Basic surgical skills

1. BASIC SURGICAL SKILLS
Dr. Junaid Shakeel
Registrar
ORAL & MAXILLOFACIAL SURGERY
SIR SYED COLLEGE OF MEDICAL SCIENCES

2. OBJECTIVES
 TO LEARN THE BASIC PRINCIPLES OF ;
 GLOVING & GOWNING
 SURGICAL SCRUBBING
 FLAP DESIGN
 INCISIONS & FLAP REFLECTION
 SUTURING TECHNIQUES
 INFECTION CONTROL & WOUND
MANAGEMENT

3. HAND WASHING
 SINGLE MOST IMPORTANT MEASURE FOR
PREVENTION OF INFECTION.
 PLAIN SOAP & WATER IS EFFECTIVE.
 WASH FOR 40 SECONDS VIGOROUSLY.
 NAILS ARE AREAS OF GREATEST
CONTAMINATION.

4. HOW TO HAND WASH

5. HOW TO HAND SCRUB

6. SCRUBBING
 REMOVE JEWELLERY.
 USE SOAP, BRUSH, RUNNING WATER TO
CLEAN.
 SCRUB ARMS UP TO THE ELBOW.
 AFTER SCRUBBING, HOLD UP ARMS TO
ALLOW WATER TO DRIP OFF ELBOWS.
 TURN OFF TAP WITH ELBOW.

7. SCRUBBING
 DRY WITH STERILE TOWEL.
 HOLD HANDS AWAY FROM BODY,
HIGHER THAN ELBOWS AND BELOW
THAN CLAVICLES.
 ONLY STERILE SURFACES CAN TOUCH
STERILE SURFACES.

8. SCRUBBING

9. GOWNING

10. GLOVING

11. INSTRUMENTS
 TISSUE FORCEPS
 NEEDLE HOLDERS
 SCISSORS
 RETERACTORS
 CHOOSE SHORTEST INSTRUMENT.
 FINE SCISSORS ONLY USED FOR
CUTTING THE TISSUES.

12. INSTRUMENT HOLDING
 USE 3 FINGER CONTROL
 EXTEND INDEX FINGER ALONG THE
INSTRUMENT
 PLACE ONLY FINGER TIPS THROUGH
HANDLE LOOPS
 ROTATION COMES FROM WRIST
 GREATER CONTROL
 QUICKER TO PICKUP, PUT DOWN

13. INSTRUMENT HOLDING

14. HOLDING SCALPELS
 USE SMALLER KNIFE.
 HOLD KNIFE LIKE A PEN.
 SIZE OF BLADES :
#10 BLADE – LARGE INCISIONS
#11 BLADE – STAB INCISIONS
#15 BLADE – FOR PRECISION WORK

15. INSTRUMENT HANDLING

16. SUTURING

17.  GOALS OF SUTURING ARE AS FOLLOWS:
 PROVIDES TENSION FOR WOUND CLOSURE.
 PREVENTING POST OPERATIVE
HEMORRHAGE.
 PROTECTING TISSUES FROM UNDERLYING
INFECTIONS.
 REDUCING POST OPERATIVE PAIN.

18. SUTURE MATERIALS
 CAN BE CLASSIFIED AS;
 RESORBABLE : CAT-GUT, VICRYL
NON RESORBABLE : SILK, PROLENE,
NYLON
 NATURAL : SILK, CAT-GUT
SYNTHETIC : PROLENE, VICRYL
 MONO-FILAMENT : PROLENE, CAT-GUT
MULTI-FILAMENT : SILK, VICRYL

20.  ORAL CAVITY :
 SILK 3/0
 VICRYL 3/0
 FACE
 PROLENE 3/0

21. TYPES OF NEEDLE
 CUTTING
 ROUND BODY / NON CUTTING
 REVERSE CUTTING
 ACCORDING TO SIZE
HALF CIRCLE
1/4TH CIRCLE
3 /4TH
3/8 CIRCLE
STRAIGHT

22. TYPES OF NEEDLES

23. CONVENTIONAL CUTTING NEEDLE

24. REVERSE CUTTING NEEDLE

25. TAPER CUT NEEDLE

26. QUALITIES OF A SUTURE MATERIAL
 ADEQUATE TENSILE STRENGTH.
 FUNCTIONAL STRENGTH.
 EASY TO HANDLE.
 FLEXABILITY & ELASTICITY.
 KNOTABLE.
 UNIFORMITY.
 ABSORBABILTY.
 SMOOTH SURFACE.

