BASIC SURGICAL TECHNIQUES G. W e ber M.D., Ph.D Professor of Surgery

BASIC SURGICAL TECHNIQUES

G. Weber M.D., Ph.DProfessor of Surgery

Department of Surgical Research and Techniques Medical Faculty, Semmelweis University

BASIC SURGICAL TECHNIQUES

Basic surgical skills are needed throughout the medical profession

Our aim

to teach and practice basic surgical maneuvers

Topics: special behavior in the operating theatre, preparation the surgical team before operation, surgical tools and instruments, wound management.

skills training and assessment

Skills training

Skills training allows

to appreciate your own technical ability,

reveal whether you are interested in participating in technical procedures, and

therefore influence your choice of residency training.

Skills training and assessment

ResearcherSurgeon OR

Key competencies required for a physician

Technical skills & Intellectual skills

Coordinated team work

Intellectual skills (non-technical skills)

manifested in aspects of performance, such as leadership, decision-making, task management, communication and

team working, situational awareness.

Recognize: collapse, Decision: help (in time!)

DEPARTMENT OF SURGICAL RESEARCH AND TECHNIQUES

Dpt. and secretary: NET XI. floor

English course director:

Györgyi Szabó e-mail: [email protected]

feedback: [email protected]

Homepage: http://semmelweis.hu/mutettan

Informations and abstracts of the lectures here following the presentations.

Date Subject Lecturer

February 3 Presentation of Dept and the curriculum. The operating room. Prof. Dr. GyörgyWéber

February 10 Asepsis, antisepsis, and desinfection. The surgeon in the Operating Room and the prevention of Surgical Site Infection.

Prof. Dr. József Sándor

February 17 Basic surgical tools and suture materials Dr. Andrea Ferencz

February 24 Basic and special suturing techniques in surgery Prof. Dr. István Gál

Marc 3 Classification and managements of wounds, principle of wound-healing, haemorrhage and bleeding control

Györgyi Szabó

March 10 Surgical procedures involving:acute, elective, preoperative patient management , and surgical explorations.

Prof. Dr. GyörgyWéber

March 17 Basics of laparoscopic surgery Prof. Dr. GyörgyWéber

Lectures: (Monday 15.00-15.45)

Monday Tuesday Wednesday Thursday Friday

‘A’ week11.20-13.35

gr. 1,28.00-10.15

gr. 4,515.00-15.45

LECTURE12.30-14.45

gr. 9,1713.10-15.25

gr. 11,15

‘B’ week11.20-13.35

gr. 3,69.30-11.45gr. 10,14

8.00-10.15gr. 7,8

15.00-15.45LECTURE

12.30-14.45gr. 12,13

13.10-15.25gr. 16,18

Practical sessions Every group has 7 practicals – week ‘A’ and week ‘B’

Location of practical sessions

The 1st to 4th and the 7th courses will be held in the Surgical Teaching Theatre.

The theatre accessed from the Main Hall of the NET.

Follow the signs down by the stairs.

Location of practical sessions

The 5th and the 6th courses will be held in the laparoscopic training lab, in

1st Seminar room.

Expectations

Students are required to attend the lectures.

Attendance is obligatory on practical sessions.

To participate on the practice is your interest: practical items you can learn only here. Without required skill you will not be able to pass exam.

You are allowed to work only in the group where you have registered on the Neptun portal.

Because of limited capacity of operating theatre, absences can be replaced only after registration by joining another group.

Expectations

Practical sessions begin exactly on time.

Do not be late because you will not be able to accomplish your task.

Please note that during each course proper nail hygiene is necessary (fingertip-high nails). In addition, the use of nail-polish, artificial nails, any jewellery, including watches are prohibited.

Who does not respect our requirements will not take part on the courses and considered absent without credit.

Expectations

Handle the surgical instruments properly.

If an instrument is damaged, cracked or broken during your practice you should sign a statement.

You do not need to pay for any damaged instruments except if your responsibility is clear.

Practical sessions every second week (3x45 perc = 2 h and 15 min.)

1. Getting acquainted with the operating theatre, ethics and behaviour, scrubbing-in, and preparation of the surgical field.

Basic surgical instruments and their proper usage.

