Basic Surg Skills

8/3/2019 Basic Surg Skills

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Basic surgical skills

SCRUBS


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Ove r v iew

CDC wound classificationTypes of wound healing

Instruments Suture material Needle

Basic suturing technique Simple interrupted suture Suture removal


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CDC wo und classificati o nClean Uninfected operative wound in which no inflammation is

encountered and no systemic tracts are entered (respiratory,alimentary etc) Closed by primary intention and are usually not drained

Clean, contaminated Operative wound in which systemic tract(s) are entered under

controlled conditions and without contamination

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 so rapidly that a contaminated woundcan become infected within 6 hoursInfected Heavily contaminated/infected wound prior to operation Includes:

Perforated viscera

AbscessesWounds with undetected foreign body/necrotic tissue


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W o und h e aling: Primary int e nti o n (I)Optimum closure method since wound heals inminimum time with no separation of its edges andminimal scar formationTakes place in 3 phases:

1. Inflammat o ryBegins immediately and completed by

Day 3-7Initially, haemostasis occursThen the wound is prepared for repairby:

Extravasation of tissue fluid, cells andfibroblasts

Increasing blood supply to the wound Debridement of tissue debris by

proteolytic enzymesNo increase in tensile strength oftissue and wound healing is dependenton approximation of edges by closurematerial


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W o und h e aling: Primary int e nti o n (II)2 . Pro lif e rati ve

Starts from Day 3 onwardsFibroblasts form a collagen matrix (granulation tissue)This matrix:

Determines the tensile strength and pliability of the healing wound Becomes vascular, supplying the nutrients and oxygen necessary

for wound healing

Tensile strength increases until wound is able to withstandnormal stressWound contraction also occurs:

Wound edges pull together in order toclose the wound

If successful, it results in a smaller woundwith less need for repair by scarformation

Beneficial in areas such as the buttocks ortrochanter

Harmful in areas such as the hand, neckand face (can cause disfigurement andexcessive scarring)

Skin grafting reduces contraction inundesirable locations


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W o und h e aling: Primary int e nti o n (III)

3.

Re

mod

ellingMay continue for a year or longer

Following completion of collagen deposition, vascularitydecreases and any surface scar becomes palerResulting scar size is dependent upon the initial volume ofgranulation tissue

The percentage recovery of the tensilestrength of the wound is: About 20% after 2 weeks

About 50% after 5 weeks About 80% after 10 weeks


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W o und h e aling: S e co ndary int e nti o nOccurs when the wound fails to heal by primaryintention due to: Infection Excessive trauma Tissue loss

More complicated and prolonged than healing byprimary intention

There may be excessive formation of granulationtissue which: Contains myofibroblasts which lead to gradual but

marked wound contraction May protrude above the wound surface, prevent

epithelialisation and thus require treatment

Imprecise approximationof tissue (leaving deadspace)


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W o und h e aling: D e laye d primary cl o sur e

Used in management of contaminated andinfected wounds with extensive tissue lossand a high risk of infection (eg. traumafollowing RTA, penetrating injury)

Steps taken include: Debridement of nonviable tissues, usually undersedation

Leaving wound open with gauze packing inserted

Wound approximation within 3-5 days if noinfection is evident If infection is present, the wound is allowed to

heal by secondary intention


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Instrum e nts: F o rc e ps & n ee dle- ho lde r

Small toothed forceps (Addisonforceps) grasp the skin edgesduring suturingHold in the first three fingers in asimilar way to a pen

Grasp the needle-holder bypartially inserting the thumb andring finger into the loops of thehandleThe free index finger providesadditional control and stability


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Instrum e nts: N ee dle (I)The main types of needle include:

TaperedGradually taper to the point and cross-sectionreveals a round, smooth shaftUsed for tissue that is easy to penetrate, suchas bowel or blood vessels

CuttingTriangular tip with the apex forming a cuttingsurfaceUsed for tough tissue, such as skin (use of atapered needle with skin causes excess traumabecause of difficulty in penetration)

