This handbook was written and revised by Mr Bill Thomas, Blond surgical skills tutor and chairman of the working party at The Royal College of Surgeons of England, with assist ance from members of the intercollegiate working party (see inside back cover). Published by The Royal College of Surgeons of England Registered Charity No. 212808 The Raven Department of Education The Royal College of Surgeons of England 35–43 Lincoln’s Inn Fields London WC2A 3PE Tel: 020 7869 6300 Fax: 020 7869 6320 Email:
[email protected] Internet: www.rcseng.ac.uk © The Royal College of Surgeons of England 2002 First edition 1996 Second edition 1998 Third edition 2002 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of The Royal College of Surgeons of England. While every effort has been made to ensure the accuracy of the information contained in this publication, no guarantee can be given that all errors and omissions have been excluded. No responsibility for loss occasioned to any person acting or refraining from action as a result of the material in this publication can be accepted by The Royal College of Surgeons of England.
The establishment of the Basic Surgical Skills course has been a major educational development project which has been greatly assisted by: • Eschmann, who kindly supported the diathermy video for the course. • Ethicon Limited, who supported supported the initial production production of the handbook, handbook, provided materials materials and equipment for the course in its pilot stage and kindly supported the production of this third edition of the course. • Keeler Limited, Limited, who kindly supported supported the handbook of this this third edition. • Regent Hospital Products, who kindly kindly suppored the production production of this handbook handbook (second and third editions). a
company
We are particularly grateful to Mr Nick Cheshire, Mr Elliot Chisholm, Mr David Hay, Mrs Sue Miles and Mr John Shepperd for their contributions to the rst edition and also to Mr Chris Fowler and the minimal access therapy training unit for permission to use extracts from the Basic Skills for Safe Laparoscopic handbook. Additional material in the minimal access section was written by Mr George Hanna Surgery handbook. and Mr David Smith and the new operative video footage was provided by Mr Nick Cheshire, Mr David Hay, Mr Graham Sunderland and Mr Peter Wilson. The new orthopaedic material was provided by Mr Nick Gilham and Mr David Large.
This handbook may be purchased from The The Royal College of Surgeons of England and used in support suppor t of courses and/or training training activities other than the Basic Surgical Skills courses approved by one of the four surgical royal colleges. However, The Royal College of Surgeons of England takes no responsibility whatsoever for the use us e of its course materials in any context, other other than as part of a basic surgical skills course it has approved.
This handbook was written and revised by Mr Bill Thomas, Blond surgical skills tutor and chairman of the working party at The Royal College of Surgeons of England, with assist ance from members of the intercollegiate working party (see inside back cover). Published by The Royal College of Surgeons of England Registered Charity No. 212808 The Raven Department of Education The Royal College of Surgeons of England 35–43 Lincoln’s Inn Fields London WC2A 3PE Tel: 020 7869 6300 Fax: 020 7869 6320 Email:
[email protected] Internet: www.rcseng.ac.uk © The Royal College of Surgeons of England 2002 First edition 1996 Second edition 1998 Third edition 2002 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of The Royal College of Surgeons of England. While every effort has been made to ensure the accuracy of the information contained in this publication, no guarantee can be given that all errors and omissions have been excluded. No responsibility for loss occasioned to any person acting or refraining from action as a result of the material in this publication can be accepted by The Royal College of Surgeons of England.
The establishment of the Basic Surgical Skills course has been a major educational development project which has been greatly assisted by: • Eschmann, who kindly supported the diathermy video for the course. • Ethicon Limited, who supported supported the initial production production of the handbook, handbook, provided materials materials and equipment for the course in its pilot stage and kindly supported the production of this third edition of the course. • Keeler Limited, Limited, who kindly supported supported the handbook of this this third edition. • Regent Hospital Products, who kindly kindly suppored the production production of this handbook handbook (second and third editions). a
company
We are particularly grateful to Mr Nick Cheshire, Mr Elliot Chisholm, Mr David Hay, Mrs Sue Miles and Mr John Shepperd for their contributions to the rst edition and also to Mr Chris Fowler and the minimal access therapy training unit for permission to use extracts from the Basic Skills for Safe Laparoscopic handbook. Additional material in the minimal access section was written by Mr George Hanna Surgery handbook. and Mr David Smith and the new operative video footage was provided by Mr Nick Cheshire, Mr David Hay, Mr Graham Sunderland and Mr Peter Wilson. The new orthopaedic material was provided by Mr Nick Gilham and Mr David Large.
This handbook may be purchased from The The Royal College of Surgeons of England and used in support suppor t of courses and/or training training activities other than the Basic Surgical Skills courses approved by one of the four surgical royal colleges. However, The Royal College of Surgeons of England takes no responsibility whatsoever for the use us e of its course materials in any context, other other than as part of a basic surgical skills course it has approved.
x
Introduction:
introduction to the course
x
course objectives
x
course programme
x
basic principles
xx
Module one:
open surgery
xx
Module two:
trauma and orthopaedics
xx
Module three: minimal access surgery
xx
Assessment
xx
Appendix A:
needles
xx
Appendix B:
suture materials
xxx
Appendix C:
gloves
INTRODUCTION TO THE COURSE
This handbook has been designed and written for participants on the Basic Surgical Skills courses, for use before, during and after attendance on a course. From August 1996 it has been a mandatory requirement of the four surgical royal colleges that all SHOs entering basic surgical training should successfully complete such a course. This course has been designed to introduce surgical trainees to safe surgical practice within a controlled workshop environment and it aims to ‘teach, assess and certify’ trainees’ ability to use safe and sound surgical techniques that are common to all forms of surgery. The course covers three main areas: • open surgery; • trauma and orthopaedics; and • minimal access surgery. It is not intended to provide comprehensive coverage of all aspects of surgery, but is designed to introduce surgical trainees to safe and sound techniques early in their career. The course is standardised with common objectives, content, structure and assessment methods as agreed by all four surgical colleges. It does not seek to impose or promote the techniques demonstrated as being the only safe and sound method for performing a surgical procedure but does endeavour to teach ‘one safe way’ that trainees may utilise. The course is intensively taught, with an emphasis on individual tuition and detailed personal feedback on performance. Features of the course include: • Hands-on practice throughout the course. • High tutor to participant ratio. • Personal tuition with a maximum of 18 participants per course. • Accompanying course handbook and video containing key points for each procedure. • Performance assessment and feedback to identify areas of strength and weakness.
Each course will be offered under the aegis of one of the surgical royal colleges at a network of regional centres, so that trainees should not need to travel too far from their hospitals. It is an intercollegiate course with a common content and structure and standardised in-course assessment, so that all trainees will have a common learning experience, regardless of location. The materials which accompany the course carry the copyright of The Royal College of Surgeons of England but have been produced with the help of representatives of all four surgical colleges and are available by prior agreement between the colleges for use on all courses. This reects the high level of co-operation between the colleges in establishing this important initiative and emphasises the intercollegiate commitment to achieve a common standard on Basic Surgical Skills courses. We are particularly grateful to the many members of faculty and the participating trainees in the regions whose comments were invaluable in the development and revision of the course and its accompanying handbook and video. It is our intention that the courses should not only be instructive and educational, but also enjoyable. I trust that you will enjoy this course and nd that it provides you with a rm foundation for your future career in surgery.
WEG Thomas Blond surgical skills tutor, The Royal College of Surgeons of England
introduction to the course
5
COURSE OBJECTIVES
Module one: open surgery • To learn safe operating techniques, gowning and gloving. • To understand that careful and sound aspects of technique are more important than simple manual dexterity or speed. • To understand the importance of universal precautions for safe theatre practice, especially in emergency situations. • To understand the principles of handling tissues and sound anastomotic technique recognising differing requirements for differing sites, eg bowel and vascular tissue.
Module two: trauma and orthopaedics • To understand the principles of assessing contaminated soft tissues, wound debridement and primary surgical management including drainage and appropriate closure. • To understand the principles of identifying and managing injury to tendons, including tendon repair, handling of tissues and subsequent management. • To understand the principles of fracture assessment, stabilisation and plaster techniques.
Module three: minimal access surgery • To understand the basic principles governing safe preparation for laparoscopic surgery. • To demonstrate the safe use of the open technique for port insertion (Hassan). • To insert the Verres needle and cannulae safely. • To understand the physiological consequences of pneumoperitoneum. • To understand the use of instruments and imaging systems. • To understand the principles governing the use of the camera. • To demonstrate an ability to manipulate basic laparoscopic instruments. • To understand the principles behind the practical use of diathermy. • To demonstrate an overall understanding of the safety issue for minimal access surgery.
6
course objectives
COURSE PROGRAMME
Day 1 module one: open surgery 8.30–9.00
Registration (faculty meeting)
9.00–9.05
Introduction and statement of course objectives
9.05–9.25
Theatre safety (principles of safe surgery) Gowning and gloving Protection, visors, masks, double gloving
9.25–9.50
Handling instruments Scalpel, scissors, dissecting forceps, haemostats, needle holder
9.50–10.30
Knots One-handed reef knot, instrument tie, surgeon’s knot, slip knot, tying at depth, Aberdeen knot
10.30–10.45
Coffee
10.45–11.30
Knots continued
11.30–13.00
Handling sutures Principles of needle and su ture use, interrupted, continuous, the art of assis ting, mattress, subcuticular, skin lesion biopsy
13.00–13.45
Lunch
13.45–15.30
Handling tissues Abdominal incision and closure, haemostasis, dissection (time permitting) Handling bowel 1 End-to-end extramucosal anastomosis (continuous suture technique if time permits)
15.30–15.45
Tea
15.45–17.15
Handling bowel 2 End-to-side anastomosis on immobile bowel
17.15–17.30
Discussion and feedback
course programme
7
Day 2 (am) module one: open surgery (continued) 8.30 –9.30
The Aberdeen knot Abdominal incision and closure Use of simulated abdominal wall and incision
9.30 –10.45
Handling vessels Vascular anastomoses, arteriotomy and closure
10.45–11.00
Coffee
11.00 –12.30
Handling vessels (continued) Vein patch graft
12.30–13.30
Lunch
Day 2 (pm) module two: trauma and orthopaedics
8
13.30 –14.10
Handling traumatised tissues Drainage and debridement
14.10 –15.10
Handling tendons Tendon repair
15.10–15.25
Principles of fracture xation Types of fracture, principles of xation and complications
15.25–15.40
Tea
15.40 –17.15
Plastering techniques Full plaster and splitting techniques
17.15 –17.30
Discussion and feedback
basic surgical skills
Day 3 module three: minimal access surgery 8.30–8.45
Introduction to minimal access surgery Ergonomics and safety principles
8.45–9.20
The laparoscopic stack Rapid ow insufator, light source, video camera, laparoscopes, monitors
9.20–10.30
Safe induction and maintenance of the pneumoperitoneum Open method of port insertion, closed method of creating pneumoperitoneum, insertion of the umbilical trocar and laparoscope, safe port management, camera handling
10.30–10.45
Coffee
10.45–11.15
Minimal access surgery instrumentation Introduction to basic laparoscopic instrumentation
11.15–13.00
Grasping and manipulation skills Multiple exercises to demonstrate manipulative skills
13.00–14.00
Lunch
14.00–15.15
Advanced dexterity skills Clipping and loop ligation (simulation of appendicectomy)
15.15–15.30
Tea
15.30–16.45
Diathermy Video and discussion (This may be shown at any time on the nal day depending on local resources) Diathermy skills exercises Chicken skin peeling
16.45–17.00
Summary and feedback
END OF COURSE
course programme
9
BASIC PRINCIPLES
Preparation for the course • There is little essential preparation for the Basic Surgical Skills course apart from reading this handbook and watching the video. • All participants will preferably be on a basic surgical training scheme. • It is preferable that all participants have had some, if only limited, experience of suture techniques and handling instruments. • Any practise of the techniques demonstrated in the video prior to the course will help the participant to progress more rapidly with the exercises.
Theatre safety (principles of safe surgery) Exercise The following procedure for putting on sterile theatre gowns and gloves is essential to the overall approach of operative sterile technique: • Wash your hands thoroughly with appropriate antiseptic soaps. • Dry your hands from the hands down towards the elbows and then discard the towels. • Pick up your gown and fold it so that the inside faces towards you. • Put on the gown without touching the outside of the gown, keeping your hands inside the cuffs. • Get an assistant to tie up the gown from the back. • Open the glove packet. • Use a closed gloving technique to put on your gloves. • Hand your assistant the tab of the posterior gown tie so that they handle only the red tab end and not the tie itself. Turn around and then pull the tie out of the tab and tie it so that the posterior aspect of the gown is now closed.
10
basic surgical skills
Other important principles
• Always wear gloves of the correct size and choose appropriate gloves to suit the surgical procedure. See ‘Principles of glove usage’ Appendix C. • Never directly handle ‘sharps’. • Never handle a needle with your ngers. When opening a needle packet, be careful to take the needle out of the specially designed packet using the needle holder and without touching the needle yourself. • When changing the position of the needle in the needle holder, always use the forceps to change the orientation of the needle as demonstrated in the video. Once again, do not use your ngers. • Always keep any needle in use in your direct sight at all times. When using a long suture length on your needle, utilise the middle nger of your right hand to control the long length, as shown in the video, and do not simply pull the needle out of view to tighten the suture material, as you can contaminate the needle or even injure your assistant. • Always hand sharp instruments to assistants in a manner such that they cannot be injured – preferably in a kidney dish or suitable container. The safety of any assistants is the surgeon’s responsibility. • When changing the blade of a scalpel, be careful to handle the blade with forceps or haemostats. The blade is extremely sharp and should not be handled with your ngers. • Always dispose of used needles or blades in the sharps container provided. • Always dispose of excised tissue in appropriate containers. • Always keep the operative eld tidy without extraneous instruments or equipment lying around. • Always check the integrity of instruments before use and do not always rely on
assistants or scrub nurses. This is particularly important for electrical equipment such as diathermy and laparoscopic equipment. • Operate with the table at the correct height – whether sitting or standing the height of the operative eld should be approximately horizontal to your forearm (Figure 1). Operating at any other height is likely to cause tiredness and stress. • Throughout the course always wear aprons and gloves when handling tissues. • Always dispose of gloves, theatre gowns and drapes in the appropriate manner.
Principles of magnication The benets of using magnication during surgical procedures are obvious. A clearer, sharper working view is provided that enables you to clearly visualise the structures that require your attention. Head-mounted optical systems (loupes) are often ideal to wear during surgery as they allow you more freedom of movement than microscopes and are individually adjusted to t the user. There are two types of loupes available. The Galilean system consists of three lenses and is often considered the easier to use. This is because it provides an increased working depth and a wide eld of view allowing you to move more freely while the image remains in focus. It is usually available in up to 3X magnication. The prismatic loupe provides a more complicated optical system and, because of the increased number of lenses and the prism, is heavier than a Galilean loupe. However, it provides superb colour rendition and an extremely at eld, which makes it particularly useful for vascular surgery and ne detailed work. The clarity of the image requires you to maintain an exact working distance. Prismatic loupes are usually available in magnications of up to 5.5X or 6X. When selecting your magnication, bear the following in mind: • Glass lenses. These are optically superior and will provide a sharp clear image with little or no distortion. • Comfort. You will often have to wear your loupes for extended periods of time, so ensure they are comfortable and practical to wear. There is usually an option to wear them on a spectacle frame or headband. For ease of use a ip-up design may be preferred as
Basic principles has been generously supported by Keeler Ltd
Figure 1
they provide magnication when needed and an unrestricted view when magnication is not required. • Fitting. Ensure that your loupes can be tted to suit your eyes. An individual interpupillary adjustment is normally required to prevent eyestrain. A well-tted pair of loupes can also help improve your posture and help avoid back problems, maintaining your comfort during surgery. • Optical advice. Before deciding to purchase loupes, contact your local optician. The correct prescription will ensure your loupes are comfortable and easy to wear helping you to maintain your chosen working distance. Contrary to popular belief, loupes are not simply something that is required as you grow older, as magnication will improve your working view regardless of whether you are normally a spectacle wearer or not. While your eyes will not become reliant upon them, you may well nd that you rely on your loupes to see the ner detail in your work and, like many wearers, prefer working with them.
basic principles
11
MODULE ONE: open surgery
This module of the course is designed to teach
Handling instruments
you basic safe methods of performing simple
In order to achieve maximum potential from any surgical instrument, it will need to be handled correctly and carefully. The basic principles of all instrument handling include: • safety; • economy of movement; • relaxed handling; and • avoidance of awkward movements. We shall demonstrate the handling of scalpels, scissors, dissecting forceps, haemostats and needle holders. Take every opportunity to practise correct handling using the whole range of surgical instruments.
surgical procedures, and to allow you to perform and practise them at the bench on prepared animal tissue, simulations and various jigs. We aim to provide you with an enjoyable hands-on experience and the opportunity of practising vital and fundamental techniques in a less stressful atmosphere than the operating theatre. The module aims to introduce you to some of the manipulative skills you will require in your career. Complex manoeuvres will need to be assiduously practis ed, preferably under critical observation, so that you do not acquire bad habits. The aim of this course is to help you acquire good habits early in your career, as it is so much harder to unlearn bad habits later in life. The techniques chosen for this course by all four surgical royal colleges are those which are simple and safe, but we make no claim that these are the only simple and safe techniques. They have been chosen as being simple and proven. An advantage of the British sys tem of training is that you will work for several surgeons in the course of your training, each of whom will show you individually
The scalpel
• Handle with great care as the blades are very sharp. Practise attaching and detaching the blade using a haemostat. Never handle the blade directly. • For making a routine skin incision hold the scalpel in a similar manner to a t able knife, with your index nger guiding the blade. Keep the knife horizontal and draw the whole length of the sharp blade, not just the point, over the tissues (Figure 2).
preferred techniques from which you will be able to select those which suit your needs best. However, the techniques taught on this course have been standardised and are recommended for their simplicity and safety.
