Basic Surgical SkillBasic Surgical Skill

General Surgery Department of Hasan General Surgery Department of Hasan Sadikin Hospital/Medicine Faculty of Sadikin Hospital/Medicine Faculty of

Padjadjaran University BandungPadjadjaran University Bandung

The Basic Principles of Wound ClassificationThe Basic Principles of Wound Classification

1. Clean1. Clean elective surgical wound e.g.hernia elective surgical wound e.g.hernia

surgery or breast biopsysurgery or breast biopsy

Low wound infection rate Low wound infection rate approximately < 2%approximately < 2%

Routine primary closureRoutine primary closure

2. Contaminated-tidy2. Contaminated-tidy low-velocity traumatic incisionslow-velocity traumatic incisions Clean and sharp with local damageClean and sharp with local damage Contamination minor and briefContamination minor and brief Minor intraoperative contaminationMinor intraoperative contamination

e.g. - kitchen knife/clean glass cute.g. - kitchen knife/clean glass cut

- Small bowel or bronchial tree - Small bowel or bronchial tree

opened intraoperativelyopened intraoperatively

Wound infection rate 1-5%Wound infection rate 1-5%

Routine primary closureRoutine primary closure

some debridement and irrigationsome debridement and irrigation

3. Contaminated-untidy3. Contaminated-untidy Low velocity lacerating, tearing or Low velocity lacerating, tearing or

bursting woundbursting wound ragged and contused with gross ragged and contused with gross

local damagelocal damage contamination apparent and contamination apparent and

prolongedprolonged major intraoperative contaminationmajor intraoperative contamination all high-velocity injuriesall high-velocity injuries

e.g. – crush injurye.g. – crush injury

- garden tool injuries- garden tool injuries

- large bowel,infected bronchial - large bowel,infected bronchial

tree or infected urinary tract tree or infected urinary tract

opened intraoperativelyopened intraoperatively

Wound infection rate 5-25%Wound infection rate 5-25%

May be closed after wide May be closed after wide debridement and copiousdebridement and copious

Irrigation or may require delayed Irrigation or may require delayed primary closureprimary closure

ClassificationClassification CauseCause CommentsComments

The Basic Principles of Wound ClassificationThe Basic Principles of Wound Classification

4. Dirty/Infected4. Dirty/Infected wound with signs of infection wound with signs of infection such such

as erythema,cellulitis or pusas erythema,cellulitis or pus grossly contaminated woundgrossly contaminated wound more than 12 hours after more than 12 hours after injuryinjury severe tissue damage and severe tissue damage and

excessive ischaemic tissueexcessive ischaemic tissue

e.g. – severe crush injurye.g. – severe crush injury

- penetrating abdominal - penetrating abdominal

trauma with hollow trauma with hollow

visceral perforationvisceral perforation

- ‘war wound’- ‘war wound’

- cloth,shrapnel,faeces - cloth,shrapnel,faeces

etc. in woundetc. in wound

Wound infection rate near to Wound infection rate near to 50% if the wound is closed50% if the wound is closed

May be closeable after total May be closeable after total excision or wide debridement excision or wide debridement and copious irrigation but often and copious irrigation but often requires healing by delayed requires healing by delayed primary closure or secondary primary closure or secondary intentionintention

Mechanism of Wound causationMechanism of Wound causation

Kinetic energy-closedKinetic energy-closed direct crush or compressiondirect crush or compression shearing forceshearing force blast injuryblast injury

internal disruption of tissuesinternal disruption of tissues haemorrhagehaemorrhage visceral rupturevisceral rupture bony fracturesbony fractures occult injuries deep or occult injuries deep or

elsewhereelsewhere

1. A direct steering wheel 1. A direct steering wheel

injury to the epigastrium injury to the epigastrium

result in duodenal, gastric, result in duodenal, gastric,

splenic or hepatic disruptionsplenic or hepatic disruption

2. A limb caught under a 2. A limb caught under a

vehicle wheel may have vehicle wheel may have

skin sheared away from skin sheared away from

deeper tissues by deeper tissues by

rotational forcesrotational forces

3. A cricket ball hit into the 3. A cricket ball hit into the

close fielder’s forehead ay close fielder’s forehead ay

lacerate skin,fracture skull lacerate skin,fracture skull

and cause contre-coup and cause contre-coup

brain injurybrain injury

Kinetic energy-openKinetic energy-open direct penetration of tissue by direct penetration of tissue by incision,tear or burstincision,tear or burst low versus high velocitylow versus high velocity