Reverse cutting needleSimilar to a conventional cutting needle exceptthe cutting edge faces down instead of upThis may decrease the likelihood of sutures

pulling through soft tissue


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Instrum e nts: N ee dle (II)Most sutures with the suture material swagedonto the base of the needleShapes vary from a quarter circle to five-eighthsof a circle, depending on how confined theoperating field is

Choice of needle should alter the tissue to besutured as little as possible and is dependent on: The tissue being sutured

(when in doubt aboutselection of a taperpoint or cutting needle,choose the taper foreverything except skinsutures)

Ease of access to thetissue

Individual preference


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Instrum e nts: Pr o pe rti e s o f sutur e mat e rialHandling of a suture Memory

Tendency to stay in one positionLeads to difficulty in tying sutures and knot unravelling

ElasticityAbility to return to its original length after stretchingHigh elasticity sutures should be used in oedematous tissue

Knot strengthForce required for a knot to slipImportant to consider when ligating arteries

Tensile strength Force necessary to break a suture

Important to consider in areas of tension (linea alba)Tissue reaction Undesirable since inflammation worsens the scar Maximal between Day 3&7

Non-absorbable or absorbableMonofilament or multifilament


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Instrum e nts: M o no filam e nt o r multifilam e nt

Monofilament (Ethilon or Prolene) Consists of a single smooth strand Less traumatic since they glide through tissues with less

friction May be associated with lower rates of infection More likely to slip and 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 resultMultifilament (Mersilk or Mersilene) Consists of multiple fibres

woven together Easier to handle and tie and

knots are less likely to slip


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Instrum e nts: N o n- abs o rbabl e sutur e mat e rial

Composed of materials which can be: Naturally occurring (Mersilk, cotton and steel) Synthetic (Prolene, Ethilon, Nurolon, etc)

Sutures may be: Left in placeindefinitely (duringclosure of abdominalfascia)

Removed followingadequate healing(closure of superficiallaceration)


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Instrum e nts: Abs o rbabl e sutur e mat e rial

Composed of biodegradable materials which canbe: Naturally occurring (degraded enzymatically)

Catgut Consists of processed collagen from animal intestines Broken down after 7 days

Chromic catgut Consists of intestinal collagen treated with chromium Loses tensile strength after 2-3 weeks and is broken down

after 3 months Synthetic

Degraded non-enzymatically by hydrolysis when waterpenetrates the suture filaments and attacks the polymerchainTend to evoke less tissue reaction than those occurringnaturally

Subclassified according to degradation time


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Instrum e nts: Siz e o f sutur e mat e rialSize originally scaled from 0-3As technology advanced and sutures becamesmaller, extra 0s were addedScale now ranges from 3 (largest) to 12/0(smallest)

Siz e U se s7/0 and smaller Ophthalmology, microsurgery

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

4/0 Mucosa, neck, hands, limbs, tendons,blood vessels3/0 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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Instrum e nts: Sutur e mat e rial summary

Me rsilk

Natural

Nur o lonEthib o nd

Braid e d

Ethil onPro le ne

Mo no filam e nt

Synth e tic

No n- abs orbabl e

Catgut

Natural

Vicryl rapid e

Synth e tic

Sho

rt te

rm

Braid e d v icryl

Braide d

Mono cryl

Mo no filam e nt

Me

dium te

rm

Panacryl

Braid e d

PD S II

Mo no filam e nt

Lo

ng te

rm

Abso rbabl e


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Arming th e nee dle- ho lde r

Grasp the needle two-thirdsthe distance from its pointed

endAvoid grasping the needle atits proximal or distalextremities since this willprevent damage to the suture