Figure 2
12
basic surgical skills
• For ner work the scalpel may be held like a pen, often steadying the hand by using the little nger as a fulcrum (Figure 3).
• Use the index nger to steady the scissors by placing it over the joint. • When cutting tissues or sutures, especially at depth, it often helps to steady the s cissors over the index nger of the other hand (Figure 5).
Figure 3 Figure 5
• Always pass the scalpel in a kidney dish. Never pass the scalpel point rst across the table.
• Cut with the tips of the scissors for accuracy rather than using the crutch which will run the risk of damaging tissues beyond the item being divided and will also diminish accuracy.
Scissors
There are two basic types of scissors, one for soft tissues and one for rmer tissues such as sutures. • Insert the thumb and ring nger into the rings (or bows) of the scissors so that just the distal phalanges are within the rings (Figure 4). Any further advancement of the ngers will lead to clumsy handling and difculty in extricating the ngers at speed.
Dissecting forceps
• Hold gently between thumb and ngers, the middle nger playing the pivotal role (Figure 6).
Figure 6
Figure 4
• Two main types of forceps are available, toothed for tougher tissue such as fascia or skin, and non-toothed (atraumatic) for delicate tissues such as bowel and vessels. • Never crush tissues with the forceps but use them to hold or manipulate tissues with great care and gentleness. open surgery
13
Needle holder Haemostats (artery forceps)
• Hold haemostats in a similar manner to scissors. • Place on vessels using the tips of the jaws (the grip lessens towards the joint of the instrument). • Secure position using the ratchet lock. • Learn to release the haemostat using either hand. For the right hand, hold the forceps as normally, then gently further compress the handles and separate them in a plane at right angles to the plane of action of the joint. Control the forceps during this manoeuvre to prevent them from springing open in an uncontrolled manner. For the left hand, hold the forceps with the thumb and index nger grasping the distal ring and the ring nger resting on the under surface of the near ring (Figure 7). Gently compress the handles and separate them again at right angles to the plane of action, taking care to control the forceps as you do so.
Figure 6
• Grasp the needle holders in a similar manner to scissors. • Hold the needle in the tip of the jaws about two-thirds of the way along its circumference (Figure 8), never at its very delicate point and never too near the swaged eye (see Appendix A).
Figure 7
• Select the needle holder carefully. For delicate, ne suturing use a ne short-handled needle holder and an appropriate needle. Suturing at depth requires a long-handled needle holder. • Most needle holders incorporate a ratchet lock but some, eg Gilles, do not. Practise using different forms of needle holder to decide which is most applicable for yo ur use. • There are a wide variety of needle and suture materials available and their use will depend on the tissues being sutured and the nature of the anastomosis. For a full description of needles and suture materials see Appendices A and B.
Exercise • Practise the correct handling of each of the instruments (scalpels, scissors, dissecting forceps, haemostats and needle holders) as demonstrated.
14
basic surgical skills
Knots Knot tying is one of the most fundamental techniques in surgery and is often performed very badly. Take time to perfect your knot tying technique as this will stand you in good stead for the rest of your career. Practise regularly with spare lengths of suture material. General principles of knot tying include: • The knot must be rm and unable to slip. • The knot must be as small as possible to minimise foreign material. • During tying do not ‘saw’ the material as this will weaken the thread. • Do not damage the suture material by grasping it with artery forceps or needle holders except at the free end when using an instrument tie. • Avoid excess tension during tying as this could damage the structure being ligated or even cause breakage of the suture material. • Avoid tearing the tissue being ligated by controlling tension at ‘bedding down’ of the knot very carefully using the index nger or thumb as appropriate You will be taught and asked to demonstrate the following: • the one-handed reef knot; • an instrument tie reef knot; • the surgeon’s knot; • a slip knot (the granny knot); and • tying at depth. The standard knot used in routine surgery is the reef knot with a third throw for security. This is usually tied using the one-handed method and this technique should be mastered and practised regularly during the course. The principles of the reef knot are the alternating ties of the ‘index nger’ knot and the ‘middle nger’ knot at the same time as the hands cross over for each throw.
open surgery
15
The one-handed reef knot technique Exercise • Hold the end of the short end of the suture between the thumb and middle nger of the left hand with the loop over the extended index nger (Figure 9a). Hold the remainder of the suture material with the right hand.
• Use the distal phalanx of the left index nger to pass under the thread held in the left hand in preparation for pulling it through the loop (Figure 9c).
Figure 9c
Figure 9a
• Pull the thread through and complete the throw by drawing the left hand towards the operator and the right hand away from the operator (Figure 9d).
• Bring the remainder of the suture material in the right hand over the left index nger by moving the right hand away from the operator (Figure 9b).
Figure 9d
Figure 9b
16
basic surgical skills
• Continue to hold the short end of the suture in the left hand between thumb and index nger looping the thread around the other three ngers (Figure 9e).
• Bring the strand through and then tighten by drawing the right hand towards the operator and the left hand away from the operator (Figure 9h).
Figure 9e
Figure 9h
• Bring the strand held in the right hand across towards the operator to cross the left-handed thread (Figure 9f).
• On completion of the reef knot, the classical pattern of the knot can be clearly seen (Figure 9i and 9j).
Figure 9f
• Use the distal phalanx of the left middle nger to bring the left-handed strand under the righthanded strand (Figure 9g).
Figure 9i
Figure 9j
Figure 9g
• For security another index nger throw is usually applied.
open surgery
17
The instrument tie Exercise • Loop the long end of the suture around the instrument, the instrument being placed over the thread (Figure 10a).
• Now form a loop around the instrument, this time the instrument being placed under the thread (Figure 10d).
Figure 10d
Figure 10a
• Grasp the short end again within the jaws of the instrument (Figure 10e).
• Grasp the short end of the suture within the jaws of the instrument (Figure 10b).
Figure 10e
Figure 10b
• Pull through to complete the classical reef knot (Figure 10f).
• Complete the rst hitch (Figure 10c).
Figure 10f
Figure 10c
18
basic surgical skills
The surgeon’s knot Exercise • A single throw is placed using a one-handed or two-handed technique (Figure 11a).
• A further throw is now fashioned in the same manner as for a reef knot but not tightened (Figure 11d).
Figure 11d
Figure 11a
• A similar throw is again fashioned producing a double throw as before (Figure 11e).
• A further throw in the same manner is placed (Figure 11b).
Figure 11e
Figure 11b
• The double throw is now tightened (Figure 11f).
• The double throw is tightened in a conventional manner (Figure 11c).
Figure 11f Figure 11c
continued over.... open surgery
19
... continued
• The result may not look very pretty but it is very secure as long as the nal throw is tightened as horizontally as possible (Figure 11g).
Figure 12b
• This does not produce the classical picture of a reef knot but it does slip and can be used to ensure the right tension of the knot (Figure 12c).
Figure 11g
The slip knot Exercise • This should be used with care as it is not secure. Two similar throws are placed consecutively and then snugged down (Figure 12a and 12b). Figure 12c
• A formal reef knot needs to be tied now in order to give the knot security (Figure 12d).
Figure 12a
Figure 12d
20
basic surgical skills
Tying at depth Exercise • The thread should be placed around the object to be ligated with the right index nger (Figure 13a) or using an instrument such as a haemostat.
• Snug the knot down using tension on the long strand against the index nger of the right hand, ensuring no tension exists on the structure being ligated. • Fashion a further throw on the surface in the manner of a reef knot (Figure 13d).
Figure 13d Figure 13a
• Fashion a classical throw for a reef knot on the surface (Figure 13b).
• Advance into the cavity and snug down with the right index nger as before (Figure 13e)
Figure 13e Figure 13b
• Advance the knot down into the cavity using the right index nger (Figure 13c).
Figure 13b open surgery
21
Handling sutures Basic principles
• Attempt to remove all elements of tension from any anastomosis. • Insert the needle at right angles to the tissue and gently advance through the tissue avoiding shearing forces. • As a rough rule of thumb, the distance from the edge of the wound should correspond to the thickness of the tissue and successive sutures should be placed at twice this distance apart, ie approximately double the depth of the tissue sutured (Figure 14).
• For long wounds being closed with interrupted sutures, it is often advisable to start in the middle and to keep on halving the wound. • No suture should be tied under too much tension or the subsequent oedema of the wound may cause the sutures to cut out or to develop ischaemia of the w ound edge and delayed healing. • In most cases it is advisable to only go through one edge of the tissues at a t ime but, if the edges lie in very close proximity and accuracy can be ensured, it is permissible to go through both edges at the same time. • For elliptical wounds following lesion excision, the edges of the wound may be undermined to help closure. However, the length of the wound will need to be approximately three times the width of the wound if closure is to be safe and not under too much tension. Skin hooks may be useful for display of the wound.
Forms of suturing
Figure 14
• All sutures should be placed at right angles to the line of the wound at the same distance from the wound edge and the same dist ance apart in order for tension to be equal down the wound length. The only situation where this should not apply is when suturing fascia or aponeuroses when the sutures should be placed at varying distances from the wound edge in order to prevent the bres parting (Figures 15a and 15b).
You will be taught and asked to demonstrate the following types of suturing: • interrupted sutures; • continuous sutures (including the art of ‘following’); • mattress sutures; • subcuticular sutures; and • inverting and everting techniques.
Interrupted sutures (Figure 16)
Figure 15a Figure 16
Exercise • Place carefully at right angles to the wound edges. • Tie a careful reef knot and lay to one side of the wound. Figure 15b
22
basic surgical skills
• Cut suture ends about 0.5cm long to allow enough length for grasping when removing. • When removing sutures, sutures, cut ush with the tissue surface so that the exposed length of the suture, which is potentially infected, does not have to pass through t hrough the tissues (Figures 17a and 17b).
an assistant ‘following’ by holding the suture at the same tension as it is when handed to them. • Take care not to ‘purse string’ string’ the wound by too much tension. • Take care not to produce produce too much tension by using too little suture length. • Secure the suture at the end of the anastomosis by a further reef knot.
Mattress sutures Exercise • Mattress sutures may be either vertical vertical (Figure 19a and 20a) or horizontal (Figure 19b and 20b).
Figure 17a
Figure 19a
Figure 19b
Figure 17b
Continuous sutures (Figure 18)
• They may be useful for ensuring either eversion (Figure 19) or inversion (Figure 20) of a wound edge.
Figure 20a
Figure 18
Exercise • Place a single suture and ligate but but only cut the short end of the suture. • Continue to place sutures along the length of the wound keeping tension by means of Figure 20b open surgery
23
Subcuticular sutures (Figure 21)
Handling tissues Haemostasis
Two methods of securing haemostasis by ligation will be demonstrated using vessels in small bowel mesentery.
Figure 21
Exercise • This technique technique may may be used used with absorbable or non-absorbable sutures. • For non-absorbable non-absorbable sutures the ends may be secured by means of beads, etc. • For absorbable absorbable sutures the ends may secured by means of buried knots. • Small bites are taken of the subcuticular tissues on alternate sides of the wound and these are then pulled carefully together.
Skin lesion biopsy Exercise • Make an elliptical incision incision around the lesion. • Dissect the lesion out taking care not to disrupt or burst it. • Remove the the lesion (always send for histological examination). • Undermine the skin edges if necessary. • Ensure that not too much much tension tension exists for for closure. • Length of the wound should be approximately three times the width of the wound. • If any tension tension exists, itit is easier easier to start in in the corners and work towards the centre. • If no tension tension exists, the the wound may be closed by starting in the centre and then halving the remaining wound. • Close the wound with interrupted sutures.
24
basic surgical skills
Exercise – single vessel ligation • Carefully dissect dissect out a single vessel in the mesentery by dividing the peritoneum over it and isolating a length of vessel on its own. • If possible do not go right through the peritoneum on the other side of the mesentery. • Pass ligature threads under under the vessel by means of haemostats and ligate at either end of the isolated length of vessel. • Divide the vessel between the two ligatures and cut the suture material of the knots.
Exercise – pedicle ligation • Isolate a pedicle pedicle or leash of vessels and place a haemostat at either end. • Divide the the vessels between the haemostats. haemostats. • Ligate the vessels in each haemostat haemostat with a three-throw reef knot.
Dissection (if time and specimen allow)
Lymph node biopsy is commonly required for Lymph histological examination.
Exercise • For this exercise the nodes in small bowel mesentery are to be used. • Carefully divide divide the peritoneum over the node. • Dissect the node with care, avoiding any crushing of the node or damage to the underlying tissues. Minimal handling of the node is desirable. • Each node will have feeding feeding vessels which which in normal circumstances will need to be dealt with by diathermy or ligation.
Handling bowel Bowel anastomosis
The basic principles of bowel anastomosis will be demonstrated using a small bowel anastomosis. The essentials for any anastomosis are: • no tension; • good blood supply supply (pulsating (pulsating mesenteric mesenteric vessels); • accurate apposition; and • impeccable and accurate accurate suture technique technique.. Although not the only safe suture method for small bowel anastomosis, the technique to be demonstrated on this course will be the single layer extramucosal suture (Figure 22).
•
•
•
•
•
• Figure 22
• The basic exercise will be performed as an end-to-end anastomosis on mobile small bowel that can be turned to reveal the posterior wall. Each participant will have an opportunity to perform a complete anastomosis and also assist their partner in their anastomosis. Two sessions on bowel anastomosis are included in the course and, for participants who perform well, the techniques of end-to-side anastomosis on non-mobile bowel will also be demonstrated. A continuous technique is also permissible, taking care not to purse string the anastomosis.
End-to-end extramucosal anastomosis Exercise • Assume resection of a lesion. • Line up the ends of the bowel. In operative circumstances non-crushing bowel clamps may be used to prevent spillage, etc. • Use 3/0 absorbable absorbable suture material with an atraumatic round bodied needle. • Each suture should perforate the bowel from
•
•
the serosal surface, penetrating the muscle layer and submucosa and emerging between the mucosa and submucosa (Figure 22). It is essential to include the submucosa as this is the strongest layer of the bowel wall. Insert stay sutures sutures at the mesenteric mesenteric and antimesenteric borders; do not ligate them but place in haemostats. Starting from the mesenteric mesenteric aspect, aspect, place interrupted sutures along the anterior wall of the bowel at approximately 0.5cm apart and tie as they are placed. On completion, tie both stay sutures, but do not cut and replace in haemostats. Pass antimesenteric antimesenteric stay suture under under bowel bowel to emerge in mesenteric defect and, at the same time, draw mesenteric stay suture towards operator which will reverse the bowel and the posterior wall will now lie anteriorly. Suture the new front wall in a similar manner using interrupted extramucosal sutures taking care to ensure the angles are adequately sutured. On completion, completion, return the stay sutures to their original position, then cut them and inspect the anastomosis. In normal situations the mesenteric defect must be closed, taking care not to damage the mesenteric vessels. In the exercise situation, situation, cut out out the anastomosis and then open it up and inspect from the inside as well as the outside. Very little suture material should should appear within the lumen if the extramucosal suture technique has been adequately inserted. If a continuous technique is to be employed, employed, place a stay suture at the antimesenteric border and do not tie but place in a haemostat. In the same s ame manner, place a stay suture at the mesenteric border using a full length of suture, ligate it and place the short end in a haemostat. Take the other end and use it to place a continuous suture across the anterior wall of the anastomosis until the antimesenteric stay is reached. Once again, an extramucosal suture technique is used. Care must be taken not to purse string the anastomosis so the careful attention of an assistant is essential. The antimesenteric stay can now be tied but not cut. The bowel is now reversed in the same way as before, passing the needle and suture under the partially fashioned anastomosis. On reversal of the bowel, either continue on with the same suture until the mesenteric stay is
open surgery
25
reached and tied to it, or use a double needle suture at the outset for the mesenteric stay suture, and the new front wall can then be sutured from the mesenteric aspect towards the antimesenteric aspect as before, using the other needle.
