Made with efforts,

1. BASIC SURGICAL SKILLS
BY
DR MEHRAJ UD DEEN KULOO

2. OBJECTIVES :-
1. To understand the principles of :-
- Asepsis :
.Hand washing /scrubbing.
.Gowning.
.Gloving.
-Skin preparation.
.Prepping.
.Draping.

3. -The principles of skin and abdominal
, incision .
-Principles of wound closure.
2.To be aware of :
-The principles of drain usage.

4. HAND WASHING/SCRUBBING
 Definition :
‘Scrubbing up’ is the process of
washing hands and arms prior to donning
a gown and gloves , to minimise the
microbial load on the parts of the surgical
staff that might come into the contact with
the patient.

5.  Hand washing is the single most important
measure for prevention of infection.
 Plain soap and water is effective for removal
of visible contamination.
 Person with open wound or an infection
should not scrub.
 All jewellery should be removed .
 A theatre dress , hat ,mask and eye protection
should be fitted so that no hair is exposed and
you are protected from splashback.

6.  A sterile scrubbing brush is used for 1-2
minutes to remove the dirt from under the
nails and deep creases in the skin .
 Hands are then washed systematically
,extending up the forearms to just below the
elbow( paying special attention to the clefts
between the fingers.).
 After applying disinfectant (soap/dettol) arms
are washed distal to proximal ,with hands up
and elbow flexed to avoid /minimise any
contamination from the more proximal
‘unclean’ areas .

7. HOW TO WASH HANDS
FIG.1 :HANDWASH

9.  Following final rinse the hand and arm should be
raised to the face level , away from the body.
This allows water to drop from the elbows .
 The hands and arms should be dried using sterile
towel for each side . Drying should start with the
fingers and work across the hand and up to the
arm .

12. Type of scrub disinfectant
solutions
 Chlorhexidine gluconate 0.5% : it has residual
effect and is effective for more than 4 hours. It
has potent antiseptic activity against G-ve and
G+ve organisms and some viruses but only
moderate activity againstTubercle Bacillus.
 Iodine : iodine has some residual effect but
these are not sustained for more than 4 hours .
It is highly bactericidal ,fungicidal and viricidal.
Good activity againstTubercle bacillus and
some activity against bacterial spores .

13.  Alcohols (isopropyl alcohol): the alcohols are
highly effective , rapidly acting anti-microbial
agents with broad spectrum activity .These
are not active against spores . Alcohol is an
inexpensive anti-microbial agent and one of
the most widely used skin antiseptics.

14. Gowning

16.  Gowns are folded with inside out .
 The folded gown is lifted away from the
surrounding wrapping and kept away from the
trolley.
 The gown is held firmly at the neck level and
allowed to unfold completely ,wit the inside
facing the wearer .
 Place/insert the arms through the
sleeves/armholes simultaneously (front of the
gown is not to be touched with ungloved
hands ).

17.  The hands should stay inside the cuffs while
glowing .
 The circulating theatre nurse/non- scrubbed
assistant should secure the gown at the neck
and waist . If a wrap-around type gown is worn
, these ties are secured with the help of
circulating staff once gloves are on

18. GLOVING

19. 1 : Open method.
Without using gown cuff
2 : Closed method .
with using gown cuff

22.  Double gloving technique ;
Reduces the chance of
breach, transmission of HIV and
HBV.

23. Gloving technique
without assistance :
 Open sealed package of
sterile gloves before
scrubbing and gowning ,
place inner package on
sterile surface .

24. Once gowned :
pick up the left
hand glove with
right hand using
thumb and
forefinger.
 .

25.  Only touch inside of glove cuff with bare
hands
 Slide the glove onto the left hand, Wriggle
the fingers slightly to help .

26.  Slide the index and middle finger of the
partially gloved left hand under the
folded cuff of right hand glove .

27.  Pull glove onto the
right hand in
similar fashion .

28.  Ensure that cuffs cover ends of both
gown sleeves .

29. Precautions while gowning and
gloving :
 once gowned and gloved ,the hands must
remain above the waist level all the times.
 When not involved in sterile procedure ,the
hands should be held together at chest level.
 If gloves are perforated during surgical
procedures ,they should be changed .