Low velocity penetration Low velocity penetration

causes disruption of all tissues causes disruption of all tissues

in the line of the woundin the line of the wound high velocity penetration high velocity penetration

causes wide internal cavitation causes wide internal cavitation

with little skin damage. This with little skin damage. This

may lead to major tissue may lead to major tissue

disruption, bleeding, visceral disruption, bleeding, visceral

rupture and even fractures at rupture and even fractures at

some distance from the point some distance from the point

of entryof entry

1. Broken beer glass to the 1. Broken beer glass to the

hand may damage digital hand may damage digital

nerves,vessels and nerves,vessels and

tendons deep to the sitetendons deep to the site

2. Stab wound to right-hand 2. Stab wound to right-hand

side of chest may side of chest may

penetrate lung,diaphragm penetrate lung,diaphragm

and liverand liver

3. High-velocity bullet wound 3. High-velocity bullet wound

to the thigh will disrupt to the thigh will disrupt

muscle widely,fracture the muscle widely,fracture the

femur and may disrupt femur and may disrupt

nerves and vessels nerves and vessels

causing distal ischaemia to causing distal ischaemia to

the limbthe limb

Causative factorCausative factor MechanismMechanism RamificationRamification ExamplesExamples

The Pathology of Wound HealingThe Pathology of Wound Healing

The repair of any soft tissue relies on:The repair of any soft tissue relies on: The body generating capillaries and collagen on The body generating capillaries and collagen on

both sides of the woundboth sides of the wound This collagen cross-linking with wound-edge This collagen cross-linking with wound-edge

collagen and new collagencollagen and new collagen The wound contracting in sizeThe wound contracting in size The unaligned,cross-linked collagen maturing The unaligned,cross-linked collagen maturing

into regularly arranged bundles (a scar) to into regularly arranged bundles (a scar) to provide the healed wound with strengthprovide the healed wound with strength

Epithelial regrowth across the defectEpithelial regrowth across the defect

Factors Affecting Wound HealingFactors Affecting Wound HealingClassClass FactorsFactors

Local factorsLocal factors ischaemiaischaemia TensionTension Dead SpaceDead Space Foreign bodies/contaminationForeign bodies/contamination Wound infectionWound infection HaematomaHaematoma Chronic tissue factorsChronic tissue factors Local traumaLocal trauma SuturesSutures IrradiationIrradiation

General factorsGeneral factors Age/comorbidity,e.g.diabetes,renal failureAge/comorbidity,e.g.diabetes,renal failure Anaemia/blood lossAnaemia/blood loss Shock hypovolaemia/hypoxiaShock hypovolaemia/hypoxia Malnutrition-protein and micronutrientMalnutrition-protein and micronutrient Major infections/septicaemiaMajor infections/septicaemia Advanced malignancyAdvanced malignancy Steroid useSteroid use

Technical factorsTechnical factors Wound evaluation skillsWound evaluation skills Surgical techniquesSurgical techniques

Factors in Wound ManagementFactors in Wound Management AntimicrobialsAntimicrobials

AntibioticsAntibiotics Tetanus prophylaxisTetanus prophylaxis

AnaesthesiaAnaesthesia HaemostasisHaemostasis Debridement and irrigationDebridement and irrigation Wound closureWound closure