End-to-side anastomosis on immobile bowel Figure 23b
Exercise • Use an end-to-side small bowel anastomosis to demonstrate this technique. • In this technique the posterior wall is sutured rst using a vertical mattress suture technique (Figure 23a). Each suture should perforate the full thickness of the bowel wall from within the lumen and then traverse the other portion of bowel full thickness from outside to inside. The suture should then return taking a small segment of the mucosa on both sides. A reef knot should then be tied on the lumen surface.
• Once again excise the anastomosis and open it up for inspection. In this case all the posterior sutures should be easily apparent within the lumen but the anterior sutures should be hardly visible.
The Aberdeen knot Exercise • This knot is useful when, having nished a continuous suture, you are left with a loop and a free end (Figure 24a).
Figure 23a
• The anastomosis should be started with the corner stay sutures inserted in an extramucosal fashion but it is best not to tie them until later. • It is advisable to insert a stay suture in the middle of both anterior walls as this w ill facilitate the view of the posterior walls that are about to be sutured. Alternatively, tissue holders such as Babcocks can be used in the same manner. • Insert all the posterior wall sutures as above, tying as you go. • Now tie the stay sutures which are the rst sutures of the anterior layer and replace in the haemostats. The mid-anterior wall stay s utures can now be released. Then insert all the anterior sutures in an extramucosal manner as before (Figure 23b).
26
Figure 24a
• Display the loop between the index nger and thumb of your left hand making it as small as possible by pulling on the other end of the thread with your right hand (Figure 24b).
basic surgical skills
Figure 24b
• Grasp the free end between the index nger and thumb of the left hand through the loop (Figure 24c) and by pulling it through and releasing the right-hand thread, the old loop is eliminated (Figure 24d).
• The whole process is repeated about 6–7 times (Figure 24f).
Figure 24f
Figure 24c
• Finally, pass the free end through the loop (Figure 24g) and tighten down (Figure 24h). The thread can now be cut.
Figure 24d
• Once again the new loop is made as small as possible by pulling on the right-hand thread, and the whole process is repeated using a type of ‘see-saw’ movement (Figure 24e).
Figure 24g
Figure 24h
Figure 24e
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27
Abdominal incision and closure Exercise • You will be provided with a simulator representing the abdominal wall. It will consist of two layers of material simulating the skin and linea alba of the abdominal wall. They will be stretched over an inated balloon which is to represent loops of bowel w ithin the peritoneal cavity. The aim of the exercise is to enter the peritoneal cavity without damaging the inated balloon, and then to close the abdominal wall again without bursting the balloon. • Make a midline incision in the simulated abdominal wall skin (Figure 25a).
• Incise the linea alba carefully ensuring no damage to the underlying balloon (Figure 25c).
Figure 25c
• Enlarge the incision using scissors until the incision is adequate for whatever procedure is intended (Figure 25d).
Figure 25a
• Expose the simulated linea alba and lift up using haemostats (Figure 25b). Figure 25d
Figure 25b
28
basic surgical skills
• Proceed to close the incision by inserting a non-absorbable suture at one end of the incision, ligating the ends with the knot on the inside. As most suture materials used for this closure are monolament, several throws are required, laying each one formally as a reef knot. Many surgeons will place at least one o f these throws as a surgeon’s knot. Currently many surgeons are now using a blunt needle (Figure 25e) for this procedure in order to minimise the risk of needle stick injuries.
Figure 25e
Figure 25g
• Ensure that there is enough suture length to close the incision which should be four times the length of the wound. If the suture length is not adequate, a further suture can be inserted starting at the other end of the incision. • Close the entire wound always ensuring that no loop of bowel or tissue is caught up by the suture material (Figure 25f).
A simplied model for this exercise can be provided by modifying a ‘lunch box’ as shown in Figure 25h (courtesy of Professor E Guiney).
Figure 25f
• Tie the suture material at the end of the closure, either by several conventional throws or by using an Aberdeen knot. If a loop suture is used, one of the strands can be cut close to the needle. The other end, still on the needle, can then be passed again through the tissues. Next the two ends can be ligated with several throws of a reef knot and the knot buried. • The knot should be buried by cutting off the short end or loop and then passing the needle through the tissues. Pull the knot deep into the closure and then cut the suture off ush (Figure 25g). The complete closure should then be inspected.
Figure 25h
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Handling vessels Vascular anastomoses
Vessels need to be handled in a very different manner from bowel. Extreme gentleness in handling is required and whenever possible a vessel should be manipulated by grasping the peri-arterial or adventitial tissues only. When direct manipulation is unavoidable, arterial wall should never be grasped between forceps for fear of injury to the intima or even a full thickness tear. Two methods for atraumatic handling of vessel walls may be used, either using the tips of closed dissecting forceps to gently open the arteriotomy (Figure 26a) or using the suture material to be used for the anastomosis to retract the arterial wall (Figure 26b).
Fine, accurate, watertight sutures need to be inserted at even tension when suturing vessels. Always insert the needle at right angles to the wall and pass it through the wall with several short ‘pushes’ which allow the needle to travel on the arc of its own circle, thus not splitting or tearing the delicate wall. The ner the vessel, the ner the sutures required and the smaller the bites taken. Therefore, aortic sutures need large bites while femoral sutures require ne bites. Distal anastomoses are often facilitated by operating ‘loupes’ – glasses which magnify the image between two and four times. A smooth internal suture line is essential or else platelet aggregates will collect and compromise the anastomosis. The suture line needs to be everted to result in good intimal apposition, unlike a bowel anastomosis in which the suture line tends to be inverted.
Technique of transverse arteriotomy
Figure 26a
Figure 26b
When suturing arterial wall it is advis able for the needle to pass from inside to out (ie from intima to adventitia) to x any atherosclerotic plaques and prevent the formation of intimal aps which may lead to dissection, embolisation or thrombosis. Non-absorbable, monolament suture material that moves smoothly through the vessel wall is required. These suture materials require a careful knot technique and several throws to prevent the knot unravelling (most vascular surgeons recommend six or seven throws). Do not damage the suture material by gripping it with dissecting forceps, the needle holder or a haemostat as this can lead to fracture. For the same reason, all knots need to be hand-tied. 30
basic surgical skills
Once an artery has been dissected free and inow and outow controlled, arteriotomy is performed to gain access to the lumen. For simple procedures such as embolectomy, a transverse arteriotomy is simplest and can be closed primarily. When more complex procedures are anticipated (eg endarterectomy or a graft anastomosis) a longitudinal arteriotomy provides the necessary exibility. In all but the largest calibre of vessels, longitudinal incisions require closure with a patch to prevent stenosis. Primary closure of a transverse arteriotomy results in minimal stenosis of the vessel lumen (Figure 27a) whereas primary closure of a longitudinal incision produces a long stenosis which may reduce ow and promote thrombosis (Figure 27b).
Figure 27a
Figure 27b
Exercise • Use a sharp, ne-pointed blade (eg a number 11 blade) and approach the vessel at right angles to the site of the incision. In most circumstances, commence your incision on the uppermost surface of the vessel. • With the blade facing away from you, use a short stabbing motion to pierce the anterior wall. Beware of the point of the scalpel entering the vessel too deeply and penetrating the opposing wall. Once the blade has entered the vessel lumen, lift it up and away to make a small opening in the wall without damaging the inside of the artery (Figure 28a).
Primary closure of a transverse arteriotomy
For primary closure of an arteriotomy, use two appropriately sized, double ended arterial sutures. Two suture lengths are used to allow suturing to begin in both corners of the arterial incision in order to avoid placing the last stitch at the corner of the arteriotomy, which can be difcult. By denition, not all of the s utures can pass through both arterial walls from inside to out. Plan the placement of your s titches whenever possible so that ‘intima to adventitia’ suturing occurs on the ‘downstream’ side of the incision (as dissection is most likely on this side once blood ow is restored).
Exercise • Commence at either end of your arteriotomy and pass both needles from inside to out (Figure 29). Tie the suture and secure in a rubber shod haemostat.
Figure 28a
• Complete the arteriotomy in a controlled manner using appropriately angled Pott’s artery scissors (Figure 28b). Lift the blade within the lumen away from the posterior wall to avoid damaging the inside of the vessel. Aim to open the vessel around 1/3 to 1/2 of its circumference, depending on how much access is required.
Figure 29
• Use your other suture in a similar manner at the opposite extreme of the arteriotomy and then continue suturing using ne, evenly spaced stitches until you reach the apex of the vessel.
continued over.... Figure 28b
• Inspect the lumen of the artery using one or more of the atraumatic techniques described above. open surgery
31
...continued
outside through the apex of your arteriotomy (Figure 31). Tie the suture and anchor one end in a rubber shod haemostat.
• At this point, secure the apical thread in a rubber shod haemostat and begin stitching with your rst placed suture (Figure 30). When the sutures come close at t he apex, the last thread can be left loose to facilitate suturing under direct vision as much as possible.
Figure 31
Figure 30
• Take the free end of the suture and work down the far side of the arteriotomy. Insert continuous stitches using ne bites while holding the redundant portion of the patch with your forceps (Figure 32). It is inadvisable to suture both vein patch and arterial walls with a single traverse of the needle unless you are experienced. Suture the two walls separately.
• Tie the knot at the apex of the vessel after ushing inow and outow vessels to get rid of air and thrombus.
Vein patch graft
A vein patch is the safest way to close an arteriotomy if there is the slightest suspicion that direct closure will produce narrowing.
Exercise • Make an elliptical arteriotomy about 3cm long in the vessel provided. Then cut one end of an elliptical patch in the simulated vein patch or prosthetic material provided. Leave the other end of the patch long and unshaped at this stage. The redundant portion can be used to handle the patch without damaging intima which will be in contact with owing blood in vivo. • Using a 5/0 prolene suture, insert an initial stitch from outside to inside at the shaped end of the patch and then pass it inside to
32
basic surgical skills – open surgery
Figure 32
• When you near the heel of the arteriotomy, cut the patch to length transversely and then shape into an ellipse. Continue around the apex and place two or three sutures along the proximal wall. • Now move back to your original suture and continue along the proximal wall until you meet the original suture. Flush inow and outow vessel before tying the two sutures at this point. • At the end of the procedure cut out the anastomosis and observe from within the lumen. There should be no roughness and no irregularity or inversion of the suture line.
MODULE TWO: trauma and orthopaedics
The orthopaedic module is designed to help
Handling traumatised tissues
you understand the principles of handling bone
The primary care of a contaminated wound is pivotal in the subsequent healing. It is frequently undertaken imperfectly. Secondary procedures, once inammation and scarring have established, may result in chronic disability. Six components to traumatic wound management are to be considered: • wound toilet and irrigation; • inspection of the wound; • deep palpation of the wound; • excision of dead or contaminated tissue; • establishment of adequate drainage; and • dressing of the wound for later inspection.
and soft tissues, such as muscle, tendons and contaminated tissues. The exercises have been chosen to give you hands on experience of handling these tissues. Participants will be expected to discuss with the faculty, patient care before, during and after the procedure being simulated. After each exercise the clinical relevance will be discussed and the results compared. The rst exercise is to debride a simulated contaminated wound. Attention should be paid to the vital structures injured and the extent of dead tissue removal.The importance of after care should be emphasised. The second exercise is a exor tendon repair in a pig’s trotter. This simulates the human arrangement of the nger exors at approximately twice the size. The exercise brings home the importance of understanding the anatomy of the tendon and the relevance of this to the strength of the repair. There will be a brief discussion of fracture management. This leads onto a discussion of the xation of fractures. Application of a complete cast and the safe removal of plasters will also be taught. The session is completed with a discussion of the pitfalls of plaster applications. Plaster application is a skill that all doctors should posses and most participants nd this messy exercise a pleasant end to the day.
Drainage and debridement Exercise • You will be supplied with a leg of either lamb or a large turkey in which a simulated traumatic and contaminated wound is shown. • Clean the wound with water. Normal irrigant and antiseptics are water bound rather than spirit bound in dealing with open tissues. Cleansing should be done by both irrigation and using a swab. It is conventional to paint the contaminated wound from the centre working outwards. • Initial inspection permits removal of gross contaminants and foreign material. The wound will have simulated glass or pebbles imbedded within it. It is essential that all of these are removed. You will subsequently be told by your tutor how may pieces of simulated glass were in your wound. • Following the initial inspection, a methodical detailed examination is required using forceps and retraction. Work methodically, for example clockwise, so that no component of the wound is left unexamined. Look out for and identify any structured anatomy including nerves, vessels and tendons. You may be asked to demonstrate these. trauma and orthopaedics
33
• Palpation will reveal tracts which might otherwise be overlooked. This should again be undertaken methodically and is a further opportunity to know every aspect of the wound. Foreign material will be felt by ngertip. Where a large overhang is present, it is wise to extend the wound to permit adequate toilet. • Excise all ‘dead’ tissue, cutting back to healthy muscle. There is an appropriate amount o f excision to be undertaken, but too little is worse than too much. Open up all cavities. • This type of wound must not be under tension. Any cavity or sump must be adequately drained and when this cannot be provided by a drain through the existing wound, it may justify the use of a dependent drain. A corrugated drain is provided to be inserted into the most dependent cavity, applying the principles of drain usage. Employing artery forceps, identify the depth of a deep tract in the wound and pass the forceps from the base to the skin or surface and the snout of the forceps are presented to the surface. A corrugated drain which has been proled by scissors is drawn back into the wound to rest through the line of penetration of the forceps. The drain should be sutured by a loose stitch into the skin and a s afety pin applied to prevent it dropping into the wound. • Wash the wound once nally with antiseptic, and place a loose pack (swab) soaked in antiseptic, such as acraavine, into the wound and its cavities. (For the exercise use water). • It is permissible to use one loose suture in order to keep the pack in place but under no circumstances should any attempt be made to close this type of wound. It is vital to have minimal tension and this will be checked by your tutor. This type of wound will be reinspected at 48–96 hours post surgery when further excision and possibly skin grafting may be appropriate.
tension of the sutures will leave voids and cause failure of the repair. This will be tested by distracting the repaired ends.
Tendon repair Exercise • The pig’s fore trotter includes a human-like arrangement of the supercialis and profundus tendons. Display a main profundus tendon and cut it transversely with scissors. • Handle the tendon at all times with the tip of a hypodermic needle and not with forceps, which may cause crushing. If necessary, trim the tendon ends until they are square and neat (Figure 33). Preserve length as far as possible.
Figure 33
• Refer to the diagram for installing a Kessler suture (Figure 34). The tendon is usually bean shaped in cross-section. Using 4/0 Ethiex, install the sutures in the proximal tendon end rst starting at the cut end. The entry suture should pass through the middle of one half of the sectioned tendon and follow parallel with the collagen bres to 1.5cm, or twice the diameter of the tendon, and then exit.
Handling tendons Tendon surgery, particularly in the exor tendon sheath in the hand, demands high surgical expertise and is beyond the remit of surgeons at SHO level. Rehearsing the technique however is of considerable value in developing surgical competence. Crushing or other forms of s urgical trauma will provoke brous tissue reaction and lead to tenodesis. Improper or inadequate
34
basic surgical skills
Figure 34
• The transverse component of the suture now passes a loop back just distal to the exit point and through the central half of the tendon. The reciprocal longitudinal suture pass is now made, exiting accurately in the middle of the second tendon half. Repeated misjudged needle placement is poor technique. Do not snug up the sutures at this st age, unless adequate length of suture material is available for the reciprocal insertion of the suture design into the distal end of the tendon. • Repeat the procedure into the distal end, having checked carefully the orientation of the tendon so that it will match the proximal end when the suture is tightened. Having placed the sutures in a satisfactory position, reduce the tendon accurately using the hypodermic needles and transx in the reduced position. Methodically tighten the suture using the same sequence as was employed in insertion which will then leave the tail and needle end of the suture to be tied and triple knotted so that the knot is buried within the cut tendon end (Figure 35).
Principles of fracture xation A fracture may be undisplaced, displaced into a position which is acceptable for adequate functional restoration or displaced into an inadequate position. Displacement must take in to account: • shortening; • angulation; and • rotation. A simple transverse fracture in which a periosteal or soft tissue hinge is present will not reduce by simple traction if displaced (Figure 37). It is necessary to exaggerate the original deformity so that the tension is taken o ff the periosteal hinge and the fracture slid into its position. Three-point xation is then adequate to keep it reduced (Figure 38).