30.  Position of hands after gowning and gloving

31. SKIN PREPRATION
‘PRE-PREP’ :
The skin of the patient must be
prepared before formal surgical skin
preparation to remove soil and
debris .
Hair if removed, using hair clippers
is wise other than shaving.
For the patients undergoing
elective surgery ,a shower on the
day of surgery with a soapy
disinfectant should suffice.

32. ‘Prep/paint’
 Paint surgical skin preparation with antiseptic
solution.
 Performed by staff who are scrubbed up.
 Skin intact :- use alcohol or sprit based
solution.
 Open wound :- use aqueous/iodine solutions.
 The prep should include incision area and a
substantial area around it .

33.  Start prepping making incision site as centre
,working outwards in continually expanding
circles away from the surgical site towards
periphery (from clean to dirty area ).prep
contaminated area last and discard the prep
sponge .
 Two separate coats of preps are generally
Applied.
 Do not blow or wipe off prepping the solution .
 Care must be taken that solution does not pool
under the patient , as the pooling can cause
chemical burn.

34.  fig

35.  fig

36. Draping of operative area
 Surgical draping involves covering with
sterile barrier material, ‘drapes’ ,the area
immediately surrounding the operative
site .
 Purpose: The purpose of surgical draping is
to create and maintain a protective zone of
‘asepsis’ , called a ‘sterile field’.
 Prevents migration of organisms between
non-sterile and sterile area.

37. Do not place drapes on patient until scrubbed
,gowned and gloved .
Only operative area is left uncovered .
Secure drapes with towel clips .

38.  fig

39. Instrument handling
 Principles :
1. Safety .
2. Freedom of movement.
3. Relaxed handling.

40.  Four basic categories of surgical
instruments.
1.Cutting and dissecting instruments .
2.Retracting and exposing instruments .
3.Clamping and occluding instruments .
4.Grasping and holding instruments .

41. Cutting and dissecting
instruments
 Scalpel:
 Scalpels of different size :
 fig

42. Common uses
 11-blade : commonly used
for stab incision and
arteriotomy (tip is used ).
 22-blade : abdominal
incision(here belly is
used).

43.  15-blade : for minor surgical procedures with
fine precision work.

44. How to hold scalpel
 Pencil grip  Power grip

45. Attaching a surgical blade
 fig

46. Removing a surgical blade
 fig

47. scissors
They may be ;-
.Straight.
FIG
.Curved

48. Sharp/sharp Sharp/blunt
 Both tips are pointed.  One tip blunt one tip sharp.
 To cut and dissect fascia
and muscles.

49. Blunt/blunt
 Both tips blunt .
 E.g. Suture cutting scissor.

50. Mayo dissecting scissor Metzenbaum scissor

51. Lister bandage scissor

52. How to hold a scissor
 foigf

53. Retractors
 Self –retaining or manual .
 To identify a retractor, look at the blade not
the handle.
 Use : to hold back or retract organs or tissues
to gain exposure to the operative site .


54. Examples
Deaver’s retractor Volkmann’s rectractor
 fig  f

55. Morris retractor Langenbeck’s retractor

56. Clamping and occluding
instruments
 Used to compress the blood vessel or hollow
organ for haemostasis or to prevent slippage
of contents.
 fiihigg

57. Artery forceps
 Large ,medium or
mosquito’
 Straight or curved.
 fig
 fig

58. Kelly forceps Right angle forcep
 fig
 To clamp hard to reach
vessels.

59. Grasping and holding
instruments
 Used to hold tissues ,drapes or sponges .

60. Alli’s tissue forcep Babcock forcep

61. Sinus forceps Towel clip forceps

62. Plain dissecting forceps Toothed dissecting forceps

63. Needle holder

64. Principles of skin incision
 surgical incisions is a cut made through the
skin to facilitate an operation or procedure .
 All the incisions should be planned in advance
of surgery and take into consideration access
to the relevant organs ,surface land marks
,pain control and cosmetic outcome .
 Incision should be long enough for good
procedure .

65.  Splitting is better than cutting.
 Avoid cutting of nerves and vessels .
 Transverse incision is better than vertical
incision.
 Close the wound layer by layer .
 Insert DT through a separate incision.