MethodMethod MaterialsMaterials

ImmobilisationImmobilisation

Surgical instruments and Handling Instruments

Cutting Instruments

• Scalpels– Scalpel handles

– Scalpel blades

– Holding scalpel

• Scissores

• Holding Scissors

Grasping Instruments

• Hand held (thumb) forceps

Tissue forceps– Toothed forceps

– Non-toothed forceps

• Holding hand-held forceps

• Ratcheted (scissor-style) forceps– Toothed forceps

– Non-toothed forceps

Vascular forceps Crushing forceps Non-crushing forceps

Haemostatic artery forcepsNon-toothed forceps Toothed forceps

Vascular clamps (non-crushing)

Needle-holding forceps

Locking needle-holding forceps

Suture materials and surgical needles

Surgical needlesAnatomy of surgical needle

Shape and curvatureShape and curvature

1/4 circle – Ophtalmic and microsurgery1/4 circle – Ophtalmic and microsurgery

3/8 circle – General use in all tissues3/8 circle – General use in all tissues

1/2 circle – General use in all tissues1/2 circle – General use in all tissues

5/8 circle – CVS and cavities (oral ,nasal ,pelvis, 5/8 circle – CVS and cavities (oral ,nasal ,pelvis, umbi ,etc)umbi ,etc)

Straight – General use (but discouraged as hand-Straight – General use (but discouraged as hand-held)held)

J-shaped – Similar to 5/8 (femoral hernia) J-shaped – Similar to 5/8 (femoral hernia)

• Tip and cross-section

• Attachment to suture materials

Suture Materials

USP size codeUSP size codeEP size codes (mm)EP size codes (mm) Suture diameter ( mm)Suture diameter ( mm)

Organic absorbable Organic absorbable materialsmaterials

Nonabsorbable Nonabsorbable materials and synthetic materials and synthetic absorbable materialsabsorbable materials

Organic and synthetic Organic and synthetic absorbable material.absorbable material.

Nonabsorbable Nonabsorbable materialsmaterials

Min.MaxMin.Max

8/08/0

9/09/0

7/07/0

6/06/0

5/05/0

4/04/0

3/03/0

2/02/0

00

11

22

33

44

55

66

11/011/0

10/010/0

9/09/0

8/08/0

7/07/0

6/06/0

5/05/0

4/04/0

3/03/0

2/02/0

00

11

22

33

44

55

66

77

0.10.1

0.20.2

0.30.3

0.40.4

0.50.5

0.70.7

11

1.51.5

22

2.52.5

33

44

55

66

77

88

99

1010

0.01-0.0190.01-0.019

0.02-0.0290.02-0.029

0.03-0.0390.03-0.039

0.04-0.0490.04-0.049

0.05-0.0690.05-0.069

0.07-0.0990.07-0.099

0.10-0.140.10-0.14

0.15-0.190.15-0.19

0.20-0.240.20-0.24

0.25-0.290.25-0.29

0.30-0.390.30-0.39

0.40-0.490.40-0.49

0.50-0.590.50-0.59

0.60-0.690.60-0.69

0.70-0.790.70-0.79

0.80-0.890.80-0.89

0.90-0.990.90-0.99

1.00-1.091.00-1.09

Suture selectionSuture selection

SizeSize ComparasionComparasion UsesUses

12/0(to 7/0)12/0(to 7/0) Four times smaller than Four times smaller than human hairhuman hair

Exclusively microsurgicalExclusively microsurgical

6/06/0 Human hair size; Human hair size; generaly the smallest generaly the smallest suture used with naked suture used with naked visionvision

Face, blood vesselsFace, blood vessels

5/05/0 Face,neck,blood vesselsFace,neck,blood vessels

4/04/0 Mucosa,neck,hands,limbs,tendons,bloMucosa,neck,hands,limbs,tendons,blood vesselsod vessels

3/03/0 Limbs,trunk,gut,blood vesselsLimbs,trunk,gut,blood vessels

2/02/0 Trunk,fascia,stomach,viscera,blood Trunk,fascia,stomach,viscera,blood vesselsvessels