Figure 37
Figure 35
• Remove the transxing hypodermic needles and apply tension to the tendon to ensure that the suture is performing adequately. If separation occurs the suture must be repeated. • Insert the running stitch using 4/0 Nylon (Figure 36). Insert the needle into the paratenon approximately 2mm away from the cut edge. Do not over-tighten. Each bight of the running suture should be at a separation of approximately 2mm. Rotate the tendon using the hypodermic needles until the complete running suture is in position. Tie off to the original starting suture at the end using a triple throw knot.
Figure 38
A spiral fracture is caused by rotation so that traction alone may not achieve reduction (Figure 39). Understanding the mechanism of rotation and reversing is necessary.
Figure 39 Figure 36
trauma and orthopaedics
35
Short oblique fractures are usually caused by indirect force to the bone and are reduced relatively easily by traction but cannot be adequately stabilised with external splintage (Figure 40).
layers must provide adequate strength without being unnecessarily cumbersome. Incorrect immersion in water will leave the plaster unsatisfactory to work, with weak spots. The reaction is rapid. A well-planned technique is necessary to ensure the optimal position for curing and crystal formation. The plaster may be a simple slab, a full plaster, or full and split. A complete plaster exposes the patient to the potential hazard of venous tamponade leading to Volkmann’s ischaemia.
Back-slab Figure 40
Comminuted fractures involve more than two simple pieces and generally are unstable (Figure 41).
Figure 41
These principles will be demonstrated by your tutor using both x-rays and w ooden models comprising fracture types with a leather simulated periosteal ap applied. Make sure that you handle the models and become familiar with the principles of reduction.
Plastering technique Plaster bandage is widely used for the splintage of fractures and immobilisation of joints and limbs to protect them while healing is occurring. The technique of plaster usage is applicable to general surgery, plastic surgery and orthopaedic surgery. Modern plaster bandage comprises anhydrous calcium sulphate which, when mixed with water, causes an exothermic rehydration to the crystalline form known as gypsum. Planning a plaster is dependent upon a particular application. It may require immobilisation of the joints above and below a mid-shaft fracture and careful selection of a limb position. The bandage
36
basic surgical skills
This procedure will be demonstrated but not actually performed during the course. The actual plastering exercise will be restricted to performing a full forearm plaster. • When applying a back-slab there should be minimal ulna deviation and, assuming the treatment is for a Colles type extension injury, approximately 10 degrees of palmar exion is appropriate. • A stockinette is prepared with a hole to permit the thumb to pass through. It s hould extend distally up to the metacarpophalangeal joints and proximally up to the elbow. • The appropriate width of undercast padding should be applied. This should be not more than 10cm and run from the metacarpal heads, covering 50% overlap. Avoid bunching, particularly around the thumb, which is more easily dealt with by making a hole in the padding. Having completed the application of padding, ensure that there are no lumps and a consistent thickness is obtained. • Six layers of plaster bandage of 15cm or 20cm width should be used. The slab should be of appropriate length and cut to accommodate the thumb and retain thumb movement (Figure 42). It should pass obliquely across the metacarpal heads as in the diagram (Figure 43) and proximally extend to within 4.5cm of the antecubital fossa to permit bending of the elbow.
Figure 42
Full plaster
Figure 43
• Dip the plaster in cold or slightly warm water retaining the two ends in your hand. Remove it, squeeze it lightly and then place it on the forearm to match the pre-prepared cuts for thumb and metacarpal heads. Stretch it longitudinally and pass the volar component carefully and smoothly under the exor tendon region at the wrist. Now ret ain the plaster on the forearm using a cotton or crepe bandage pre-dipped in water, making sure that the bandage is applied smoothly. • Mould the plaster as in the diagram using the at of the hands so that three-point xation is achieved (Figure 44). The shape of the plaster around the wrist is crucial in retaining position and should match the arrangements of the bone which are oval and not round (Figure 45). Make sure that no movement occurs until adequate setting of the plaster has been conrmed. The plaster will not be fully dry from surplus water until 24 hours after application, at which point it will have achieved full strength.
Exercise • You will be required to apply a below elbow cast on your partner and to s plit the cast. Your partner will then have the opportunity to reciprocate on you. • All the equipment must be gathered before you start. • Apply the stockinette only if there is no likelihood of swelling. The stockinette can cause constriction and, when cut through, may crease, thereby causing pressure. Having decided to apply the stockinette it needs to be measured distally up to the metacarpophalangeal joints and proximally up to the elbow allowing a bit extra. Cut a hole for the thumb, roll and apply to the limb. • It is important to position the limb before you apply the padding. Maintain the position throughout until the cast is completely set, as movement equals ridges in the cast. The position will vary according to the injury. • Open the bandages and keep them away from the water until you are ready to use them. In this case two 10cm POP bandages are required, with a spare on the trolley. • Prominent bony areas, such as the ulnar styloid, may require protecting with felt (Figure 46). A single layer of 10cm undercast padding should be applied smoothly, making a hole for the thumb (Figure 47). As you break the padding, hold the wrist rmly so that the patient doesn’t suffer discomfort or movement at the fracture site.
Figure 44
Figure 46
continued over... Figure 45 trauma and orthopaedics
37
... continued
Figure 47
• Soak the bandage in lukewarm water (20–25°C) according to the manufacturer’s instructions. Cold water retards and hot w ater quickens the setting process. Both extremes are uncomfortable for the patient. Hold the bandage at 45 degrees loosely in the palm of the hand with the rst few centimetres unwound to make it easier to nd the end. Count three full seconds, remove and squeeze very gently to take out the excess water. • Bandaging commences at the elbow end of the cast rolling the bandage from within out (Figure 48). Roll the bandage on evenly and without tension, covering about one-third of the previous turn and allowing tucks to form to accommodate the contours of the limb. The bandage should be brought up through the grip, gathering it together very gently (Figure 49). It should not be pulled down through the grip as this pulls the metacarpal heads together. Three times through the grip in total should be adequate; two w ith one bandage and one with the other. The second bandage is applied quickly before the rst bandage has set. Constant smoothing and moulding is necessary to make the cast w hole and not a succession of layers. Moulding must be done with the palms of the hands. Do not use the ngers as this can cause dents in the cast. Make sure the cast is moulded well into the palm. This can be done with the thenar eminence. Maintain the position until the cast is completely set, otherwise ridges will form.
38
basic surgical skills
Figure 48
Figure 49
• The limb needs to be rested on a pillow, because the cast could easily be dented and this might cause a sore. Trim the edges of the cast to allow full movements of the joints not held. The completed cast should extend from 4cm below the antecubital fossa to the heads of the metacarpals (Figure 50) and show the palmar crease (Figure 51). If stockinette has been used it can be turned back over the edge and secured in place with strips of plaster of Paris afterwards. Be careful when you apply the strips of plaster that you don’t go over the stockinette edge and thereby create a sharp ridge.
Instructions to patients in casts
Contact the doctor or hospital immediately if you experience any of the following: • The toes or ngers become blue or swollen or you are unable to move the limb. • The limb becomes painful. • You feel ‘pins and needles’ or numbness. • Any blister-like pain or rubbing under the cast. • Discharge or wetness under the cast. • If you drop any object down inside the cast.
Care
Figure 50
• Exercise the joints not held in the cast as much as possible. • Do not let the limb hang down unless it is being used, elevate the limb especially during the rst few days. • Allow the cast to dry naturally and leave it uncovered for 48 hours. • Do not sit close to a re. • Do not let the cast become wet. • If the cast becomes cracked, soft or loose, return to the hospital.
I conrm that I have received a copy of ‘Instructions to patients in casts’. Name: (capital letters please)
DOB: Signed: Date:
Figure 51
• It is very important to give full verbal and written instructions to a patient on the care of the plaster and the prevention of possible complications. Make sure the patient really understands when they should urgently return to hospital. (See example sheet on the right).
trauma and orthopaedics
39
Splitting a cast
Using plaster shears
• To split a cast to relieve circulatory or nerve impairment, a single lengthways/longitudinal cut is required for a plaster of Paris cast. If the cast is a resin-based product, it may need to be bivalved (cut in two halves) to relieve pressure. The padding, stockinette and any dressings must be cut right through to the skin. • Bearing in mind the underlying injury and, if possible, avoiding bony prominences, mark the cast (Figure 52). This task can be performed with either plaster shears or, providing the cast is dry, an electric oscillating cast cutter.
• The blade of the shears should pass between the plaster and the padding. Keep the blade parallel with the limb. If the blade is tilted either way the point or the heel will dig in or nip the patient (Figure 53).
Figure 52
Figure 53
• The hand nearest to the cast holds the blade parallel and remains still. To cut the cast push the shears together with the other hand.
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Using the electric cast cutter
• The saw has an oscillating circular blade which rubs its way through the hard plaster. It is relatively safe to use if handled correctly. It must be used on dry, padded casts with the blade held at right angles to the cast and a straight cut made without dragging the saw along the cast. • Cut with the saw using an in and out motion holding the blade at right angles to the cast. • Beware, the saw blade can cut the skin or get hot enough to create a burn if: • You drag the blade along the cast, instead of the in and out motion. • The cast is bloodstained when the padding and gauze becomes hard and the saw cuts straight through. • There is the presence of swelling or oedema and the skin has become taut and therefore easy to cut with the s aw. • There is prolonged use. • The cast material is thick. • The cast is very large. • The blade is blunt or damaged. • The padding is thin and the patient may feel the heat even in normal use. • The cast is unpadded, in which case special care is needed. • The cast is a resin-based material, where more energy is required to cut through the material and therefore heat is generated and may burn the patient. • If the patient moves or complains, always believe the patient, stop, reassess and continue carefully. • Use the cast spreaders to separate the cast and the bandage scissors to cut the padding and any dressing down to the skin. • A strip of padding can be placed in the split and a crepe bandage applied around the cast.
Bivalving
• To remove a cast fully, it should be bivalved, that is cut in two halves. Mark the cutting lines down the medial and lateral sides avoiding bony prominences and proceed as before using either the shears or the saw.
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MODULE THREE: minimal access surgery
Minimal access surgery (MAS) is performed through small incisions in order to minimise the trauma of the surgical wound. This module of the course is about laparoscopy and, in particular, therapeutic laparoscopy - a form of MAS particularly challenging to the theatre team. The main purpose of this module is to help course participants acquire the skills they need to perform laparoscopy efciently and, above all,
Operations carried out using the minimal access approach should have the same quality of their conventional open counterpart. It should be emphasised that the difference between minimal access surgery and open surgery is the extent of the access as indicated by the name of the technique. Minimal access surgery must not compromise patient safety. There are several factors which inuence the use of minimal access surgery:
safely. What happens in theatre is only a relatively brief part of the patient’s overall care. For the patient, MAS begins with preoperative assessment and counselling and ends only when there has been a full recovery and return to normal activities. Before turning to skills and safety, we begin with an overview of minimal access surgery and some of the ergonomics relating to its use.
• Safety of the access to body cavity
With previous abdominal surgery, there is a risk of bowel injury owing to adhesions. The technique and the site of induction of pneumoperitoneum need to be modied in patients with previous surgery. Laparoscopy is contraindicated in patients with a history of previous extensive abdominal surgery.
• Adequacy of exposure
Optimum assessment using the minimal access approach requires adequate space to expose and handle different organs. With gross obesity, the laparoscopic approach is more difcult and technically demanding. In the presence of bowel obstruction or organomegaly, the intraabdominal space is reduced and, therefore, experience and caution are required. In certain cases, laparoscopy may not be practical.
• Task difculty
The mechanical and imaging constraints in minimal access surgery make laparoscopic task performance more difcult than its open counterpart. The individual surgeon has to balance his or her own laparoscopic experience
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against the operative task. While a surgeon may be competent in carrying out bowel anastomosis using an open approach, he or she may not be able to perform laparoscopic bowel s uturing.
• Patient safety
Some patients require effective and quick intervention as in the cases of uncontrolled shock or faecal peritonitis. These patients are not suitable for lengthy laparoscopic procedures. The surgeon must be prepared to convert to an open approach should he or she encounter technical complications or experience a lack of progress with the procedure. This should not be regarded as a sign of failure. All patients undergoing laparoscopic surgery should be warned of the risks of converting to an open procedure. For example, the ‘standard’ conversion rate for elective cholecystectomy is about 5% and all patients should be warned of this possibility.
Constraints in minimal access surgery The minimal access approach creates a set of mechanical and visual restrictions on the execution of surgical tasks. Some of these are considered below.
1. Mechanical restrictions
These are the restrictions encountered on handling the tissues by endoscopic instruments (Table 1).
Table 1. Constraints in minimal access surgery
Mechanical restrictions • Limited degrees of freedom of instrument movement. • Diminished tactile feedback. • Small and long instruments. • Problems of organ retrieval.
Visual limitations • Two-dimensional imaging. • Reduced eld of endoscopic vision. • De-coupling of motor and visual spaces (monitor location). • Endoscope-instrument-tissue spatial relation (port location). • Quality of video-endoscopic system (resolution, illumination and chroma).
• Standard endoscopic instruments have four degrees of freedom of movement. A degree of freedom is the potential for movement in a single independent direction, or a rotation around one axis. In contrast to the 4° of freedom in minimal access surgery, there are more than 36° of freedom of the bodyarm-ngertips movement in open surgery. This limited number of degrees of freedom makes handling of tissues in laparoscopic procedures more difcult than during conventional open surgery. • In minimal access surgery, direct tactile feedback (hand to tissue) is lost and the indirect tactile feedback (through the instrument) is markedly diminished owing to the length of endoscopic instruments and the friction between the instruments and the ports. This degrades the ability of the surgeon to identify the nature of component tissues and tissue planes. It can also lead to tissue damage from excessive instrument grip, which can be poorly appreciated by the surgeon. • The small size of endoscopic ports dictates the size of endoscopic instruments. This causes several difculties in the design of endoscopic instruments to perform the same function as their open counterparts. Long thin instruments have a poor mechanical advantage. The length of endoscopic instruments exaggerates hand tremors, especially in a magnied endoscopic eld.
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• Another intrinsic problem in minimal access surgery is tissue retrieval after detachment from adjacent tissues. This problem has two aspects: (i) the tissue must be reduced to the size of access wounds with preservation of tissue architecture and (ii) the risk of contamination including spillage of cancer cells must be eliminated.
2. Visual limitations
The use of an image display system as the visual interface between the surgeon and the operative eld has several visual limitations compared to conventional open surgery (Table 1). The limitations of current image display systems are responsible for the degraded task performance in minimal access surgery compared to direct normal vision.
• Standard monitors in current use in surgical practice are two-dimensional imaging systems. They present only two-dimensional depth (pictorial) cues of the operative eld to the surgeon. For controlled endoscopic manipulations, the surgeon has to reconstruct a three-dimensional picture from a twodimensional image. This entails intense perceptual and mental processing which has to be sustained by the surgeon throughout the operation. • Reduced eld of endoscopic vision compared to ordinary unrestricted sight results in a decrease of the sensory input from the periphery of the operative eld. The eld of view describes the area inspected by the endoscope. At a given distance from the objective lens, the larger the eld of view, the greater the area that can be observed. Restricted eld of endoscopic vision accounts for the incidental tissue injury when instruments move outside the eld of view. All instruments should be moved within the abdomen under direct vision to avoid accidental injury. • The current layout of operating theatres with crowding of free-standing equipment often precludes optimal placement of the viewing monitor in front of the surgeon who usually operates from one or other side of the patient. In consequence, the visual axis between the surgeon’s eyes and the monitor is no longer aligned with the hands and instruments.
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Furthermore, the monitor is often far removed from the surgeon and thus the spatial location of the display system (sensory information) is remote from the manipulation area at the hand level of the operator (motor space). These factors degrade task performance in minimal access surgery. • The position of the instrument ports in relation to each other and to the optical port is an important determinant of the ease of performance of an endoscopic procedure and its execution time. • There are three major components that determine the quality of the image: resolution, luminance and chroma. Resolution determines the clarity of the image; luminance measures the amount of light available in the image signal and the chroma represents the intensity or saturation of the colour. In addition to the quality of the monitor, the nal image produced by the endoscopic system depends on the optical characteristics of the endoscope and quality of the camera.
Ergonomics of the set-up in minimal access surgery For a particular operation, the surgeon has to select the appropriate endoscope and place the ports and the monitor in optimum locations. The principles of the set-up of endoscopic equipment are summarised in Table 2. Table 2. Ergonomics of set-up
Endoscope selection • Optical axis-to-target angle of 90°. • Visual eld changes on rotation of obliqueviewing endoscope.
