basic knowledge of surgery

1. Dr . Bijay Kumar Sah
Phase A resident, MS, CVTS
Bangabandhu Sheikh Mujib Medical University

2. LEARNING OBJECTIVES
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TO UNDERSTAND:
1) The principles of patient positioning and operating
theatre safety
2) The principles of skin and abdominal incisions.
3) The principles of wound closure.
4) The principles of performing bowel and vascular
anastomoses.
TO BE AWARE OF:
1) The principles of drain usage.
2) The principles of diathermy and advanced energy
devices.

3. CONTENT
 Introduction
 Safety checklist and universal precaution
 patient positioning and saftey on the operation table
 Principles of skin and abdominal incision
 Principles of wound closure
 Suture materials
 Suture technique
 Knotting technique
 Principles of anastomoses
 Drains
 Energy devices

4. INTRODUCTION
Successful outcomes in surgery depend on knowledge,
skills and judgement. While todays discussion
concentrates on technical skill. It is important for the
modern surgeon to remember that non-technical skills,
such as communication, empathy and teamwork. We used
to think of technical skill starting with ‘knife to skin’; but it
is also include with other factors, such as positioning and
equipment, considered first. Teamwork includes
adherence to modern ‘human factors’ principles, such as
team brief and the use of safety checklists.

6. UNIVERSAL PRECAUTION
Universal precautions have been drawn up by the CDC in
the United States and largely adopted by the National
Health Service (NHS) in the UK:
● use of a full face mask ideally, or protective spectacles;
● use of fully waterproof, disposable gowns and drapes,
particularly during seroconversion;
● boots to be worn, not clogs, to avoid injury from dropped
sharps;
● double gloving needed (a larger size on the inside is more
comfortable);
● allow only essential personnel in theatre;
● avoid unnecessary movement in theatre;
● respect is required for sharps, with passage in a kidney dish;
● a slow meticulous operative technique is needed with
minimised bleeding.

7. PATIENT POSITIONING AND SAFETY ON THE
OPERATING TABLE
The safety of the patient in the operating theatre is
paramount at all times, and is a key responsibility of
the surgeon, regardless of grade, experience or
seniority. For all cases it is the surgeon’s
responsibility to make sure the patient is placed on
the table to maximise exposure for the procedure
itself and to ensure risks of injury are avoided.
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8. Transfer to and from the operating table
The transfer of the anaesthetised patient is a
critical moment where there are significant risks
of falls, injuries. Staff should all receive regular
training in manual handling. Patients at
additional risk include the obese, elderly and
emaciated. These groups require additional care
and specialised equipment.

9. Positioning on the table
The surgeon should take personal responsibility to
maintain safety and to make sure exposure is adequate
for the procedure. This includes placement of the
passive diathermy electrode (‘pad’) to minimise the
risk of electrosurgical burns and to account for
metallic prostheses and pacemakers. The surgeon
should also make sure that ancillary equipment, such
as energy generators, suction and diathermy etc. The
operating lights should also be placed in an optimal
starting position. All these actions need to be
undertaken before the surgical team scrubs, including
any final checks before the patient is draped.

10. INCISION
Skin incisions should be made with a scalpel, with the
blade being pressed firmly down at right angles to the skin
and then drawn gently across the skin in the desired
direction to create a clean incision, the site and extent of
which should have been clearly planned by the surgeon.
The incision is facilitated by tension being
applied across the line of the incision by the fingers of the
non-dominant hand, but the surgeon must ensure that at
no time is the scalpel blade directed at their own fingers as
any slip may result in a self-inflicted injury.

12. Blades for skin incisions usually have
a curved cutting margin, while those
used for an arteriotomy or drain-site
insertion have a sharp tip. Scalpels
should at all times be passed in a
kidney dish rather than by a direct
hand-to-hand process because the
latter can lead to injury. Diathermy,
laser, harmonic scalpels and
combination devices can be used
instead of blades when opening
deeper tissues, as they can reduce
blood loss and save operating time,
and may reduce postoperative pain

13. Factors considered when planning a skin incision
1) Skin tension lines (Langer’s lines):-
These lines repersent the orientation of
the dermal collagen fibres and any incision
placed parallel to these lines results in a
better scar.
2) Anatomical structure:-
Incision should be avoid bony
prominences, and crossing skin creases if
possible, and take care of underlying
structures , such as nerves and vessels.