27. COMPARISION:
 MONOFILAMENT:
 SINGLE STRAND
 MINIMAL TISSUE TRAUMA
 SMOOTH TYING BUT MORE KNOTS
NEEDED
 HARDER TO HANDLE DUE TO MEMORY
 MULTIFILAMENT (BRAIDED)
 MORE TISSUE RESISTANCE
 EASIER TO HANDLE & FEWER KNOTS.

28. SUTURING
TECHNIQUES

29. BASIC SUTURING TECHNIQUES
 NEEDLE SHOULD BE GRASPED WITH
NEEDLE HOLDER APPROX 1/3RD
DISTANCE FROM THE EYE & 2/3RD FROM
THE POINT.
 NEEDLE SHOULD BE PLACED
PERPENDICULAR TO SURFACE BEING
ENTERED & PUSHED THROUGH TISSUES
FOLLOWING CURVATURE OF NEEDLE,
ROTATING WRIST.

31.  SHOULD NOT FORCE THROUGH TISSUE
MAY BEND OR BREAK THE NEEDLE.
 NEVER CLOSED UNDER TENSION.
 KNOT SHOULD NEVER LIE ON INCISION
LINE.
 NEEDLE ENTERS 2-3mm AWAY FROM THE
MARGIN OF THE FLAP (MOBILE TISSUE)
AND EXIST AT THE SAME DISTANCE ON THE
OPPOSITE SIDE.

32.  KNOT TIED 0.8cm ABOVE THE KNOT.
 OVER TIGHTENING OF THE SUTURE
MUST ALSO BE AVOIDED, AS WELL AS
OVERLAPPING OF WOUND EDGES.
 TIGHTLY TIED SUTURES CAN CAUSE
ISCHEMIA & WOUND EDGE NECROSIS.

33. SUTURES KNOTTING TECHNIQUE

34. TYPES OF KNOTS

35. SQUARE KNOT OR REEF KNOT
 FORMED BY WRAPPING THE SUTURE
AROUND THE NEEDLE HOLDER ONCE IN
OPPOSITE DIRECTIONS BETWEEN TIES.
3 TIES ARE RECOMMENDED.

36. GRANNY’S KNOT OR SLIP KNOT
 GRANNYS KNOT INVOLVES A TIE IN ONE
DIRECTION FOLLOWED BY TIE IN SAME
DIRECTION & THIRD TIE IN OPPOSITE
DIRECTION TO SQUARE THE KNOT &
HOLD IT PERMENANTLY.

38. SURGEONS KNOT
 FORMED BY 2 THROWS OF SUTURE
AROUND THE NEEDLE HOLDER ON THE
FIRST TIE & ONE THROW OPPOSITE
DIRECTION IN 2ND TIE.

39. HOW TO TIE A KNOT
 SUTURE IS INNITIALLY WRAPPED TWICE
AROUND THE NEEDLE HOLDER.

40. HOW TO TIE A KNOT
 THE TWO ENDS OF THE SUTURE ARE
TIGHTENED TO CREATE A SURGEON’S
KNOT OVER THE WOUND (DOUBLE
KNOT).

41. HOW TO TIE A KNOT
 SAFETY KNOT, CREATED BY THE SINGLE
WRAP OF THE SUTURE IN THE
COUNTERCLOCKWISE DIRECTION AS
OPPOSED TO THE FIRST ONE.