Port placement • Manipulation angle of 60°. • Equal azimuth angle. • Narrow manipulation angle necessitates narrow elevation angle. • Intra:extra corporeal shaft ratio below 1.0 degrades performance. • Endoscope and instrument aligned in the same direction.
Monitor location • In front of the surgeon. • At the level of the workspace.
Endoscope selection Direction of view of the endoscope describes the angle between the centre of the visual eld (optical axis) and the physical axis of the endoscope. Endoscopes can be of forward viewing (0°) or forward oblique direction of view (30°, 45°). The angle between the optical axis of the endoscope and the plane of the target is referred to as the optical axis-to-t arget view angle (Figure 54).
manipulation angle (1), Azimuth angle (2), elevation angle (3)
optical axis 30° endoscope 1 2 physical axis 3
optical axis
horizontal plane
30°
optical axis-to-target view angle
Figure 55. Angles govern port location
target surface Figure 54
The best task performance during endoscopic work is obtained when the optical axis-to-target view angle approaches 90° and the decrease in this viewing angle causes a signicant degradation of task performance. In practice, however, only oblique viewing endoscopes or ones with exible tips can achieve an adequate optical axis-to-target view angle approximating to 90°. For this reason, forward oblique endoscopes are preferable, despite the easier deployment of forward viewing types.
Port placement For bimanual tasks, manipulation, azimuth and elevation angles govern optimal port sites (Figure 55). The manipulation angle is the angle between the active and assisting instruments, while the azimuth angle describes the angle between either instrument and the optical axis of the endoscope. The elevation angle of the instrument is dened as the angle between the instrument and the horizontal plane. These angles determine optimal port location.
The maximal efciency and quality performance of intracorporeal knotting are obtained with a manipulation angle ranging between 45° and 75° with the ideal angle being 60°. A better task efciency is achieved with an equal azimuth angle on either side of the optical port. In practice, equal azimuth angles may be difcult to achieve but wide azimuth inequality should be avoided since this degrades task efciency. When a 30° manipulation angle is imposed by the anatomy or build of the patient, the elevation angle should also be 30° as this combination enables the shortest execution time and allows an acceptable level of performance. Likewise with a 60° manipulation angle, the corresponding optimal elevation angle, which yields the shortest execution time and an optimal quality of performance, is 60°. Thus within the range of angles that ensure adequate task efciency, a good rule of thumb is that the elevation angle should be equal to the manipulation angle. On planning port location, an adequate intracorporeal instrument length should be obtained. This depends on the size of the patient and the site of the operation. The intra:extra corporeal shaft ratio for optimal task performance is 2:1. minimal access surgery
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The ports for instruments (active and assisting) and the endoscope should be inserted so that the instrument and endoscope should be aligned in the same direction. The surgeon must avoid operating against the endoscope/camera as this produces a mirror image and makes manipulations extremely difcult.
Monitor location The best task performance is obtained with the monitor located in front of the operator at the level of the manipulation workspace (hands), permitting ‘gaze-down viewing’ and alignment of the visual and motor axis. Gaze-down viewing by the endoscopic operator allows both sensory signals and motor control to have a close spatial location and thus brings the visual signals in correspondence with instrument manipulations, similar to the situation encountered during conventional open surgery. In practice, the location of the monitor is determined by the site of the operation. For upper abdominal procedures, such as cholecystectomy and fundoplication, the monitor is placed near the patient’s head. During appendicectomy, the monitor is located over the right iliac foss a and the surgeon stands on the left side near the patient’s hypochondrium. Members of the operative team should look at the monitor placed in front and must avoid following the procedure on the side monitor.
Principles of camera operation The operation of the camera is crucial to surgical manipulations. Operating the endoscope and camera is a dynamic process throughout the surgical procedure. The camera operator actively takes part in the operation, and at times it can be quite hard work!
Maintaining the task in the centre of the endoscopic field The centre of the endoscopic eld has the best illumination and least image distortion. This provides the surgeon with the optimum image quality. The best performance therefore, is obtained with the task maintained in the centre of the endoscopic eld. In addition, if the surgeon works at the periphery of the eld, instrument movement may accidentally occur outside the displayed image, potentially damaging adjacent structures. 46
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Adjusting the size of the visual field and image details The distance between the endoscope and the target determines the size of the visual eld and the resolution at the target area. The smaller the endoscope-to-target distance, the smaller the size of the visual eld and the higher the resolution at the target. Withdrawal of the endoscope increases the area of the operative eld viewed by the surgeon. The surgeon needs this view to insert endoscopic instruments or to perform a task which requires a large area for manipulation such as knot tying. On the other hand, advancing the endoscope towards the target increases the detail of the image viewed by the surgeon at the expense of a smaller operative eld. The surgeon prefers this view to perform detailed tasks, such as dissection and picking up a thread.
The laparoscopic stack As a member of the laparoscopic theatre team you need to know what equipment is needed and how to set it up and use it safely. Important basic items of equipment for laparoscopic surgery include: • rapid-ow insufator; • light source; • video camera and camera cable; • laparoscopes; • monitors; • electrosurgical unit; and • suction/irrigation.
Rapid-ow insufator
The insufator supplies carbon dioxide (CO 2) to create and maintain the pneumoperitoneum. It is recommended that the intra-abdominal pressure should not rise above 12–14mmHg, to avoid compression of the IVC, with resultant decreased cardiac return (see section on pathophysiology of carbon dioxide pneumoperitoneum on page 53).
Key features • Indicates the intra-abdominal gas pressure. • Stops the ow when a certain pre-set pressure has been reached (usually 12mmHg). • Has an alarm to indicate excessive pressure.
• Indicates the rate of ow of CO2 into the abdomen. • Records the total volume of gas delivered.
Light source and cable
A powerful high-intensity light source is necessary to give a clear view of the abdominal cavity. A light source with 150–300w xenon or halogen lamp and automatic intensity control will give continuous optimal illumination. The appropriate liquid light or bre optic light cable is also essential.
Key features • Automatic light control adjusts light intensity to give optimum illumination, reducing glare from bright surfaces as the endoscope moves within the peritoneal cavity. • In some systems light output and lamp life is continually monitored and displayed to reduce interruptions of the surgical procedure owing to lamp failure. • All systems have an internal cooling system that help to extend the life of the lamp. • The brightness of a high intensity light source may cause retinal damage if s hined directly into the eye. This can happen if the shutter is opened without the light cable in place or if the light cable and laparoscope are not carefully handled. • The instrument ends of some light cables become very hot during use and can burn the patient or staff if disconnected from the laparoscope. The temperature at the end of the laparoscope is 95°C and at the end of the light cable as high as 225°C. The light should be on its lowest setting or switched off unless the laparoscope is in use.
laparoscope has a camera attached directly to the lens system.
Key features • Camera head is lightweight, comfortable to hold and easy to move and manipulate. • ‘White’ or ‘colour’ balance adjustment allows accurate colour reproduction. Some cameras do this automatically. • Laparoscopes are available with a distal chip camera and a light guide and video lead in one cable. • Adjustments for variations in light intensity maintain a constant light, usually by an automatic iris. • An override or ‘gain’ exists to improve exposure if necessary. • Some camera heads have accessory buttons to control light sensitivity as well as the printer and the VCR function.
Camera etiquette • The camera operator is the ‘eyes’ of the team and should be ready to move where requested by the operating surgeon. • It is the job of the camera operator to keep the operative eld in the centre of the monitor screen. • Jerky movements hinder precise surgery. • The camera is marked to help orientation. The marks differ between manufacturers. • Ensure that the camera is focused to give a sharp picture at the start of the procedure by focusing on an object outside the patient. • Instruments out of view are a potential danger to the patient, especially if they are att ached to the diathermy machine. • The camera operator has an important role during port insertion, guiding the surgeon and minimising the risk of damage to intraabdominal organs
Video camera and camera cable
The camera may be single chip or three-chip. Single-chip cameras process the three primary colours, red, blue and green, while three-chip cameras have a chip for each of the three primary colours and therefore give a better denition, especially with red. The camera head is an optical/electronic interface which is attached to the laparoscope. A standard eye-piece laparoscope requires a coupler to connect to the camera head. A video
Laparoscopes
A standard laparoscope uses a rigid rod lens system to transmit the image from within the abdominal cavity. The operating eld is illuminated by light conducted through a breoptic illumination bundle, alongside the lens system.
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Key features • Laparoscopes are usually 10mm or 5mm in diameter, with 0° or 30° eld of v iew. • 10mm 30° is most commonly used now. • Standard mount for attaching the camera. • Separate attachment for the light cable unless it is a distal chip camera instrument.
Using the laparoscope • Make sure that the telescope is undamaged before starting the operation. Defects at either end can distort the image and broken bres reduce light transmission. • Warm the telescope to body temperature before insertion to minimise fogging of the distal lens. Anti-fog chemicals can also be useful. • Thoroughly wipe the eyepiece dry to prevent moisture in the space between it and the camera. • The CO2 inow is cold and preferably should not go down the same port as the camera. • If a small lm of blood adheres to the objective lens, remove the laparoscope and wipe the lens clean when the surgeon requests it. Never clean the laparoscope with anything abrasive. Surgical spirit, warm saline and special solutions of anti-fog will break down grease.
Suction/irrigation
Suction and irrigation is usually necessary. This can be carried out by a suction unit and a pressure bag for the irrigation uid. Alternatively, the surgeon may prefer to use a suction/ irrigation pump. Some surgeons add heparin to the irrigation uid to discourage blood clotting (eg 1,000 units of heparin to 500ml of Hartmann’s solution).
Theatre set-up
The positioning of all equipment must be carefully planned. Exact placement will vary depending on the procedure to be performed, the surgeon’s preference and the size of the theatre. However, some generalisations can be made. The monitors should be positioned on either side of the patient to provide a clear unobstructed view for surgeon and assistant. Ideally, the screen should be positioned directly in the surgeon’s line of sight (Figure 56).
Monitors
A high-resolution colour television monitor is necessary with at least an equal-line resolution to that of the camera. The monitor should be at least 13” in size, ideally 20”, depending on the distance from the screen the surgeon is working. The ideal distance between the surgeon and the monitor should be four to ve times the diagonal measurement of the screen. A second monitor is preferable to give both surgeon and assistants a clear and comfortable view of the procedure. Controls on the monitor allow adjustment of the image if necessary. However, ddling with the controls should be discouraged.
Other accessories
A video cassette recorder and/or video printer may also be required for teaching purposes and documentation of procedures.
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Figure 56
The insufator should be within view of the surgeon so that he or she can always monitor the abdominal pressure. Instrument trolleys, diathermy, suction/ irrigation, etc, should be positioned to allow the surgeon mobility and to give theatre staff access to equipment. Leads and cables should be positioned so that when connected, they do not become tangled or restrict the surgeon’s movements. Take care not to damage an expensive cable with a carelessly applied sharp towel clip! Picture interference will also be minimised if the diathermy machine is positioned away
from the camera/monitors and if t he diathermy instrument is not close to the camera head when in use. The diathermy and video leads should also be kept apart. Safety note: specialised storage trolleys with a single power cable leave fewer trailing wires as hazards for theatre staff. The diathermy power cable should be connected into a different socket and preferably a different electrical circuit from the imaging equipment, to reduce picture interference. Do not x more than one diathermy cable. Remember that all attached electrodes become active when the footswitch is pressed.
Positioning
Positioning of the patient is dependent on the procedure and the access needed to perform the operation. The patient may need to be in a modied Lloyd-Davis position, eg for laparoscopic Nissen’s fundoplication, laparoscopic colectomy and laparoscopic gynaecological procedures. During laparoscopic cholecystectomy a cholangiogram may be needed. Check to ensure the patient is on an x-ray lucent t able. For some procedures, eg laparoscopic hernia repair, the surgeon may not want the patient’s arms on the chest (for venous access for the anaesthetist) as this may restrict the camera position. Always make sure that the patient is properly secured to the table. A steep tilt may be needed in some advanced procedures.
Exercise • Familiarise yourself with the various components of the system including: the insufator, the light source, the camera and the cable, the laparoscope, the bre-optic cable, the monitor, the suction and irrigation unit and the principle of white balance.
Safe induction and maintenance of the pneumoperitoneum Preliminaries For surgery in the pelvis it is sensible to drain the bladder with a urinary catheter. For upper abdominal surgery a nasogastric tube may be inserted to empty the stomach to make space and prevent accidental visceral perforation. Both can usually be removed at the end of the procedure.
Positioning The patient is placed supine or in a modied lithotomy position. A diathermy pad is attached to the thigh and the diathermy machine settings checked. The patient is then draped widely to expose the entire abdominal wall, which has been prepared with antiseptic solution. At this point the surgeon should check the following: Preoperative checks • Patient check • Patient position • Palpate for masses or organomegaly • Diathermy machine • Diathermy plate • Suction and irrigation • Insufator • Telescope, camera and video • Insufator tubing • Instruments Penetrating the intact abdominal wall to induce the pneumoperitoneum and insert the rst port is probably the most hazardous part of a routine laparoscopic operation. If this is not done with care and skill there is a danger of injury to underlying viscera such as bowel and bladder. Even deeper structures like the aorta, iliac vessels and vena cava have been speared by the inept and unwary. Once the rst port is in place and the pneumoperitoneum has been induced, the surgeon can insert a laparoscope and work with the abdominal contents safely in view. There are two main methods, the open and the closed methods. Each has its fervent advocates who say they only use one method. The open method is safest and is increasingly being accepted as best practice. Many surgeons prefer to have both methods available for use when appropriate.
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Open method of inserting the rst port
(See Figure 57.) Open laparoscopy is favoured for all cases by many surgeons who prefer not to insert a sharp instrument where they cannot see. Open access is recommended to all surgeons where there are scars in the abdominal wall close to the site of insertion of the laparoscope. A 1–2cm intraumbilical incision is deepened down to the linea alba which is incised between stay sutures. The peritoneum is exposed and an incision made into it under vision. A nger may then be inserted to sweep away adhesions. A blunt-tipped trocar is then inserted which will not penetrate structures attached to nearby scars. A supraumbilical incision may be preferable for the obese patient. Alternatively, the laparoscope and port can be introduced together so that insertion can be controlled endoscopically. A disposable port and cutter instrument for insertion under v isual control is available. Insufation through the port begins once it is safely in the peritoneal cavity. A purse string suture around the port may help minimise gas leakage. The open insertion method is very safe but there is a possibility of increased gas leakage around instruments passed through the incision. Proprietary trocars with occlusive balloons to make a seal round the instrument may help. Figure 57
Exercise • In the simulator provided, place a mark to represent the umbilicus. • Make a 1–2cm umbilical incision and deepen to a level representing the linea alba (this may be marked with a red felt-tip pen for clarity). Insert a stay suture to both edges. • Deepen the incision to reach peritoneum and incise through into the peritoneal cavity. Insert a nger to ensure that there are no adhesions. • Different types of port may be available for you to examine and practise with. I nsert one such port with a blunt trocar into the peritoneal cavity and use the stay sutures to secure the cannula. A purse string suture may be inserted instead of the stay s utures and this may help prevent gas leakage. • There are a series of commercially available cannulae that try to seal the wound and prevent gas leakage.
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Closed method of creating pneumoperitoneum
This technique is not as safe as the open method and therefore is not encouraged. However, many laparoscopic surgeons still use this technique and the safety issues regarding its use are covered in this course. Usually an intraumbilical incision is used but for the very obese, for some advanced upper abdominal procedures and where there are pre-existing abdominal wall scars, other access points may be used, such as the left hypochondrium. For simplicity, only the umbilical approach will be detailed here.
The Verres needle The Verres needle is a hollow needle with a spring loaded blunt central core. At the proximal end is a Luer port closed by a tap. The tap and spring mechanism of the Verres needle should be checked and its patency tested by attaching it to the insufator and running gas through at 1 litre per minute.