14. 3) Cosmetic factors:-
It should be only the part of operation the patient sees,
especially in exposed parts of the body so incision should
be performed as a single movement.
4) Adequate access for the procedure:-
The incision must be functionally effective for the
procedure in hand because any compromise purely on
cosmetic grounds may render the surgery ineffective or
even dangerous.
5) Should not cross longitudinally across the flexor surface of
a joint.
6) Margin must not be uneven or beveled.
7) Should not be close enough to the previous scar for risk of
ischemia.

15. Abdominal incisions
As for skin incisions, all abdominal incision should be
planned in advance of surgery and taking into consideration
access to the abdominal organs ,surface anatomy, pain
control and cosmetic outcome . E.g. transverse incision tend
to be associated with fewer respiratory complications & a
better cosmetic outcome.
The incision should be carried deeper through the
subcutaneous tissues, the muscle layer should be divided or
split, and the peritoneum displayed which is picked up
between 2 clips and gently incised.
The closure is done either by non-absorbable or slow
absorbable suture which estimated length should be at least
4 times the length of the wound.

16. 1- Midline incision
2- Kocher’s incision
3- Thoraco abdominal incision
4- Rectus split incision
5- Paramedian incision
6- Transverse incision
7- McBurney’s incision
8- Inguinal incision
9- Pfannenstiel incision
10- MvEvedy incision
11- Rutherford Morison

17. WOUND CLOSURE
The suturing of any incision or wound needs to take into
consideration the site and tissue involved, suture material, &
the technique for closure. For examples:-
1) Vascular anastomoses require smooth, non-absorbable and
non-elastic material. Like polypropylene or nylon.
2) Biliary anastomoses require an absorbable material that will
not promote tissue rection or stone formation. Like vicryl.
There is no ideal wound closure technique that would
be appropriate for all situitions, and the ideal suture has yet
to be produced, although many of the desired characteristic
are listed below:-

18. Desired characteristics:-
1) Easy to handle.
2) Predictable behaviour in tissues and tensile strength.
3) Sterile and Inexpensive.
4) Glides through tissues easily & Secure knotting ability.
5) Minimal tissue reaction.
6) Non-capillary, non-allergenic, non-electrolytic and
non-shrinkage.
Therefore, the correct choice of suture technique & suture
material is vital, but will never compensate for inadequate
operative technique, and, for any wound to heal well, there
must be good blood supply and no tension on closure.

19. Types of wound closure:-
A) ON THE BASIS OF HEALING:-
 Healing by primary intention: for clean wound with
good supply , simply requires accurate apposition of edges.
 Healing by secondary intention: wound is left open and
heals by granulation tissue composed of capellaries,
fibroblasts & inflamatory cells. Wound contraction and
epithelialisation assit in ultimate healing but the process
may take several weeks or month.
 Healing by tertiary intention: for infected wound.
Wound is initially left open for 5 to 7 days and after
infection subsides the closure is done to promote healing
by primary intention. It is also called delayed primary
closure.

20. B) ON THE BASIS OF SUTURE TECHNIQUE:-
i) interrupted sutures
ii) continuous sutures
iii) mattress sutures- vertical & horizontal
iv) subcuticular sutures
C) ALTERNATIVES OF SUTURE MATERIAL:-
i) skin adhesive strips
ii) tissue glue: solution of n-butyl-2-cyanoacrylate
monomer.
iii) staples
iv) clips

21. ADHESIVE STRIPS TISSUE GLUE SKIN STAPLE

22. SUTURE MATERIALS:-
History:-
Sutures are best made of soft thread, not too hard twisted that it
may sit easier on the tissue, nor are too few nor too many of
either of them to be put in.
Aurelius Cornelius Celsus
Few example of ancent suture material:
1) East African tribes ligating blood vessels with tendon strips, and
closing wounds with acacia thorns pushed through the wound
with strips of vegetable matter wound round these in a figure of
eight.
2) A South American method of wound closure involved using
large black ants to bite the wound together with their pincers or
jaws acting like skin clips, and then the ant’s body was twisted
off leaving the head in place keeping the wound apposed.