0-10-1 Small pencil leadSmall pencil lead Abdominal wall closure and other Abdominal wall closure and other heavy fascial usesheavy fascial uses

Properties of Common Suture MaterialsProperties of Common Suture Materials

Catgut (Softgut)Catgut (Softgut)

Natural,multifilament and absorbableNatural,multifilament and absorbable Sheep gut submucosa/beef gut serosaSheep gut submucosa/beef gut serosa Digested by proteolytic enzyemes in 80-120 daysDigested by proteolytic enzyemes in 80-120 days Common useCommon use

• Subcuticular and subcutaneous suturesSubcuticular and subcutaneous sutures• Liver suturesLiver sutures• Appendiceal stump/oversewAppendiceal stump/oversew• Urinary tractUrinary tract• mesentery mesentery

Properties of Common Suture MaterialsProperties of Common Suture Materials

Polyglycolic acid (PGA) (Dexon II)Polyglycolic acid (PGA) (Dexon II)

Synthetic,multifilament and absorbableSynthetic,multifilament and absorbable A polymer of glycolic acidA polymer of glycolic acid PGA hydrolyses from the 10PGA hydrolyses from the 10thth to 90 to 90thth day day Common usesCommon uses

• GI anastomosisGI anastomosis• Muscle and fascial closuresMuscle and fascial closures• Subcutucular skin closure (undyed suture)Subcutucular skin closure (undyed suture)

Properties of Common Suture MaterialsProperties of Common Suture Materials

Polyglactin 910 (Vicryl)Polyglactin 910 (Vicryl)Synthetic,multifilament and absorbableSynthetic,multifilament and absorbable Copolymer of glycolide and lactideCopolymer of glycolide and lactide Absorption at around 20-40 days and is Absorption at around 20-40 days and is complete by 60-90 dayscomplete by 60-90 days Common usesCommon uses

• GI anastomosisGI anastomosis• Muscle and fascial Muscle and fascial • Subcuticular skin closureSubcuticular skin closure

Properties of Common Suture MaterialsProperties of Common Suture Materials

Trimethylene/Glycolic acid (Maxon)Trimethylene/Glycolic acid (Maxon)

Synthetic, monofilament, absorbableSynthetic, monofilament, absorbable The monofilament polymerThe monofilament polymer Hydrolisis is generally completed between the Hydrolisis is generally completed between the

180180thth and 210 and 210thth day. day. Common usesCommon uses

• GI anastomosisGI anastomosis• Fascial closureFascial closure• Caesarean sectionCaesarean section

Properties of Common Suture MaterialsProperties of Common Suture Materials

Polydioxanone (PDS II)Polydioxanone (PDS II)

Synthetic,monofilament and absorbableSynthetic,monofilament and absorbable The polyester polymerThe polyester polymer Absorption by hydrolisis starts at 90 days and Absorption by hydrolisis starts at 90 days and

complete by 6 monthscomplete by 6 months Common usesCommon uses

• GI anastomosesGI anastomoses• Fascial (abdominal) closureFascial (abdominal) closure• Subcuticular (skin) closureSubcuticular (skin) closure

Properties of Common Suture MaterialsProperties of Common Suture Materials

Poliglecaprone 25Poliglecaprone 25

Synthetic, monofilament and absorbableSynthetic, monofilament and absorbable Copolymer of glycolide and caprolactoneCopolymer of glycolide and caprolactone Fully absorbed between 91 and 119 days)Fully absorbed between 91 and 119 days) Common usesCommon uses

• Subcuticular (skin) sutureSubcuticular (skin) suture• LigationLigation• Subcutaneous sutureSubcutaneous suture

Properties of Common Suture MaterialsProperties of Common Suture Materials

Polybutester (Novafil)Polybutester (Novafil)

Synthetic,monofilament and nonabsorbableSynthetic,monofilament and nonabsorbable PolymerPolymer Common usesCommon uses