Inserting the Verres needle Prior to making an incision a nasogastric tube is usually placed to ‘decompress’ the stomach and a urinary catheter passed (or ensure that the patient has voided urine immediately prior to theatre), so that neither the stomach nor the bladder can be damaged by the Verres needle. Usually a vertical or transverse incision is made deep inside the inferior aspect of the umbilicus. It overlies the area where skin, deep fascia and parietal peritoneum meet at the thinnest point in the abdominal wall. In this position, the needle has the least chance of tenting the peritoneum to leaving its tip in the space between the posterior rectus sheath and the peritoneum. Gas accidentally insufated more supercially will cause surgical emphysema of the anterior abdominal wall. This is a common error for the novice, but merely a nuisance, as opposed to the more dangerous error of too forceful an insertion. The patient is placed in a Trendelenberg position of 20–30°. The anterior abdominal wall is lifted up by the surgeon and assist ant on either side of the umbilicus to create negative pressure within the abdominal cavity. A Verres needle is then inserted, initially perpendicular to the abdominal wall, and
advanced until it penetrates the linea alba and peritoneum. When it does this, there is usually a distinct ‘give’ as the point enters the cavity. It is now that damage to underlying structures can occur. The needle is advanced under careful control, held in the sensitive pinch grip between forenger and thumb, like a pen or a dart, to feel the way through the layers. The sacral promontory with its overlying great vessels rises remarkably closely beneath the umbilicus, especially in a thin patient. As soon as the needle is through the abdominal wall, it is then aimed towards the pelvic cavity. The central spring-loaded core of the Verres needle should advance when the sharp tip of the needle is lying free within the peritoneal cavity (but do not rely on it). The needle is inserted with the tap open so that the negative intra-abdominal pressure caused by lifting the abdominal wall allows some air to enter so that the abdominal contents fall away from the point of puncture.
Step by step • Check and test Verres needle. • Incise umbilicus. • Trendelenberg. • Lift abdominal wall. • Open tap of Verres needle. • Insert perpendicular to abdominal wall. • On entering abdominal cavity, aim needle towards sacrum.
Checking the needle position Once through the peritoneum the needle should move freely from side to side. There are a number of tests to conrm that the tip of the needle is free in the peritoneal cavity.
The drop test A drop of saline dropped into the open Luer tting of the Verres needle should fall from sight.
Saline injection A small amount of normal saline is injected into the needle. It should ow in without difculty. Drawing back should draw air or clear uid into the syringe and not bile, blood or bowel contents.
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Test insufflation Slow insufation at 1 litre per minute produces little rise in the pressure reading if the needle is in the right place. Occasionally the Verres needle is blocked by a plug of fat. This can sometimes be freed by gently rotating and moving the tip from side to side.
Insufflation Insufation can begin once it is certain that the needle is correctly placed. The controls of the insufator are turned to automatic to deliver a faster ow of gas. The pressure reading is constantly monitored. The abdominal wall should be percussed at intervals to check for the characteristic uniform tympanic sound as the abdominal cavity lls with gas. If insufation of t he rectus sheath occurs this can be detected by a rise in ination pressure, asymmetrical distension of the abdominal wall and unevenness of the sound when percussed. Once liver dullness is lost, the head down angle of the operating table is levelled. As long as there is no appreciable rise in pressure (certainly not above about 14cm of w ater), insufation continues until 3.5 to four litres of gas have entered and there is visible distension of the abdomen.
• Check that the needle is free in the peritoneal cavity by aspirating gas/air back into the syringe of saline and then by ushing through and meeting no resistance. A further drop test can be used, dropping saline onto the end of the Verres needle and seeing it disappear spontaneously into the peritoneal cavity on elevation of the abdominal wall. • Connect the gas ow tubing. • Turn the gas pressure on the insufator to approximately 12–14 mmHg. • Turn the gas ow on to one litre per minute initially. Check the gas pressure reading – it should be low initially. • Once you are satised that free ow is occurring, the ow rate can be increased to three litres per minute. • If an obstruction to ow is encountered, the commonest cause is from the Verres needle lying against the omentum or small bowel. Rotate the needle and if that fails, withdraw the needle by a few millimetres. If there is still a problem check that the gas ow tap on t he cannula has not been inadvertently turned off or that the gas supply tubing has not been kinked. If ow is still not free, the needle may have been withdrawn into the abdominal wall musculature and the procedure will have to start again.
Insertion of the umbilical trocar and laparoscope Step by step • Check freedom of movement. • Drop test. • Inject saline and aspirate. • Slow insufation with minimal pressure rise. • Percuss abdomen during insufation.
Exercise • Familiarise yourself with the Verres needle. • Make a small infra-umbilical incision. • Lift up the simulated abdominal wall (in the simulator it is easier to use a towel clip). • Insert the Verres needle perpendicular to the simulated abdominal wall. As the needle encounters resistance, the blunt tip withdraws and the needle cuts through the tissue. Once the simulated abdominal wall has been penetrated there is a distinct ‘give’ and usually a click can be heard. Angle the needle down towards the pelvis and advance a little. • The needle can be rotated to show that it is not caught in an adhesion or bowel loop. 52
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If the abdominal cavity is well distended, the peritoneal contents should fall away from the abdominal wall. However, insertion of the rst port in the closed method remains one of the most dangerous procedures in laparoscopy. Pressure on the upper abdomen will move gas into the space below the umbilicus. Lifting the abdominal wall is not usually necessary at this stage and may cause unpleasant bruising. The port is inserted with great circumspection. The body of the device is held in the palm while an index nger extended along the insertion tube will act as a guard to prevent more than a centimetre or so of the sharp end entering the peritoneal cavity. Disposable trocars are equipped with ingenious guarding devices which slide forward to cover the point when it penetrates the peritoneum. Unfortunately, time lapse photography has conrmed that damage to intra-abdominal structures can occur before the
shield has had time to advance and such devices should not induce a false sense of security. Once in place the trocar is angled almost horizontally and pushed towards the pelvic cavity with due regard to the great vessels coursing over the sacral promontory. This is particularly crucial if the patient has a signicant lumbar lordosis. The laparoscope can then be inserted. Watch the video screen as the laparoscope is inserted. Sometimes there is a lm of peritoneum or an omental adhesion which has to be carefully negotiated by moving the end of the instrument in order to enter the peritoneal cavity. All other ports are introduced under direct vision.
Exercise • Familiarise yourself with the various types of trocar and cannulae provided. Examine both disposable and non-disposable ports with their appropriate reducers. • The Verres needle should be removed once the peritoneal cavity has been distended by 3–4 litres of gas and the pressure has risen to 12– 14mmHg. • Insert the umbilical trocar into the simulator perpendicular to the skin, lifting the abdominal wall as before. • With reusable trocars the action of insertion tends to be a screwing action, but for t he disposable trocars a straight pushing action is needed. Once the simulated abdominal wall has been penetrated, a characteristic ‘give’ is felt. Hold the trocar in such a way as to prevent too deep penetration in an uncontrolled manner by positioning a nger along the shaft of the trocar. • Check position by venting gas from the peritoneal cavity either through the Luer lock or by pressing the gas valve. • Connect the gas ow tubing. • Insert the camera. Ensure there is no damage immediately under the port. You may see the saline used earlier in the exercise lying on the oor of the simulator. • Inspect the inside of the simulated peritoneal cavity. • Insert two working ports. The sites of these ports will depend upon the procedure to be undertaken. All secondary ports should be inserted under direct vision. Pressure on the
abdominal wall indicates the site of insertion. Make a small incision in the skin and then insert the port under direct vision. A screw grip may be used to secure the cannula.
Maintenance of the pneumoperitoneum
The insufator should be set to a pre-set pressure of 12–14mmHg. The machine detects a fall in pressure and responds by insufating more gas. If pressure exceeds a pre-set limit an alarm sounds. If the alarm sounds • Stop insufating. • Recheck port positioning. • Check that gas tubing is not obstructed and tap is open. • Let gas out to reduce intra-abdominal pressure. • Check that anaesthesia has not lightened.
Physiology of carbon dioxide pneumoperitoneum The attraction of carbon dioxide as a gas for insufation is its solubility. This speeds its elimination but increases its physiological effects. When CO 2 production exceeds its elimination, acid base and respiratory homeostasis is disturbed. CO2 absorbed as the result of insufation is stored until eliminated by the lungs. The total CO2 storage capacity of the human body is approximately 120 litres. Bone is the largest potential long-term reservoir. When CO 2 retention occurs for less than an hour or so skeletal muscle and visceral stores are more important.
Pathophysiology of carbon dioxide pneumoperitoneum Effects of carbon dioxide CO2 pneumoperitoneum can cause adverse cardiovascular, respiratory and metabolic changes. In all patients, there is a 25–30% drop in the cardiac return in the rst 20 minutes of a laparoscopic procedure, but most healthy patients demonstrate no ill effects. There is, however, a risk to patients with reduced cardiopulmonary reserve. CO 2 accumulation in these patients results in decreased stroke volume and accelerated heart rate which stresses the myocardium. Ventilation-
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perfusion shunts occur so that increases in arterial PaCO 2 may not be matched by changes in the CO 2 measured in the expired gases. Patients with signicant respiratory or cardiovascular disease must therefore have their arterial gases monitored.
Volume effects Insufation of gas into the peritoneum has a number of effects related to the volume of gas used. Partial obstruction of the inferior vena cava and splinting of the diaphragm become important when the procedure lasts longer than 20 to 30 minutes. Venous pooling in the legs may predispose to deep venous thrombosis. Diaphragmatic splinting may compromise ventilation, especially when there is pre-existing lung disease. Cardiac dysrhythmias may occur during insufation. Sinus bradycardia is most common and can be corrected by temporarily releasing the pneumoperitoneum and administering intravenous atropine. Other dysrhythmias are usually secondary to reduced venous return and cardiac output with underperfusion of the myocardium. The anaesthetist must have adequate intravenous access throughout a laparoscopic procedure and effective monitoring, including central venous pressure measurement if necessary, is mandatory. Gas insufated at room temperature does not cause signicant hypothermia. However, gas leakage allows water vapour t o escape and there may be heat loss as latent heat of vaporisation. (It is as if a wind were blowing over the exposed abdominal contents.) If the procedure is prolonged, the core temperature should be monitored and hypothermia corrected.
Difculties with access Long needles and trocars are available for use in the very obese but they should never be used by mistake in patients of normal st ature because of the increased risk to deep structures. Inserting the Verres needle in thin people may also be problematic. Not only are the great vessels close to the surface, but t actile recognition of the layers of the abdominal wall may be impaired.
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Inspecting the peritoneal cavity The rst port must be large enough to allow the laparoscope to pass and a 10mm port is usually selected. The rst and vital step is to identify any structure that could be harmed during the procedure. No two abdominal cavities are identical and signicant variants are quite common.
Insertion of additional ports The number and sites of additional instrumentation ports depend upon the operation to be performed. Their size depends on the instruments to be passed through them. The port trocars are inserted through skin incisions which may be prepared with an injection of bupivacaine. The course of the epigastric vessels should be avoided. When the ports are in place they are secured by a threaded securing collar or by a suture. When instruments are removed the ports are closed by a gas-tight trumpet or ap valve. The entry of the point is viewed with the laparoscope so that damage to intra-abdominal structures cannot occur.
Management of profuse bleeding during port insertion If a large vessel in the abdominal wall (for example an inferior epigastric vessel) is punctured by a trocar, the bleeding can sometimes be very dramatic. Do not panic. Wait a while because the bleeding sometimes stops spontaneously. If it does not, DO NOT REMOVE THE TROCAR because it marks the track of insertion along which the bleeding vessel is located. A strong suture on a straight needle should be passed directly alongside the trocar and retrieved in the abdomen with a needle holder. It is then passed out through the abdominal wall on the other side of the trocar. The procedure is repeated forming a Z-stitch embracing the track of the trocar. The trocar is removed and the knot tied to achieve haemostasis. Unfortunately, an untidy scar results. Alternatively, a Foley catheter can sometimes be inserted through the port and the inated balloon used to tamponade the bleeding. If in doubt, convert to an open procedure.
Removal of ports All ports should be removed under direct laparoscopic vision to be sure that there is no bleeding from port holes. The last port should be removed slowly with the laparoscope inside the port to be sure that there is no bleeding.
Closure of port holes The 10mm port holes must be closed with care to avoid later hernias. Most surgeons advocate formal closure of deep layers with interrupted synthetic absorbable or non-absorbable suture (usually using a J-needle) with separate skin closure. Take care not to pick up small bowel in the closing stitch. The 5mm port holes do not require closure of the abdominal wall and simply need skin closure.
Minimal access surgery instrumentation The expanding range of laparoscopic procedures creates a demand for novel instruments. However, a number of basic instruments are common to all therapeutic laparoscopic procedures.
Basic instruments A basic instrument set might consist of: 1 x 10mm 0° laparoscope. 2 x Verres needles (120mm and 15 0mm). 2 x 10mm trocar and cannula with trumpet valve and gas inlet. 2 x 5mm trocar and cannula with trumpet valve and gas inlet. 1 x 5mm insulated grasping forceps. 1 x 5mm insulated grasping forceps with ratchet. 1 x 5mm insulated dissecting forceps. 1 x 5mm insulated scissors. 1 x 5mm reducing sleeve. 1 x 10mm clip applicator. 1 x 5mm right angled diathermy hook. 1 x 5mm suction/irrigator. 1 x 10mm retrieval forceps. 1 x light cable. 1 x diathermy lead. 1 x gas lead. 1 x cholangiography catheter.
diathermy electrode tting. Have bipolar forceps available.
Verres needle • Used for closed method of creating pneumoperitoneum. • Has a spring-loaded obturator that advances over the sharp tip as soon as the needle enters the abdominal cavity. • Luer tting to attach gas input from the insufator. • Tap to control gas ow.
Trocar and cannula • Used to establish a port of entry into the abdominal cavity. • Spring-loaded valve to allow instruments to pass while preventing the escape of gas. • Most common sizes are 5mm and 10mm in diameter. • Cannulas with or without gas inlet. • Reusable 10mm and 5mm trocar and cannula. • Disposable cannulas for single use may be more expensive but have the advantages of: • always being sharp; • a protective safety shield; and • are radiolucent.
Grasping forceps • Used for grabbing and retracting tissues within the abdominal cavity. • May have a ratchet to keep the jaws closed. • Traumatic or atraumatic jaws. • Type used will depend on the surgery being performed.
Dissecting forceps • For spreading, separating and dividing. • Atraumatic. • Straight or curved.
Scissors • For cutting tissue or sutures. • May be hooked, straight, curved or micro. Grasping/dissecting forceps and scissors may or may not be insulated and/or rotating. Insulated instruments have the advantage that they do not reect light.
Note: Try to ensure that all diathermy instruments are compatible with a single
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Instruments for preparation, incision and closure • Sponge holders. • Blade handle and blade. • Fine toothed dissecting forceps. • Mayo and suture scissors. • Artery forceps. • Needleholder. • Baby Langenbeck retractors. These instruments are also needed for the open method of inducing pneumoperitoneum. Always have available, if not ready, the instruments necessary if the case proceeds to open surgery. Additional instruments – available for particular procedures or surgeon preference: 10mm 30° laparoscope – for hernias and advanced procedures. 5mm 0° laparoscope – for use with a 5mm port. 2 x 5mm needleholders. 1 x 10mm retractor. 5mm and 10mm Babcocks (Beware! Some of these are very traumatic.) 5mm and 10mm bowel clamps. Biopsy forceps. Bipolar forceps. Endoscopic stapling instruments. Endoscopic retrieval bags. Endoloops. Dejardin stone grasping forceps. The number of instruments and sets you will have depends on the level of service, the type of procedures being performed and nancial constraints. It is important for theatre staff to have a good knowledge of the instruments available within their unit. They are then able to offer assistance or guidance, especially if the unexpected occurs or the surgeon is inexperienced. For example, if the cystic duct is too wide to clip safely, an endoscopic stapling gun or endoloop might be a suitable alternative, thus avoiding conversion to an open procedure. Selecting and purchasing instruments for minimal access surgery is complex as more than one department/specialty is involved. There are a number of manufacturers supplying instruments, each of which may have different preparation, sterilisation, assembly and disassembly, cleaning, and maintenance requirements. It is therefore obviously easier for theatre staff and a better use of resources if some standardisation can be agreed and maintained. 56
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Selection of instruments will also depend on unit policy with regard to disposable equipment and the surgeon’s preference.
Disposable instruments Advantages • Sterile, sharp, functional, insulated and ready to use, with safety features such as the shield on the trocar and cannula and caps to cover the working end of the instrument for safe disposal in a sharps bin. • If discarded correctly, the instrument is safer for theatre staff as there is no risk of injury during cleaning and maintenance. • Keeps pace with improvements in instrument design. • No time spent on cleaning and maintenance.
Disadvantages • Cost. • Require storage space. • More waste for incineration – pollution and environmental issues. It is tempting to reuse a dispos able instrument but it is impossible to guarantee adequate cleaning and instrument function after re-sterilisation. Reuse must be avoided. Manufacturers will not accept product liability if a disposable product is reused.
Reusable instruments Advantages • Cost containment – larger initial outlay but seen as more cost-effective in the long run, simply because they can be used again and again. • Less storage space required. • Less clinical waste.