42. HOW TO TIE A KNOT
 TIGHTENING OF THE SAFETY KNOT
OVER THE INNITIAL SURGEONS KNOT.

44. SUTURING TECHNIQUES
 INTERRUPTED
 CONTINUOUS
 MATRESS SUTURE

45. SIMPLE INTERRUPTED SUTURE

46. SIMPLE INTERRUPTED SUTURE
 SUTURE IS PASSED THROUGH BOTH EDGES AT
AN EQUAL DEPTH & DISTANCE FROM THE
INCISION & KNOT IS TIED.
 COMMON.
 STRONGER.
 USED IN AREAS OF STRESS.
 EACH SUTURE IS INDEPENDENT & LOOSENING
OF ONE SUTURE WILL NOT PRODUCE
LOOSENING OF OTHER.

47. SIMPLE INTERRUPTED SUTURE

48. FIGURE 8 (MODIFICATION OF INTERRUPTED SUTURE)
 NEEDLE IS FIRST INSERTED INTO THE
OUTER SURFACE OF BUCCAL FLAP &
THEN EITHER THROUGH THE OUTER
EPITHELIAZED SURFACE UNDER THE
SURFACE.
 THE NEEDLE IS THEN RETURNED
THROUGH THE EMBRASSURES & TIED
BUCCALLY.

51. SIMPLE CONTINUOUS SUTURE
 INNITIALLY, SIMPLE INTERRUPTED SUTURE
IS PLACED & NEEDLE IS REINSERTED IN A
CONTINUOUS FASHION SUCH THAT
SUTURE PASSES PERPENDICULAR TO
INCISION LINE BELOW & OBLIQUELY
ABOVE.
 SUTURE IS ENDED BY PASSING A KNOT
OVER THE UNTIGHTENED END OF SUTURE.
 DISTRIBUTES TENSION UNIFORMLY.

52. SIMPLE CONTINUOUS SUTURE

53. CONTINUOUS LOCKING(MODIFICATION OF CONTINUOUS SUTURE)
 IT IS INDICATED PRIMARILY FOR LONG
EDENTULOUS AREAS, TUBEROSITIES,
OR RMP AREAS.
 IT HAS THE ADVANTAGE OF AVOIDING
MULTIPLE KNOTS OF INTERRUPTED
SUTURES

54. CONTINUOUS LOCKING
 A SINGLE INTERRUPTED SUTURE IS
USED TO MAKE THE INNITIAL TIE.
 THE NEEDLE IS NEXT INSERTED
THROUGH THE UNDERLYING SURFACE
OF THE LINGUAL FLAP.
 THE NEEDLE IS THEN OFTEN PASSED
THROUGH THE REMAINING LOOP OF
SUTURE, & SUTURE IS PULLED TIGHTLY,
HENCE LOCKED.

55. CONTINUOUS LOCKING

56. MATTRESS SUTURE
 This is a special type of suture & is described
as horizontal & vertical.
 Its indicated in cases where strong & secure
re approximation of wound margins is
required.
 They also allows for good papillary
stabilization & placement.

57. HORIZONTAL INTERRUPTED MATTRESS
 Used for high tension areas with fragile skin.
 Knot is parallel adjacent to the wound edges.

58. HORIZONTAL INTERRUPTED MATTRESS

59. HORIZONTAL CONTINUOUS MATTRESS

60. VERTICAL MATTRESS SUTURE
 Most commonly used in anatomic locations
which tend to evert, such as the posterior
aspect of the neck, deeper wounds.

61. VERTICAL MATTRESS SUTURE
 It has a far-far-near-near order of bites.
 The knot will is perpendicular adjacent to
wound edge.
 Good for deep lacerations.

62. VERTICAL MATTRESS SUTURE

63. SUTURE REMOVAL
 Average time frame is 7 to 10 days.
 Face 3 – 5 days
 Oral mucosa 3 to 5 days
 Neck 5 to 7 days

64.  Use of disinfecting mouth washes.
 Suture knot is elevated off the tissue utilizing
cotton pliers.
 The suture is cut as close to the tissue as
possible in order to avoid dragging bacteria
through the wound.

65. SUTURE REMOVAL

66. WOUND MANAGEMENT

67.  Clean.
 Clean contaminated.
 Contaminated.

68. TYPES OF FLAPS