67.  Aim :-
 Well planed incision has four essential
elements/aims :-
1. Accessibility.
2. Extensibility.
3. Preservation of function.
4. Security.

68.  Incision technique:-
 Should be made with scalpel with the blade of
appropriate size .
 Blade being pressed firmly down at right
angels to the skin and then drawn across the
skin in desired direction.
 The incision is facilitated by tension being
applied across the line of incision by the
fingers of non- dominant hand.

70.  Blades for kin incision usually have curved
cutting margins .
 Those used for arteriotmoy/stab
incision/drain insertion have sharp tip.
 fig

71.  AlternativesTo blades :-
 Diathermy ,laser and harmonic scalpel can be
used instead of blades when opening deeper
tissues .
 Advantage :-
 Reduce blood loss.
 Save operating time .
 Reduce post operative pain.

72. Four factors should be consider when planning
an incision :-
1.Skin tension lines(Langer’s lines):-
 .Represent the orientation of dermal collagen
fibrils.
Any incision made parallel to these lines result in
better scar.
.

73.  ffffffffffffffffffffffffffffjig
Langer’s lines

74. 2. Anatomical structure :-
Should avoid bony prominences , skin creases
and vessels and nerves .
3.Cosmetic factors:- especially in exposed
areas as incision is the part of the operation
that patient sees ,
4.Adequate access for the procedure.

75. Abdominal incisions
Vertical Transverse and oblique
 Median .
 Para median .
 Kocher’s .
 Mac Burney’s .
 Transverse.
 Pfannential.
 Rutherford Morison.
 Thoracoabdominal.

76. Abdominal incision
VERTICAL
median
Para-median
Transverse/oblique
Kocher’s .
Mac Burney’s .
Transverse.
Pfannential.
Rutherford
Morison.
Thoracoabdominal.

77. Abdominal incisions
 Fifhiuiwf. Transverse/oblique
 Incisions

78. Vertical
incisions
 kiuiufu

79. Principles of wound closure
Goal :- “approximate, not strangulate”.
Principles :-
 Depends upon the site and type of tissue
involved .
 Wound should be closed with minimum
tension.
 Correct choice of suture technique and
suture material.

80.  Wound edges should be left slightly gaping to
allow swelling(to avoid edge necrosis and
exogenous infection).
 Insert the needle at right angels to the skin.
 Edges should everted(best condition for
primary healing/).
 For abdominal wall closure ,the length of suture
material should be four time the length of
wound to be closed to minimise the risk of
abdominal dehiscence or herniation .

81.  Knot should be place on one side of wound .
 Knot must be secured ,with the ends long
enough to grasp when removing the suture

82.  Note : “Dog ear”:-
 often a skin lesion is excised with a circular
incision with is further converted into an
elliptical incision .
 As a rule(rule of thumb) ,this elliptical incision
must be at least 3 times as long as it is wide .
 Wile suturing an elliptical incision ,one-sided
redundant tissue remains(puckering of skin)
,called “dog ear”.

83. Elimination of “dog ear”:-pick up the dog ear with
skin hook and excise it.
fihjh

84. Avoidance of dog-ear

85. Types of skin closure
 Primary suturing :-
 with in 6 hours.
 Done in clean incised wounds.

86.  Delayed primary suturing:-
 Within 48 hrs to 10 days .
 Done in lacerated wounds time is allowed for
oedema to subside .

87. Secondary suturing :-
 Within 10 -14 days or later .
 Done in infected wounds .
 Once healthy granulations tissues appears ,sec
suturing is done.

88. Suturing technique
. Simple sutures :- may be Interrupted sutures

89. Continuous sutures Mattress sutures

91. Subcuticular sutures

93. Knotting technique
Principles of knot tying :-
 The knot must be tied firmly ,but without
strangulating the tissue.
 The knot must be unable to slip.
 The knot must be tightened without exerting
any tension or pressure on the tissue being
ligated , i.e.The knot should be bedded down
carefully ,only exerting pressure against
counter-pressure from index or thumb .

94.  During tying ,the suture material must not be
‘sawed’ as this weakens the thread.
 When tying an instrument knot ,the thread
should only be grasped at free end ,as gripping
with forceps may damage the material .