23. 3) By 1000 BC, Indian surgeons were using horsehair, cotton
and leather sutures.
4) Roman times, linen and silk and metal clips, called
fibulae, were commonly used to close gladiatorial wounds.
5) By the end of the nineteenth century, developments in the
textile industry led to major advances, and both silk and
catgut became popular as suture materials.
6) However, catgut is no longer in use in UK as it causes an
inflammatory cellular reaction with release of proteases
and may also carry the risk of prion transmission if of
bovine origin.

24. TYPES OF SUTURE MATERIAL:-
1) According to source:
a) Natural- catgut, silk
b) Synthetic- vicryl, prolin
2) According to absorbability:
a) Absotbable- catgut, vicryl
b) Non-absorbable- prolin, silk
3) According to number of filament:
a) Monofilament- prolin, nylon
b) Polyfilament or braided- catgut, vicryl
4) According to relation with needle:
a) Atraumatic- eyeless needle
b) Traumatic- needle with eye

25. SUTURE CHARACTERISTICS
There are five characteristics:
1. Physical structure : may be mono or multifilament.
2. Strength: depends upon its consituent material, its
thickness and how it handle in the tissue.
3. Tensile strength: may be elastic or plastic.
4. Absorbability: may be absorbable or non absorbable
5. Biological behaviour: The biological behaviour of suture
material within the tissues depends upon the
constituent raw material.

26. SUTURE TYPES RAW MATERIAL TENSILE
STRENGTH
ABSORPTIO
N
SILK Multifilament,
non-absorbable
Natural protein.
Raw silk from silk worm
Loss 20% when
wet; 80-100% lost
by 6 month
Fibrous
encapsulation,
absorbed slowly
over 1-2 yrs.
POLYPROP
-YLENE
Monofilament,
non-absorbable
Polymer of propylene Infinite(>1yr) Non absorbable,
encapsulated
PDS Monofilament,
absorbable
Polyester polymer 50% loss with 4
wks
Hydrolysis
180 days
CATGUT Plain, absorbable Collagen derived from
healthy sheep or cattle
Lost within 7-10
days
Phagocytosis &
enzymatic
degradation
within 7-10 days
CATGUT Chromic,
absorbable
Collagen derived from
healthy sheep or cattle
tanned with chromium
salt.
Lost within 7-10
days
Phagocytosis &
enzymatic
degradation
within 90 days
VICRYL Multifilament,
absorbable
Copolymer of lactide
and glycolide, coated
with polyglactin &
calcium stearate.
70% loss with 3
wks
Hydrolysis
60-90 days

27. Size of suture material
 Size originally scaled from 0-3
 As technology advanced and sutures became smaller, extra
0s were added
 Scale now ranges from 3 (largest) to 12/0 (smallest)
SIZE USES
7/0 and smaller Ophthalmology, microsurgery
6/0 Face, blood vessels
5/0 Face, neck, blood vessels
4/0 Mucosa, neck, hands, limbs, tendons, blood vessels
3/0 Limbs, trunk, gut blood vessels
2/0 Trunk, fascia, viscera, blood vessels
0 and larger
Abdominal wall, fascia, drain sites, arterial lines,
orthopaedics

28. NEEDLE TYPES
The main types of needle includes:-
– Tapered cut or round body
• Gradually taper to the point and cross-section reveals a
round, smooth shaft
• Used for tissue that is easy to penetrate, such as bowel or
blood vessels
– Cutting
• Triangular tip with the apex forming a cutting surface
• Used for tough tissue, such as skin (use of a tapered
needle with skin causes excess trauma because of
difficulty in penetration)
– Reverse cutting needle
• Similar to a conventional cutting needle except the
cutting edge faces down instead of up
• This may decrease the likelihood of sutures pulling
through soft tissue