Open the suture packet withone tear to reveal the needle


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Simple int e rrupt e d stitch: St e ps 1 &2Grasp the skin edge with theforceps and slightly evert theskin edgeThen pronate the needle-holder so that the needle willpierce the skin at 90 oEnsure the trailing suture

material is out of the way toavoid tangling

Drive the needle through thefull thickness of the skin bysupinating the needle-holder

Keeping the shaft of theneedle perpendicular to theskin allows the curvature ofthe needle to traverse theskin as atraumatically aspossible

Images courtesy of BUMC


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Simple int e rrupt e d stitch: St e ps 3&4

Release the needle andpronate the needle-holderRegrasp the needleproximal to its pointed endMaintain tension with theforceps to prevent theneedle from retracting

Again, supinate the needle-holder to rotate theneedle upwards andthrough the tissue


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Regrasp the needle in orderto rearm the needle-holder(due to HIV risks it is betterto use the forceps to do this)

Grasp and slightly evert theopposing skin edge with theforcepsPronate the needle-holder


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Again, supinate the needle-holder to rotate the needlethrough the skin, keepingthe shaft 90 to the skinsurface

After releasing the needle,pronate the needle-holderbefore regrasping theneedle


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Simple int e rrupt e d stitch: St e ps 9& 10

and again supinate the needle-holder to rotate the needlethrough the skin

Pull the suture material throughthe skin until 2-3 cm is leftprotruding

Discard the forceps and use yourfree hand to grasp the long endin preparation for an instrumenttiePlace the needle-holder betweenthe strands


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Simple int e rrupt e d stitch: St e ps 11 &1 2

Wrap the long strand around theneedle-holder to form the loop forthe first throw of a square knot

Rotate the needle-holder away yourself and grasp the short endof the suture


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Simple int e rrupt e d stitch: St e ps 1 3&1 4

Now draw the short end backthrough the loop towards

yourself

Now tighten the first throw


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The throw should be tightened just enough to approximate theskin edges but not enough tostrangulate the tissue

To begin the second throw of the

square knot, wrap the long strandaround the needle-holder bybringing the long strand towards

yourself


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Rotate the needle-holdertowards yourself to retrieve theshort end

Grasp the short end and draw itthrough the loop by pulling itaway from yourself


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Simple int e rrupt e d stitch: St e p 1 9&20

Finally, tighten the second throwsecurely against the firstEnsure the knot is to one side ofthe wound to avoid involvement inthe clot

In one hand hold the scissors asshownWith the other hand maintaintension on the suture materialSlide the tips of the scissorsdown the strands to the pointwhere they will be cutCut the suture material leaving 4-5mm tails (important for removalof external non-absorbable

sutures)


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Sutur e r e mov alSutures should be removed: Face: 3-4 days Scalp: 5 days Trunk: 7 days Limb: 7-10 days

Foot: 10-14 daysSteps involved in removal: Reassure patient that the procedure is not painful Cleanse the skin with hydrogen peroxide Grasp one of the suture tails with forceps and elevate Slip the tip of the scissors under the suture and cut

close to the skin edge (to minimise the length ofcontaminated suture that will be pulled through thewound)

Gently pull the knot with the forceps and reinforce thewound Proxi-Strips if required


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SummaryWound classification Clean Clean, contaminated Contaminated Infected

Types of wound healing Primary intention Secondary intention Delayed primary closure

Suture material

PropertiesNatural or syntheticNon-absorbable or absorbableMonofilament or multifilament

SizeRanges from 3 12/0


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Re f e r e nce s

Ethicon Kno t Manualhttp://www.jnjgateway.com/public/useng/5256ethicon_encyclopedia_of_knots.pdf

W o und Clo sur e Manualhttp://www.jnjgateway.com/public/useng/ethicon_wcm_feb2004.pdf

Student BMJ Taylor B and Bayat A, (May 2003, June 2003 &

July 2003), Basic plastic surgery techniquesand principles.

Boston University School of Medicine http://www.bumc.bu.edu/departments/pagemai

n.asp?page=5734&departmentid=69

Documents

Basic Surg Skills