95.  The standard surgical knot is ‘‘reef knot or
square knot’’, with third throw for security .For
vascular surgery , 6 -8 throws are required.



97.  Granny knots is a two-throw knot of same
type of throw and is a slip knot ,which helps in
achieving a right tension ,but must be
secured by a standard reef knot to ensure
security.

98.  When added security is required ,a “surgeon’s
knot” using two-throw technique ,and it
doesn’t slip .

 fig

99.  When suture is cut after knotting, the ends
should be cut about 1-2 mm long , especially
when non-absorbable monofilament material
is used .
 If end are left long , may cause wound
irritation, wound pain or sinus formation.

100. Alternatives to sutures
 Skin adhesive strips (self-adhesive tapes or
steristrips , polyurethane films).
 Tissue glue :- cyanoacrylates or fibrin tissue
glues.
 Staples ;- three basic types :
1. linear stapler.
2.side-to-side stapler .
3.end-to-end stapler.

101. Surgical needles
 The choice of surgical needle(size ,shape or
body) is as important as choice of suture.
 The passage of the needle through the tissue
should follow its curvature, this minimises
tissue damage.

102. Anatomy of s.needle

103. Classification of surgical
needles
 On the basis of curvature:-
 Straight .
 Half curved(1/2 circle ).
 ¼ circle.
 3/8 circle .
 5/8 circle
 J shaped.

105. On the basis of trauma/ eye:-
 Traumatic /eyed.
 Atraumatic /swaged or eyeless.
 French eye.

106. On the basis of point:-
On the basis cutting edge

107. Use according to type :-
TYPE TYPE USE
Taper-point Separates tissue fibre
Rather than cut through
Cvs and intestinal .
Blunt-taper point Reduce needle-stick injury.
Closure of abdominal wall.
Suturing of friable tissue.
Conventional cutting
edge
Cutting edge on inside.
Skin ,tendon.
Reverse cutting edge Cutting edges on outside .
Tough structures.
Micro-point
Stapulated
Ophthalmic procedures.

108. Note:-
 Needle should be grasped by needle holder
approx. ¼ the rare end.
 More confined the operative space , the
more curve the needle .
 E.g. Half circle commonly used in GIT.
 ¼ circle ,compound curve or J shaped
needles are commonly used in oral ,eye and
vaginal procedures.

109. 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 .

110. Use :-
 Remove any intra-peritoneal or wound
collection of ,pus ,serous exudates, bile ,urine
, lymph, pancreatic or intestinal secretion.
 Act as signal for any post-operative
haemorrhage or anastomotic leakage
 Help to eliminate dead space.
 Provide track for later drainage.

111. Disadvantages/complications:-
 Trauma during insertion.
 Failure to drain because of incorrect
placement or blockage.
 Increase intra-abdominal or wound infection
.
 Precipitate to the patient discomfort .
 Drain site metastases.
 Increase hospital stay.

112. Advantages
 The quantity and character of drain fluid can
be used to identify any abdominal
complication resulting in fluid leakage e.g.
Bile.
 In clean surgery ,such as joint replacement
,blood collected in drains can be transfused
back into the patent , provided that an
adequate volume(>150ml) is collected rapidly
(<12 hrs)

114. Types of drain systems
 Open drain:- works on the principle of
gravity. E.g. Corrugated drain.
 Semi-open drains :- works on the principle of
capillary effect.
 Closed drain :- utilizes suction vacuum .
 Under water seal drain;- to drain pleural
space .
 T- tube drains:-after exploration of CBD.

115. Removal of drains
 Drain should be removed once the drainage
has stopped or become less than 25 ml/day,
as they are a potential tract contamination an
infection into the wound.
 For removal following principles may
apply:-
 Drains put in to cover perioperative bleeding
usually removed after 24 hours e.g.
thyroidectomy .

116.  Those used to drain serous collection ,usually
removed after 5 days, e.g. Mastectomy.
 Drains put in to cover colorectal anastomosis
should be removed at about 5-7 days .
 Drains put in because of infection should be
left until infection subsides.
 T-tube drain should remain in for 10 days.

117.  During the removal of chest drain ,patient
should be asked to breath in and hold his
breath .Once the drain is out previously
inserted purse-string suture should be tied .

118. 
Thank you all