• Skin closure (plastics)Skin closure (plastics)• OphtalmologyOphtalmology• Fascial closure (general)Fascial closure (general)

Properties of Common Suture MaterialsProperties of Common Suture Materials

Polyvinylidene (Vilene)Polyvinylidene (Vilene)

Synthetic,monofilament and nonabsorbableSynthetic,monofilament and nonabsorbable Minimally reactive monofilament sutureMinimally reactive monofilament suture Common usesCommon uses

• Fascial (abdominal closure)Fascial (abdominal closure)• Skin closureSkin closure• Hernia surgeryHernia surgery• Vascular surgeryVascular surgery• neurosurgeryneurosurgery

Properties of Common Suture MaterialsProperties of Common Suture Materials

Polyether (Dycloc)Polyether (Dycloc)

Synthetic, monofilament and nonabsorbableSynthetic, monofilament and nonabsorbable Minimally reactive stretchable monofilament sutureMinimally reactive stretchable monofilament suture Common usesCommon uses

• Skin closure (plastics)Skin closure (plastics)• OpthalmologyOpthalmology• Fascial closure (general)Fascial closure (general)

Properties of Common Suture MaterialsProperties of Common Suture Materials

Polyamides (Nylon)Polyamides (Nylon)

Synthetic,multi/monofilament and nonabsorbableSynthetic,multi/monofilament and nonabsorbable Common usesCommon uses

• Fascial (abdominal)Fascial (abdominal)

• Skin closureSkin closure

• Hernia surgeryHernia surgery

• Vascular surgeryVascular surgery

• neurosurgeryneurosurgery

Properties of Common Suture MaterialsProperties of Common Suture Materials

Polypropylene (surgilene,prolene)Polypropylene (surgilene,prolene)

Synthetic,monofilament, and nonabsorbableSynthetic,monofilament, and nonabsorbable Non-reactive polymerNon-reactive polymer Minimal tissue reactionMinimal tissue reaction Common usesCommon uses

• Fascial (abdominal closure)Fascial (abdominal closure)• Vascular anastomosesVascular anastomoses• Subcuticular (skin) closureSubcuticular (skin) closure• Tendon repairsTendon repairs• opthalmologyopthalmology

Properties of Common Suture MaterialsProperties of Common Suture Materials

PolyesterPolyester

Synthetic,multi/monofilament and nonabsorbableSynthetic,multi/monofilament and nonabsorbable High and permanent tensile strengthHigh and permanent tensile strength Common usesCommon uses

• Cardiac valve surgeryCardiac valve surgery

• Tendon sutureTendon suture

• OthopaedicsOthopaedics

• OpthalmologyOpthalmology

Properties of Common Suture MaterialsProperties of Common Suture Materials

Silk/Cotton/LinenSilk/Cotton/Linen

Natural,multifilament and nonabsorbableNatural,multifilament and nonabsorbable Common usesCommon uses

• Skin closureSkin closure• Vascular ligation Vascular ligation • GI anastomosisGI anastomosis• OpthalmologyOpthalmology• Cardiac surgeryCardiac surgery

Basic Suturing Techniques

Basic Suturing Techniques

Basic Suturing Techniques

• Simple suture

Basic Suturing Techniques

Basic Suturing Techniques

Basic Suturing Techniques

• Vertical matterss suture

Basic Suturing Techniques

Basic Suturing Techniques

• Horizontal matterss suture

Basic Suturing Techniques

• Continuous suture

Basic Suturing Techniques

• Subcuticular suture

Basic Suturing Techniques• Subcuticular suture

Basic Suturing Techniques

• Barron suture

Basic Suturing Techniques

• Three-corner suture

Surgical Knot tying

Surgical Knot tying

Surgical Knot tying

• Instrument knot

Surgical Knot tying

Surgical Knot tying

• Instrument knot

Surgical Knot tying• One-handed knot

Surgical Knot tying• One-handed knot

Surgical Knot tying• One-handed knot

Surgical Knot tying

• Two-handed knot