29.  Most sutures with the suture material swaged onto the base
of the needle
 Shapes vary from a quarter circle to five-eighths of a circle,
depending on how confined the operating field is
 Choice of needle should ‘alter the tissue to be sutured as
little as possible’ and is dependent on:
– The tissue being sutured (when in doubt about selection of a taper
point or cutting needle, choose the taper for everything except skin
sutures)
– Ease of access to the tissue
– Individual preference

30. SUTURE TECHNIQUES
 Interrupted sutures:-
Interrupted sutures require the needle to be inserted at right
angles to the incision and then to pass through both aspects
of the suture line and exit again at right angles. It is important
for the needle to be rotated through the tissues rather than to
be dragged through, to avoid unnecessarily enlarging the
needle hole.

31.  Continuous sutures:-
For a continuous suture, the first suture is inserted in an
identical manner to an interrupted suture, but the rest of
the sutures are inserted in a continuous manner until the
far end of the wound is reached (Figure 7.13). Each throw of
the continuous suture should be inserted at
right angles to the wound, and
this will mean that the externally
observed suture material will
usually lie diagonal to the axis
of the wound.

32.  Mattress sutures:- either vertical or horizontal
Mattress sutures may be either vertical or horizontal and
tend to be used to produce either eversion or inversion of a
wound edge (Figure 7.14). The initial suture is inserted as
for an interrupted suture, but then the needle moves either
horizontally or vertically, and
traverses both edges of the wound
once again. Such sutures are very
useful in producing accurate
approximation of wound edges,
especially when the edges to be
anastomosed are irregular in
depth or disposition.

33.  Subcuticular suture:-
Small bites of the subcuticular tissues are taken on
alternate sites of the wound and then gently pulled
together, thus approximating the wound edges without the
risk of the cross-hatched markings of interrupted sutures.
For non-absorbable sutures, the ends may be secured
by means of a collar and bead, or tied loosely over the
wound. When absorbable sutures are used, the ends
may be secured using a buried knot.
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34. KNOTTING TECHNIQUES
 Knot tying is one of the most fundamental techniques.
 The general principles in knot tying include:-
1) The knot must be tied firmly, but without
strangulating the tissues.
2) The knot must be unable to slip or unravel.
3) The knot must be as small as possible to minimise
the amount of foreign material.
4) The knot must be tightened without exerting any
tension or pressure on the tissues being ligated, i.e.
the knot should be bedded down carefully, only
exerting pressure against counter-pressure from the
index finger or thumb.

35. KNOTTING TECHNIQUES cont:
5) During tying, the suture material must not be ‘sawed’ as
this weakens the thread.
6) The suture material must be laid square during tying,
otherwise tension applied during tightening may cause
breakage or fracture of the thread.
7) When tying an instrument knot, the thread should only
be grasped at the free end, as gripping the thread with
artery forceps or needle holders can damage the material
and again result in breakage or fracture.
8) The standard surgical knot is the reef knot, with a 3rd
throw for security, although with monofilament sutures,
such as used for vascular surgery, 6 to 8 throws are
required for security.

36. KNOTTING TECHNIQUES cont:
9) A granny knot involves two throws of the same type of
throw and is a slip knot. It may be useful in achieving the
right tension in certain circumstances, but must be
followed by a standard reef knot to ensure security.
10) When added security is required, a surgeon’s knot using a
two throw technique is advisable to prevent slippage.
11) When using a continuous suture technique, an Aberdeen
knot may be used for the final knot. The free end of the
suture is partially pulled through the final loop several
times before being pulled through a final time completely
prior to cutting.
12) When the suture is cut after knotting, the ends should be
left about 1–2 mm long to prevent unraveling. This is
particularly important when using monofilament
material.

