STRIPS:• These tapes can be used either with sutures or alone. • Some skin adhesives (eg, Mastisol, tincture of Benzoin)

aid in tape adherence.• The porous paper tapes (eg, Steri-Strips) are used to

ensure proper wound apposition & to provide additional suture reinforcement.

• Newer products (such as the ClozeX adhesive strip) allows for rapid & effective wound closure that results in adequate cosmosis.

• Wound closure with adhesive strips can be significantly cheaper than suturing or using a tissue adhesive.

• However, adhesive strips are not appropriate for many types of lacerations.

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((E)) SURGICAL WOUND ZIPPER:♠ Totally non-invasive, atraumatic, & promotes faster &

more natural wound healing. ♠ Painless removal from the skin wound without special

instruments after 7 - 8 days.♠ May be used for surgical incisions & lacerations up to

47 cm.

♠ It combines a zipper & two multilayered adhesive support strips.

♠ After surgery, the strips are adhered to both sides of the surgical incision.

• ♠ As the zipper is closed, it draws the edges of the wound

together, securing atraumatic closure of the wound.

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((E)) SURGICAL WOUND ZIPPER:• The slider of the slide fastener contains a contact

electrode for electro-coagulation fitted with a cutting edge.

• As the slide fastener is opened, the slider simultaneously effects the incision by means of the cutting edge of the electrode, severing both the flexible sheet & the skin beneath.

• For closing the incision, the stringer tapes of the slide fastener interlock by the action of the slider, thereby bringing both the edges of the flexible sheet & the wound beneath into apposition.

• As the slider is drawn forwards closing the stringer tapes, electrical energy is applied by the electrode at the union site of the wound edges, which have previously been brought into apposition by the mechanical action of the slide fastener, thus ensuring that the edges become adhered in full depth as a result of electrical coagulation.

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((F)) Energy-based modalities

• Wound closure techniques based on energy methods such as ultrasound & radio frequency are under research.

• It is established that heating the edges of a cut or wound to a temperature around 60 °C, (using e. g. an appropriate laser beam), leads to a closure of the incision.

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Nanotech Wound Closure: (light activated tissue repair)PTB [Photochemical Tissue Bonding] process is a new technique

used to repair wounded skin.A light-sensitive dye is applied to the tissue surfaces,The surfaces are placed in contactThe dye-stained area is exposed to visible radiation (green light)

that does not cause thermal damage for 2-3 minutes. An immediate, water-tight strong bond is produced without

additional glues or proteins. The bond prevents inflammation or risk of infection, & speeds up

the formation of scar tissueThe process uses a hand-held laser device. Advantages over sutures & staples for tissue repair.

*PTB does not stimulate inflammation or cause additional damage to tissue, thus reducing fibrosis & scarring.* Very small structures that require time-consuming microsurgery can be rapidly joined with less damage using PTB.* Soft, delicate, difficult-to-suture tissues can be joined with PTB* An immediate, water-tight seal is formed.

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Dermaclose RC®The DermaClose™ RC is a device used to facilitate rapid wound closure. This device automatically expands skin adjacent to a full thickness wound facilitating delayed primary closure or significant reduction in wound size.

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Post wound anti-scar preparations

• To reduce risk of hypertrophic scars & Keloid formation.

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