Disadvantages • Hidden costs of cleaning, sterilisation, maintenance, repair and the training to do this. • Less safe for patients and staff: • More risk of injury to staff when disassembling and cleaning. • May be difcult to check that all surfaces are clean and sterile. • Possibility of incorrect re-assembly causing instrument malfunction. • Possibility of unnoticed damage to insulation.
• Less able to take advantage of developments in instrumentation because of a reluctance to lay out more expenditure. The actual cost of disposable instruments, with their saving in time and safety benets to patients and staff, should be compared with the actual costs of maintaining reusable instruments in optimum working condition.
Exercise • Familiarise yourself with and practise the correct handling of each of the instruments displayed.
Grasping and manipulation skills Exercise 1 – grasping and manipulation • Insert a 5mm grasper into the right-hand port constantly watching as it is inserted. Pick up an object such as a cotton pledget from a galley pot and place it on the oor of the simulator. Release it and pick it up again and return it to the galley pot. Withdraw the instrument. • Repeat the exercise using the left hand and a grasper in the left-hand port. • Now use both hands to pick up a pledget from the galley pot with the right-hand grasper, transfer it to the left-hand grasper and then place it on the oor. Pick it up again with the left-hand grasper, transfer it to the right-hand grasper and replace it in the galley pot. • Repeat the exercise starting with the left-hand grasper. • Withdraw both instruments watching and following each move with the camera. There are many such exercises that you may be required to perform, such as passing matchsticks through loops or sweets one on top of another.
Exercise 2 – manipulation and cutting • Draw a disc on a glove and pin the glove out on a cork board. Insert the board into the simulator. • If you are a right-handed surgeon, insert a grasper via the left-hand port and scissors via the right-hand port. Use the left hand to expose the target and then cut out the disc, taking care not to cut through both layers of the glove. Only cut when you have a good view.
• Try and position the curve of the scissors so that the incision is not too ragged. • Withdraw the excised disc through the lefthand port.
Advanced dexterity skills Clipping and loop ligation • Therapeutic laparoscopy constantly requires pedicles, such as the cystic duct, to be ligated and divided. Clips are used for this, followed by a division using scissors. Occasionally for larger pedicles, such as t he appendix stump, a surgical loop (endoloop) is used. Familiarise yourself with these instruments.
Exercise • Isolate a limb from a foam tree within the simulator by dissection using a grasper in the left-hand port and scissors in the righthand port. Insert a clip applicator and place three clips on the foam limb, ensuring no other tissue gets caught in the clips. Before ring each time, rotate the clip applicator to demonstrate that the jaw of the clip extends beyond the structure to be divided. Cut between the clips. • Practise using an endoloop outside the simulator initially. Insert the endoloop in an introducer and then pass the loop over the nger of an assistant. Break off the end of the endoloop and tighten the knot. If endoloops are in short supply, ensure that you understand the principles behind its use and then omit the exercise outside the simulator. • Now practise applying the endoloop within the simulator. • Blow up a rubber glove and secure it by tying the base. Then use an endoloop to ligate the base of one of the inated ngers, which is used to simulate a distended appendix. • Insert an endoloop into a 3mm introducer and pass into the simulator via the right-hand port. Extend the loop out of the introducer. • Pass the grasper through the loop, pick up the inated nger and draw it through the loop.
continued over....
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Bipolar diathermy In bipolar diathermy, the heating occurs in t issue held between two small active electrodes.
... continued
• Break off the end of the endoloop and then tighten the knot around the base of the nger. Cut the suture material. Now grasp the nger with grabbers and then cut the nger off using scissors inserted via the left-hand port. • If the endoloop has been positioned and tightened properly, the rest of the glove will not deate.
Diathermy Dangers of diathermy (electrosurgery) Surgeons have employed electrical current to cut and coagulate tissue for over 70 years although few have had any formal training in its use. Many of the accidents that occurred in therapeutic laparoscopy arose when s urgical diathermy was used. This has drawn attention to the need for better understanding of this useful, but potentially hazardous, surgical tool. Most accidents are caused by unintended burns which are avoidable if diathermy is used with care.
How surgical diathermy works When an electrical current passes through a conductor some of its energy appears as heat. For any given conductor, the heat generated depends upon its resistance and the density of current ow. This is the principle of the light bulb and the electric re. When a lot of current passes through, a lot of heat is produced. The same applies to human tissue. When a large amount of electrical current passes through a piece of tissue, the temperature rise can be enough to give a useful surgical effect.
Figure 58
What is the difference between monopolar and bipolar diathermy? (Figure 58) Monopolar diathermy In monopolar diathermy, the surgeon uses an active electrode with a small surface area tip to concentrate a powerful current producing heat at the operative site (the power density is high). The large return electrode plate which completes the circuit spreads the current over a wide area so that it is less concentrated and it produces little heat (the power density is low).
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Why is the patient not electrocuted? An alternating current of low frequency stimulates nerves and muscles and it is this stimulation which kills someone connected to the mains current. This effect, which is named after Michael Faraday (Faradism), does not occur when the frequency is very high. A low frequency current as small as 1mA can stimulate the heart fatally, but the radiofrequency (RF) currents as high as 2A used in surgical diathermy pass through the body without dangerous neuromuscular effects. These currents have a frequency which is up to a million times that of the mains current which alternates at 50Hz (50 oscillations/sec). High frequency alternating currents have some surprising properties which have safety implications in laparoscopic diathermy.
Bipolar diathermy has been generously supported by Eschmann equipment
How does cutting current differ from coagulating current? Surgical diathermy is used for cutting and coagulation. Cutting occurs when sufcient heat is applied to tissue to cause cell water to explode into steam. As we have seen, to get a high temperature we need to pack a high current into the tissue. For coagulation, a less violent heating effect leads to cell death by dehydration and protein denaturation. The dead tissue is s hrunken and dried – distortion of walls of blood vessels, coagulation of plasma proteins and stimulation of the clotting mechanism all act to check bleeding. Ideally, intracellular temperatures do not reach boiling point so there should be no unwanted cutting. You will nd that monopolar diathermy is most effective when you hold the active electrode a small distance from the tissue. The electrical discharge arcs across the tiny air gap creating a series of sparks which produce the high temperatures needed for cutting. The CUT current is a continuous wave form. If you set the machine to CUT and gradually reduce the power setting, you will come to a level when the effective voltage is no longer enough to drive sparks across the gap and no current will ow. If you now touch the electrode onto the tissue, current will ow again because it does not have to jump across a gap. There will be no sparks and the current will ow away into the adjacent tissue. The heating effect is relatively gentle with loss of intracellular water and coagulation with tissue necrosis in depth. This effect is called desiccation and gives reasonable coagulation. Desiccation is more commonly achieved by using COAG current in contact mode.
Contact diathermy In contact diathermy, the main impedance (resistance) to current ow is at the interface between the electrode and tissue, where it is inuenced by the type of tissue and its st ate of hydration. The impedance of fat is high compared to muscle and contact diathermy works badly on adipose tissue. As diathermy proceeds, the tissue in contact with the electrode dries and impedance rises. Eventually, the current ow is insufcient to produce further heating and the surgical effect ceases. This limits the depth of penetration of diathermy
applied to one spot. The effect of contact diathermy also depends upon the size and shape of the active electrode. A ball electrode with a large surface area held in contact with tissue will tend to apply current at a relatively low density, coagulating to a depth of tissue which is proportional to the square of the diameter of the ball. Contact cutting by point diathermy is mainly by physical disruption of tissue softened by coagulation and is usually less effective than non-contact cutting.
Fulguration If you set the diathermy machine to COAG or press the COAG pedal you can fulgurate tissue. In fulguration, you use a higher effective voltage to make longer, fatter sparks jump an air gap – the word means ‘to ash like lightening’. The COAG current has an interrupted (modulated) wave form with the current chopped into bursts. Because the current is turned off most of the time, COAG current can have large peak voltages and currents and yet apply less electrical energy over a given time than a CUT current of equivalent amplitude. A less explosive, more sustained heating effect leads to coagulation and haemostasis. The high peak voltage can drive current through the high resistance (impedance) of desiccated tissue. Thus fulguration can continue until carbonisation or charring occur.
Summary
The CUT current is typically a continuous wave, producing sparks whose heat explodes intracellular water to steam. The C OAG current is a sine wave current supplied in bursts to fulgurate tissue. This allows the sustained heating in depth needed for coagulation. Peak voltage and mean power output can be varied by adjusting the duration of bursts of current and their intensity to give a combination of cutting and coagulation. This is known as ‘blended’ current. Be wary. Surgical diathermy generators differ widely and there is often little relationship between the output settings of one machine and another. In particular, there may be a signicant difference between the power displayed and the power in watts which is actually delivered to the patient. The setting recommended by the manufacturer for a particular application is frequently on a scale which is meaningless to the surgeon. minimal access surgery
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What is capacitative coupling? One of the peculiar properties of alternating currents is that they can apparently pass through insulating material. This effect occurs in an electrical device called a capacitor in which an insulator is sandwiched between two electrode plates. When the alternating current is switched on, it seems to ow from one electrode plate to another. In laparoscopic surgery, it is potentially possible to construct a capacitor without knowing it. The insulated electrode passes through a metal tube, say a laparoscopic port – the core of the electrode acts as one plate, the metal tube as the other with an insulator between – which results in a capacitor (Figure 59). In these circumstances, even though the instrument is well insulated, a part of the current can ow to the patient. This capacitative coupling is an interesting and remarkable result of the high frequency alternating current which induces an alternating magnetic eld, which itself induces electrical currents in nearby conducting objects. This is how diathermy owing through an active electrode (hook, graspers) can induce a current in its metal cannula despite insulation. This is termed electro-magnetic induction.
Figure 59
The current ow is relatively small, but if there is a small point of contact then dangerous overheating can be produced which could damage adjacent tissues (Figure 59). The current ows from the metal sheath directly to the bowel. It is greater in open circuit activation and in 5mm cannulae compared to 10mm cannulae. There remains some doubt about the frequency with which injury has occurred as a result of capacitative coupling during laparoscopic surgery. Most accidents probably happen through causes which are easier to understand such as inept handling or poor maintenance of diathermy equipment.
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General hazards of diathermy Electrocution Diathermy machines are manufactured to national and international safety standards which minimise the risk of any part of the machine becoming ‘live’ with mains current. As with any electrical device, servicing must be regular and expert.
Fire and explosion Alcohol-based skin preparations can catch re if they are allowed to pool on or under the patient. This is less likely in endoscopic work but you must still take care that all excess spirit is removed before using diathermy. Better still, avoid inammable chemicals if you can. Do not use diathermy with explosive gases, including those which may occur naturally in the colon.
Neuromuscular stimulation Although the high frequency current used for surgical diathermy does not cause neuromuscular stimulation, the sparks which it induces may invoke secondary currents which can do so. The sparks make random electrical ‘noise’ in the midst of which are alternating frequencies able to induce a Faradic effect. Such currents can be electronically suppressed by capacitors in the circuit. However, they may be sufcient to cause trouble in the special conditions of diathermy in the region of nerves or large masses of skeletal muscle which can be induced to contract strongly and unexpectedly. The problem is especially seen in urological surgery where diathermy near the ureteric orice can induce an ‘obturator kick’ by stimulation of the obturator nerve and the psoas muscle. The problem is seen with both CUT and COAG current and can usually be abolished by full chemical neuromuscular blockade.
Pacemakers and diathermy Diathermy currents can interfere with the working of pacemakers with possible danger to the patient. Modern pacemakers are designed to be inhibited by high frequency interference so that the patient may receive no pacing stimulation at all while the diathermy is in use. Some demand pacemakers revert to a xed rate of pacing and the anaesthetist must have a magnet available so that they can be reset if necessary.
A number of additional precautions are wise in these patients. First, if monopolar diathermy is to be used, the patient plate should be sited so that the current path does not pass through the heart or the pacemaker. Secondly, the heartbeat should be monitored throughout the operation. Lastly, a debrillator should be on hand in case a dangerous dysrhythmia develops through malfunction of the pacemaker.
Burns Burns are the most common type of diathermy accident in endoscopic and open surgery. They occur when current ows in some way other than that intended by the surgeon. Burns are much more common in monopolar rather than bipolar diathermy. When monopolar diathermy works properly, heating occurs only at the tip of the active electrode. The current passes through the patient’s body and escapes safely via the return electrode. Unfortunately this long current path offers opportunities for alternative unwanted passage of current to earth.
Return electrode plate Most devices monitor the attachment of the patient plate and sound an alarm when contact is inadequate. A simple method is to att ach the plate by two wires through which a small current ows. If a wire breaks, the current is interrupted and the diathermy can be automatically inactivated. This checks the integrity of the connection of the plate to the diathermy machine. It does not guarantee that the plate itself is properly attached to the patient. Another safety device uses a small direct current which in passing through the active electrode, the patient and the patient electrode, monitors the integrity of the whole diathermy circuit. Other machines have even more sophisticated safety measures. Remember that the safety of the return electrode depends upon its proper attachment. Both the surgeon and the theatre nurse have a duty to see that it is checked. If the patient electrode is incorrectly attached, there is a particular danger that the circuit might be completed by a small earthed contact point such as a drip stand, a metal component of the operating table, electrodes used for patient monitoring or even the surgeon! If the current density at this point is sufcient, the patient (and/or the surgeon) will be burned.
All patient monitoring equipment should be isolated from earth wherever this is possible. Electro-cardiograph electrodes should be wellgelled and of a large enough area to disperse the current. Needle electrodes should not be used. As a general rule, the return pad should be sited as near to the operation area as possible so that the main current path will be dist ant from other potential routes that the current might take to ground. Safety rule: always check that the return pad is properly connected, that safety monitors are active and that there are no small earthed contacts attached to the patient.
Laparoscopic diathermy Inadvertent burns to the patient are a special hazard of laparoscopic surgery. There are several mechanisms: • Burning the wrong structure. • Inappropriate or inadvertent activation of electrodes out of view. • Faulty insulation. • Instrument to instrument coupling (direct coupling). • Retained heat. • Capacitative coupling.
Burning the wrong structure Probably the most common cause is misidentication of the structure to which the diathermy is applied.
Inappropriate or inadvertent activation of electrodes Pressure on the footswitch leads to activation of all the active electrodes which are connected. In open surgery, any devices which are not in use must not be in contact w ith the patient and an unused electrode should be safely stored in an insulated quiver where it will be safe if the footswitch is inadvertently activated. In laparoscopic surgery, devices connected to the diathermy generator often remain within the operating eld while not in immediate use. If they are in contact with tissue when the foots witch is activated, a burn will occur. There is particular danger if the electrode is out of view at t he time. • Devices attached to the diathermy machine must not touch tissue while not in use.
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• It is safest to remove or disconnect devices attached to the diathermy machine when not in use. • Do not attach more than one active electrode.
Faulty insulation It is possible for burns to occur when conducting parts of instruments other than the operating electrode come into contact with the patient. In practice, this arises when there is a defect or crack in the insulation of a laparoscopic diathermy instrument which allows current to travel to tissue as well as by the intended path from the electrode. Abrasives used to clean laparoscopic instruments may wear away the thin insulation near the tip increasing the length of the exposed active electrode. Raising the temperature of the bowel to 60°C for even a short time leads to denaturation of intracellular enzymes and tissue death in situ. Subsequent autodigestion of the necrotic tissue leads to late perforation. Instruments are more likely to become damaged with age but you must not assume that single-use instruments are immune from this problem. The higher the effective voltage of the current being used, the more likely it is to leak. Leakage is also more likely if the diathermy is activated when the electrode tip is distant from target tissue (open circuit activation). • Do not use diathermy instruments which are damaged or badly maintained. • Avoid open circuit activation.
Flow of current from one instrument to another Contact or close approximation of the active electrode and another conducting instrument can establish an unwanted and unnoticed current path. This is known as direct coupling of the current. In an open operation such contacts are easily noticed and appropriate action taken. In laparoscopy, arcing between instruments may occur outside (behind) the eld of view and you may not notice anything other than that the diathermy does not work as expected at the site where you think you are applying it. Turning up the power in these circumstances can have disastrous consequences. Remember that COAG and BLEND currents have a larger effective voltage and can jump bigger gaps. Open circuit activation is particularly dangerous.
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Instrument to instrument coupling is more likely with open circuit activation. • Do not activate the diathermy unless the whole of the active electrode is in view. • Do not activate the diathermy if there is a chance that two instruments are in electrical contact or close enough for arcing to occur.
Retained heat When you have been using the diathermy for some time the tip of the active electrode becomes hot and remains so for some time. The electrode may be hot enough to damage tissue although no current is owing. • Do not allow a hot active electrode to touch tissue.