2. Knotting and basic suturing techniques on the skill model (simple interrupted suture).

3. Basic suturing techniques on the pig foot(interrupted sutures).

4. Basic suturing techniques on the pig foot (continuous sutures).

5. Presentation of the laparoscopic tower, the associated equipment and laparoscopic instruments.

6. Practicing  hand movements using a  laparoscopic pelvitrainer.

7. Lessons in tissue dissection and suturing using anesthetised rats (removal of a „naevus” from the back and median laparotomy).

1. Practical session: scrubbing-in, gowning and gloving

Goal: To train in the appropriate procedures and methods of gowning and gloving in preparation for participation in the operating room.

Teacher will provide a brief introduction, demonstrate the appropriate technique, and provide feedback on each step.

1. Practical session: surgical instruments

Goal: To introduce to the use and names of various surgical instruments.

2. Practical session Knot tying/Basic Suturing on a skill model

Goal: To introduce to the technique of knot tying and basic suturing.

Task: to learn the appropriate use of suture equipments (needle holder, forceps, scissors), tie a two-handed knot, to perform an instrument tie and the proper technique of simple interrupted suture

3. Practical session Basic suturing techniques on the pig foot

interrupted sutures: Horizontal mattress and vertical mattress (Donati)

simple interrupted suture

4. Practical sessionBasic suturing techniques on the pig foot

Simple continuous suturing

intracutaneous suture

5. Practical session Laparoscopic instrumentation

By the end of the session the students will be able to demonstrate an understanding of laparoscopic instrumentation

6. Practical session laparoscopic basic skills

A series of 6 plastic rings are picked up in turn by a grasping forceps from a pegboard on the surgeon's left, transferred in space to a grasper in the right hand, then placed around a post on the corresponding right-sided pegboard.

After all rings are transferred from the left to right, the process is reversed, requiring transfer from the right to left hand.

Peg transfer This task is designed to

develop depth perception and

visual-spatial perception in a monocular viewing system and

coordinated use of both the dominant and nondominant hands.

7. Practical session Wound management on anaesthetized rats

Tissue preparation and wound closure: removal of a „naevus” from the back and median laparotomy.

The exam

The number of missed practices may not exceed more than 25%. (only one absence!)

Missing two or more practices, the semester will not be credited. (only one replacement is possible!)

Basis: lectures and practices

The textbook and DVD can be downloaded on the Neptun portal {Homepage » Information » Education » Documentations of faculties}

Additional textbook (offered):R.M. Kirk: Basic Surgical Techniques ed. Elsevier

The exam

The exam starts with a test of a minimum requirements.

Knowledge of relevant history of surgeryDetails of asepsis and antisepsis Understand the sterile field of the operating roomTheoretical and practical aspects of wound healing, knot

tying, suturing materials, and suturing Knowledge of general surgical and laparoscopic instruments

You are allowed to continue exam achieving at least 80 %.

The exam

Workstation:1.) scrubing- in – gowning and gloving2.) knowledge of basic surgical instruments3.) manual knots4.) making stitches5.) knowledge of laparoscopic instruments6.) laparoscopic practice in pelvitrainer

Last step is the theoretical part.

Next step is the practical exam:Examinees rotate through six stations, where they perform elements of surgical tasks and are graded by expert examiners using global rating forms such as respect for tissues, economy of motion etc. and task-specific checklists.

Practical exam- workstation I.Scrubbing and gowning – aseptic technique

Task: to demonstrate the ability:

• to perform perfect surgical scrub• assisted-gowning technique• gloving

understand the sterile field of the operating room

There is no part sterility!!

Evaluation: perfect (20 point), any failure: (0 point)

Practical exam- workstation II. surgical instruments

Task: to identify, appropriately handle and know the use of:

• Basic cutting/dissecting instruments• Basic clamping/occluding instruments• Basic grasping/holding instruments• Basic retracting/exposing instruments• Needle holders instruments

You should recognize and use 5 surgical instruments asked randomly: 0-5 point

Practical exam- workstation III. manual knots

Task: to demonstrate the ability to tie a two-handed knot (square and surgeons knot)

You will be asked to tie four times two-handed knots.Based on quality and dinamic performance: 0-10 point

Practical exam- workstation IV.Basic Suturing

Task: demonstrate the appropriate use of suture equipment

(needle holder, forceps, scissors) demonstrate the ability to perform an instrument tie. demonstrate the proper technique for closing a wound

simple interruptedsimple continuoushorizontal and vertical mattressintracutaneous suture

You should demonstrate the proper technique of suturing Based on quality and dinamic performance: 0-10 point

Practical exam- workstation IV.Basic Suturing

You should demonstrate the appropriate use of suture equipment (needle holder, forceps, scissors)

Performance: 0 point !!