38. THE PRINCIPLES OF ANASTOMOSIS
The word anastomosis comes from the Greek ‘ana’, without, and
‘stoma’, a mouth, reflecting the join of a tubular viscus (bowel) or
vessel (usually arteries) after a resection or bypass procedure.
Bowel anastomosis
 Ensure good blood supply to both bowel ends before and after
anastomosis.
 Ensure the anastomosis not under tension.
 Avoid risk of mesenteric vessels not involved by suture or clamps.
 Use atraumatic bowel clamps to minimize contamination
 Interrupted or continuous single layer suture technique is adequate
and safe.
 Stapling devices are an alternative when speed is required or access
is a major factor.

40. VASCULAR ANASTOMOSIS
 Need to be extremely accurate closure and
immediately watertight at the end of operation when
vascular clamps removed ,
 Knots security is important.
 Use monofilament and a traumatic needle .

41. DRAINS
 Drains are inserted to allow fluid or air that
might collect at an operation site or in wound
to drain freely to the surface.
 Three basic principles apply in the use of drains;
1. Open drains work in gravity principle.
2. Semi open work in principle of capillary effect.
3. Closed system drains work in principle of siphon
or negative suction .

42. Advantages and Disadvantage of using drains
 To remove any
intraperitoneal or wound
collection
 Act as signal for any
postoperative internal
hemorrhage or
anastomotic leakage
 Provide track for later
diagnostic and therapeutic
options.
 Increase chance of
infection(FB)
 Increase chance of
anastomotic leak
 Increase abdominal pain
 Increase hospital stay.
 Decrease pulmonary
function.
ADVANTAGES DISADVANTAGES

43. Special use of drains
 Chest drains

44.  T-tube drain

45. PRINCIPLES OF REMOVAL OF DRAINS
A drain should be removed as soon as it is no longer
required because, if left in, it can itself predispose to fluid
collection as a result of tissue reaction. Indeed there is
evidence that by 7 days only 20% of drains are still
functioning.
If a drain is used at all, the following principles may apply:-
1) Drains put in to cover perioperative bleeding may usually
be removed after 24 hours, e.g. thyroidectomy.
2) Drains put in to drain serous collections usually can be
removed after 5 days, e.g. mastectomy.
3) Drains put in because of infection should be left until the
infection is subsiding or the drainage is minimal.

46. PRINCIPlES OF REMOVAL OF DRAINS
5) Drains put in to cover colorectal anastomoses should be
removed at about 5–7 days.
6) Common bile duct T-tubes should remain in for 10
days.
7) Any suction drain should have the suction taken off
prior to removal of the drain.
8) During removal of a chest drain, the patient should be
asked to breathe in and hold their breath, Once the
drain is out, a previously inserted purse-string suture
should be tied.

47. The principles of diathermy
 This one of way used in surgery to cut tissue or to
coagulate site of bleeding to do hemostasis in
surgical site.
 The heat produced depend on:
 The intensity of the current
The wave from the current
The electrical property of the tissue through which
the current passes
The size of two electrodes

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49. EFFECTS OF DIATHERMY:-
1) Coagulation : the sealing of blood vessels.
2) Fulguration : the destructive coagulation of
tissue with charring.
3) Cutting : used to divide tissue during
bloodless surgery.

50. Complication of diathermy
 Electrocution
Explosion
Burns
Channelling this can happened when the intensity of
current is great, for examples
 Coagulation of the penis if use diathermy.
 Coagulation of spermatic cord when the electrode applied
to the testis .
pacemakers
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51. PRINCIPLES OF ADVANCED ENERGY DEVICES
 Ligasure; use fusion technology is a vessel sealing
system that is used in open and laparoscopic surgery, it
was a combination of pressure and energy to create
vessel fusion.
 Harmonic scalpel; use ultasound technology to cut
tissue while at same time sealing them
 Thunderbeat (olympus); has a combined modalities
of harmonic and bipolar diathermy and can seal &
devide vessels up 7 mm in diameter.
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52. TAKE HOME MESSAGE
Surgical procedure is a teamwork and skillfull
technique. Proper handling of the instruments
lead to smooth surgery, less time consuming with
less complication.

53. THANKS
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