Practical exam- workstation V.knowledge of laparoscopic instruments

Task: to identify, appropriately handle and know the use of laparoscopic instrumentation

You should recognize and use 5 laparoscopic instruments asked randomly: 0-5 point

Practical exam- workstation VI.laparoscopic practice in pelvitrainer

Task: Peg transfer with mid air transfer

Time0:00-2:30 min 10 point2:31-2:45 92:46-3:00 83:01-3:15 73:16-3:30 6 3:31-3:45 5 3:46-4:00 4 4:01-4:15 3 4:16-4:30 24:31-4:45 14:46 - 0

Exercise is scored for efficiency (time) and precision (penalty).

Final result

Workstations 60 pointTheoretical part (oral) 40 point

100 point

The final grade is determined by the practical and the theoretical performance

0-59 points: failed (1)60-69 points: passed (2)70-79 points: average (3)

80-89 points: good (4)90-100 points: excellent (5)

DEPARTMENT OF SURGICAL RESEARCH AND TECHNIQUES

After the successful final exam students are allowed to participate in the research program of the department (Students’ Scientific Association (TDK)

and demonstrator students are also welcome!

Please, contact course director or your teacher!

Operating theater

in which students and other spectators could watch surgeons to perform surgery.

Today the term is used as operating room, the room that provides a sterile environment within a hospital where surgical operations are carried out.

Operating theater

Gaetano Petrioli (Róma, 1750)

Würzburg 1804

SRI International, Menlo Park, CA January, 2007

Operating theater - XXI.

SRI International, Menlo Park, CA January, 2007

Operating theater - XXI.

Operating theater - XXI.

SRI International, Menlo Park, CA January, 2007

Patient care – Future

Operating team

consists of the chief surgeon, who directs the surgery; one or more assistant surgeons, who help the chief surgeon; the anesthesiologist, who controls the supply of anesthetic and monitors the person closely; the scrub nurse, who passes instruments to the surgeon; and the circulating nurse, who provides extra equipment to the operating team.

Anesthesia

The monitoring equipment and anesthesia used during surgery are usually kept at the head of the bed.

The anesthesiologist stands here to monitor the patient's condition during surgery.

Depending on the nature of the surgery, various forms of anesthesia or sedation are administered.

Operating roomtypically contains a monitor that displays vital signs, an instrument table, and an operating lamp. Anesthetic gases are piped into the anesthetic machine. A catheter attached to a suction machine removes excess blood and other fluids, which can prevent surgeons from seeing the tissues clearly. Intravenous fluids, started before the person enters the operating room, are continued.

Operating room

All personnel wear protective clothing called scrubs. They also wear shoe covers, masks, caps, eye shields, and other coveringsto prevent the spread of germs.

The surgical site is cleansed and surrounded by a sterile drape.

Location of the Operating Theatre Suites

Separated from the main flow of hospital traffic

Should be easily accessible from surgical wards and emergency rooms.

Floor should be covered with antistatic material,

The walls should be painted with impervious, antistatic paint. (reduces the dust levels and allows frequent cleaning)

The surfaces must withstand frequent cleaning and decontamination with disinfectant.

Layout of the Operating Theatre

clean corridor

scrub-upareaRecovery

areaAnesthetic

room

sterile supplies store

Temperature and Humidity

The temperature and the humidity (not less than 55%) play a important role in maintaining staff and patient comfort.

They must be carefully regulated and monitored.(In low humidity there is a danger of the production of electrostatic sparks.)

Ideally, the operating room should be 1ºC cooler than the outer area. (This aids in the outward movement of air: the warmer air in the outer area rises and the cooler air from within the operating theatre moves to replace it.)

Laminar flow & ultraclean airLaminar airflow is designed to move particle free air over the aseptic operating field in one direction.

It can be designed to flow vertically or horizontally and is usually combined with high efficiency particulate air (HEPA) filters.

HEPA filters remove particles > 0.3 micron in diameter with an efficiency of 99.97%.