Unintentionally high current density in pedicles The heating effect of diathermy depends upon the current density and the resistance of the tissue. The sight of penile necrosis on a small boy is so disturbing that most surgeons are aware of the danger of using monopolar diathermy to perform a circumcision. The current path through the base of the infant penis is small in cross-section, the current density is high and the heating effect disastrous. The same effect can also occur when applying diathermy to a pedicled structure such as the appendix or a gall bladder freed from the liver and attached to the common bile duct by the cystic duct. The heating effect may be sufcient to cause destruction of tissue and the effects may be just as awful as penile necrosis.
Safety rule: monopolar diathermy should not be used on organs attached by small pedicles to important structures.
Capacitative coupling Finally, there is the more difcult concept of capacitative coupling. This is probably very rare and only occurs in special circumstances. There are two ways to avoid capacitative coupling. When using a diathermy instrument through a trocar, either: • use a non-conducting troca; or • if you use a metal trocar, it should make a good electrical contact with the abdominal wall.
Also, avoid open circuit activation and avoid using high voltage diathermy currents in noncontact mode (eg fulguration).
Bipolar diathermy Bipolar diathermy is intrinsically safer than monopolar diathermy because current passes between two small electrodes on the same hand-piece. Secondary currents induced by the main radiofrequency may leak to ground but they are too small to cause trouble. Bipolar diathermy devices are being developed for laparoscopic surgery but their use is not yet widespread because they tend to be less effective at cutting.
Exercise – diathermy cutting and dissection • Mark a star on the skin of a piece of chicken. • You may wish to check the instruments and practise initially outside the simulator. • Place the marked piece of chicken in the simulator and then insert a grasper via the lefthand port and a diathermy hook via the righthand port. Cut the star of skin out using the diathermy hook being careful not to damage the underlying tissues. Use the left hand to produce traction and elevation of the skin ap and to ensure that each cut is safe. • Take care to avoid contact between the metal of the grasper and the diathermy hook. • During dissection it is important that the foot controlling the foot pedal is moved away from the pedal when not in use to avoid inadvertent activation. • Remove the skin disc via the left-hand port.
minimal access surgery
63
ASSESSMENT
We will be continuously assessing your performance throughout each module of the course, in order to give you a prole of your strengths and weaknesses. You will be individually assessed, and will receive advice on the areas in which you need further practice. On the following page you will nd a s ample assessment sheet that covers all the three modules of the course, ie open surgery, trauma and orthopaedics and minimal access surgery. This assessment seeks to concentrate on the ‘generic’ skills listed under each course module and a grading will be given at the end of each half day session for each of the generic skills. These gradings are: 3 no errors observed 2 occasional errors, but corrected by participant 1 frequent errors or occasional errors uncorrected by participant 0 persistently unsatisfactory performance A grading will be given at the end of each half day, and this will demonstrate how a participant has improved over the period of the course and over each module (where it consists of more than one half day). The overall grade for each module will be recorded at the end of each module in the last column (ie the column with a heavy box around it. Any ‘0’ grading or four or more grade ‘1’s out of the six skills assessed, would result in a ‘not satisfactory’ performance for that module. It is expected that the great majority of participants will receive results in the ‘satisfactory’ category. Trainees with such results will receive a certicate of completion after the end of the course. Only participants whose performance is deemed to be ‘not satisfactory’ in either the open surgery module, or any two modules of the course as a whole, will need to repeat the three-day programme – and we do not anticipate that many trainees will fall into this category.
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basic surgical skills
One of the most important aspects of the assessment is the ‘feedback’ between instructors and participants. This has proved most valuable in previous courses and participants have greatly appreciated the ‘constructive criticism’ that helps them improve their technique. The comments will be both verbal and recorded in the ‘feedback’ section of the assessment form. In summary, we hope you will look upon this activity as another way in which to build upon the skills you already possess, and not as an ordeal to be endured! In our turn, we will use the assessment process to measure how effectively we have been teaching you, and to reect on how we can continue to improve the course.
NB: temporary assessment form – will be replaced with new design
m p m y a r e g r u s s s e c c e a g u l s n q i a l i l l n d i m i k h n c a n s i e h t t / c m i n n s : r o e e i 3 e t m r n u c e e d t e e l g l u G n a e e e n s n c d o r o t a o m i e t p n r c e e m l M a s
t o * n y / r y r t o o c t c f a a s f i s t i t a a s S
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m r o f k c a b d e e f d n a t n e m s s e s s a s l l i k s l a c i g r u s c i s a B
t o * n y / r y r t o o c t c f a a s f i s t i t a a s S
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s c i d e a p o h t r t o n s g e e d n l l u n i a m q i i l k s a s d s n e h c n m i s c a s u r h e t / a e A r n n s t e i o e e r u : G t u q 2 c i g d e n n e e l l i c e u s h c l o d e d t t n r o p n a l e g h M a n m i
t o * n y / r y r t o o t c c f a a s f i s t i a t a s k S c
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assessment
65
8 9 9 1 d n a l g n E f o s n o e g r u S f o e g e l l o C l a y o R e h T ©
APPENDIX A: needles
Selection of appropriate needles Surgical eyeless needles are manufactured in a wide range of types, shapes, lengths and thicknesses. The choice of needle to be used depends on several factors such as: • the requirements of the specic procedure; • the nature of the tissue being sutured; • the accessibility of the operative area; • the gauge of suture material being used; and • surgeon preference. Regardless of use, however, all surgical needles have three basic components: the point, the body and the swage (Figure 60).
Figure 61
Figure 60
The point depends on the needle type (see next section). The body of the needle usually has a attened section where the needle can be grasped by the needle holder. In addition, some needles have longitudinal ribs on the surface which reduce rotational movement and ensure that the needle is held securely in the jaws of the needle holder. If the needle does not have a attened section, then it should be grasped at a point approximately one third of the needle length from the butt (Figure 61).
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basic surgical skills
The majority of surgical needles nowadays are eyeless, that is they are already swaged to the suture material. This has many advantages, including reduced handling and preparation and less trauma to the tissue. (An eyes needle has to carry a double strand which creates a larger hole and causes greater disruption to the tissue). A swaged (eyeless) needle has either a drilled hole or a channel at the end of the needle for insertion of the suture material. The drilled hole or the channel is closed round the needle in the swaging process.
Types of surgical needles Needles are normally classied according to needle type. The main categories are described in this section.
Round-bodied needles Round-bodied needles are designed to separate tissue bres rather than cut them, and are used either for soft tissue or in situations w here easy splitting of tissue bres is possible. After the passage of the needle the tissue closes tightly round the suture material, thereby forming a leak-proof suture line, which is particularly vital in intestinal and cardiovascular surgery.
Needle type
Description
Typical application
Intestinal
The hole made by this needle is no larger than the diameter of the needle. The hole is then lled by the material, which reduces the risk of leakage.
Gastrointestinal tract; biliary tract; dura; peritoneum; urogenital tract; vessels; nerve.
Heavy
In some situations where particularly strong needles are required a heavy wire diameter needle would be appropriate.
Muscle; subcutaneous fat; fascia; pedicles.
Blunt taperpoint
Where needlestick injury is a major concern, particularly in the presence of blood borne viruses, the blunt taperpoint needle virtually eliminates accidental glove puncture.
Uterus; pedicles; muscle; fascia.
Blunt point
This needle has been designed for suturing extremely friable vascular tissue.
Liver; spleen; kidney; uterine cervix for incompetent cervix.
appendix a: needles
67
Cutting needles Cutting needles are required where tough or dense tissue needs to be sutured.
Needle type
Description
Typical application
Tapercut™
This needle combines the initial penetration of a cutting needle with the minimised trauma of a roundbodied needle. The cutting tip is limited to the point of the needle, which then tapers out to merge smoothly into a round cross-section.
Fascia; ligament; uterus; scar tissue.
Cutting
This needle has a triangular crosssection with the apex on the inside of the needle curvature. The effective cutting edges are restricted to the front section of the needle.
Skin; ligament; nasal cavity; tendon; oral.
Reverse cutting
The body of this needle is triangular in cross-section with the apex on the inside of the needle curvature.
Skin; fascia; ligament; nasal cavity; tendon; oral.
In addition, there are surgical needles for specialist areas, such as microsurgery, ophthalmics and endoscopic surgery.
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Needle shape The choice of needle shape is frequently governed by the accessibility of the tissue to be sutured and normally the more conned the operative site, the greater the curvature required. The following table shows the basic shapes and typical applications.
Shape
Typical application
Straight
Skin; subcuticular; purse string.
1/4 circle
Eye; microsurgical.
3/8 circle
Eye; fascia; muscle; vascular; plastic; skin; subcuticular.
1/2 circle
Gastrointestinal tract; pelvis; respiratory tract; peritoneum; muscle; urogenital tract.
5/8 circle
Urogenital tract; pelvis; oral cavity.
J-shape
Laparotomy closure; vagina; rectum (per anus).
Compound curve
Oral; eye, anterior segment.
Needles has been generously supported by Ethicon Ltd a
company
appendix a: needles
69
APPENDIX B: suture materials
Characteristics of suture ‘The ideal suture would consist of material which permits its use in any operation, the only variable being the size as determined by the tensile strength. It should handle comfortably and naturally to the surgeon. The tissue reaction stimulated should be minimal and should not create a situation favourable to bacterial growth. The breaking strength should be high in small calibre. A knot should hold securely without fraying or cutting. The material must be sterile. It should not shrink in tissues. It should be non-electrolytic, non-capillary, non-allergenic and non-carcinogenic. Finally, after most operations the suture material should be absorbed with minimal tissue reaction after it has served its purpose.’ 1 No single type of suture material has all these properties and therefore, no one suture material is suitable for all purposes. Besides, the requirement for wound support varies in different tissues from a few days for muscle, subcutaneous tissue and skin to weeks or months for fascia and tendon, to long-term stability for vascular prosthesis. However, the surgeon must be assured that the selected suture has the following properties: • predictable performance; • pliable for ease of handling and security of knots; • minimal tissue reaction; • high uniform tensile strength, permitting use of ner sizes; • sterile, ready for use; and • consistently uniform diameter per size.
Types of suture materials Suture materials are either absorbable or nonabsorbable. Absorbable sutures offer temporary wound support over a period of time and thereafter are gradually absorbed either through a process of enzymatic reaction (catgut) or
70
basic surgical skills
hydrolysis (synthetic materials). It is important to recognise that losing tensile strength and losing mass absorption are two separate events, because a suture may support the wound for only a very short time, and yet be present as a foreign body for a long period after. The ideal suture would be one which disappeared immediately after its work was complete, but such a suture does not yet exist. Non-absorbable sutures do not absorb, but some, especially those of biological origin, lose strength without any change in the mass of the suture material. Others gradually fragment over time. Yet other non-absorbables, especially those of synthetic origin, never lose tensile strength or change in mass following implantation. Sutures can be subdivided into monolament or multilament. A monolament suture is made of a single strand. It resists harbouring micro-organisms and ties down s moothly. A multilament suture consists of several laments twisted or braided together. This gives good handling and tying qualities. A further classication is based on the origin of the raw material; it can either be from a biological source of from man-made bres. Sutures have been produced from a biological or natural source for many thousands of y ears. They tend to create greater tissue reaction than man-made sutures; the result can be localised irritation or even rejection. Another disadvantage is that factors present in the individual patient, such as infection and general health can affect the rate at which enzymes attack and break down absorbable natural sutures. Man-made or synthetic sutures, on the other hand, are very predictable and elicit minimal tissue reaction. 1
Postlethwait RW: Wound Healing in Surgery , Somerville, NJ: ETHICO N Inc, 1971, pp8-9.
, a s o c l c i a r r u t a o m i , , s r . i d d a d r n e e t a a p n u s e r o l n p a , l i k y w p a s r r e l f e e n p o g r i a r d u e c n e s r s u u r p , , a s o y s o i n r s d l e o c m g c n u r r o g u u o F e s m w
t e r p e e r h c x e w e d s l e n e b u u a n s i o s r i i t . t s e a d e e m i r r d i u i s x u t o u e r q s l p e r b p r s o a a i b e r e t o r s a s e s e r g b h t i L a w s
; e u s s . i t c s y r i c u e g a r r o u o e s n h t t a l a d u t n c c a e r l b a u s d n i ; n m e r a o u n o d s l o o b l A c c
s . e s u e r y s i a s i t u q d n e i r n e d d v e n e s a s u l y d n e o b w o t l y e s o l b n a t d e r l h u t o o a p p h h u S t s
r t e o d n n u d l d e u g s e o u h n o s l s s i , o . e r t l d f b p o e r a e r n i b e i r h o u t q o s w a e r b d i s a e m x i s g s o s n u r i e p r e e p t B b a s
r t e o d n n u d l d e u g s e o u h n o s l s s i , o t . e r l d f b p o e r a e r n i b e i r h o u t q o s w a e r b d i s a e m x i s g s o s n u r i e p r e e p t B b a s
s y a d 0 8 1
s e s u t n e u q e r F
d n ; a s s e u u o s s e i n t a g t n . u i y c l g b a e o u h l s t o ; s l n f a m a o i t r h t a e h g h t p i L o o
. y g o l o ; l n m o a i t h a t g h p i L o
t e r p e e r h c x e w e d s l e n e b u u a n s i o s r i i t ; t s e a d e . e m i r y r d i u i s x g u t o r q l u e o s l p e o r r b p s m o a a i l a e b r e t r s t s h a o e h s h e r p g b i t L a w s o
s n o i t a c i d n i a r t n o C
s e u e r s i s i t u q n e i r d d e n s a u l y e b w o t l s o l n a t . d e r l h o u t p o a p h h u S t s
r t e o d n n u d l d e u g s e o u h n o s l s s i , o . e r t l d f b p o e r a e r n i b e i r h o u t q o s w a e r b d i s a e m x i s g s o s n u r i e p r e e p t B b a s
r t e o d n n u d l d e u g s e o u h n o s l s s i , o t . e r l d f b p o e r a e r n i b e i r h o u t q o s w a e r b d i s a e m x i s g s o s n u r i e p r e e p t B b a s
e t a r n o i t p r o s b a s s a M
s y a d 0 9 y B
s y a d 0 9 y B
s y a d 0 7 – 6 5
s y a d 2 4
s y a d 0 9 – 0 6
h t g n e r t s n o e i l i t s n e n t e e T r
s y a d 1 2 t s a e l t A
s y a d 8 2 t s a e l t A
s y a d 8 2
s y a d 4 1 – 0 1
s y a d 0 3
s y a d 6 5
s e n i t s e t n . i l ) f a e e m i b n r a o d p e e i e r h u s P (
d n a e h t i d i w d n . t c d a e a l t 0 t f e 7 a r o a 3 a o r c n t e i s e e t m d c y l a m i l l u o o g i y l p c l c y o a o l C g p c
d n a e h t i d i w d n . t c d a e a l t 0 t f e 7 a r o a 3 a o r c n t e i s e e t m d c y l a m i l l u o o g i y l p c l c y o a o l C g p c
. d i c a c i l o c y l g f o r e m y l o P
r e m y l o p e d a m n a M
d e t a e o l b c a , d b r e o i s d a b r A b
l o n o m e l b a b r o s b A
e d i l o c y l G
e n o n a x o i d y l o P
l a i r e t a m w a R
e p y T
e r u t u S
r o p l e e a h m ( s i n a s e d i n . e t s ) f i r e e u t e n b P i
e l b a l b r o o s n b o A m
l o n o m e l b a b r o s b A
t u g t a c n i a l P
t u g t a c c i m o r h C
d e t e a l b o , a c d b r e o i s d a b r A b d n a e d i l e o d c i y t l c a G l
d e t a e o l b c a , d b r e o i s d a b r A b d n a e d i l e o d c i y t l c a G l
) n o i t p r o s b a d i p a r (
appendix b: suture materials
71
s e s u t n e u q e r F
, g , n i r l a u n t i u t s s e n t i i k n s o r r t a s l u a c g i , . t n e u o l c c i t b a s u g u S i l m
n ; y o r i t e a g g r u i l s r l o f a r s e e n u e . s g y s ; g i t g l o n o y i r d u m o t l b u a t s h s d t o n h p M a o
s n o i t a c i d n i a r t n o C
. l y e d a r g r e e r u o h i l e o w u n m r q , l n r r i o e a ) a s h d l i u t s e c h u t r s s p u a o m o s v e o y , i p b p b i r u a t d e r s r o a g t n c r s d t e d , u s p d l e o u u r e n e o s i c c x t h i s e x S t m ( e
l a r e n e . g n ; o r i a t l u n e c t s e a r v ; r o y i e d r g a r u C s
g ; r n e i t u a s o g l i l c r l o f a r s e e n u e s g . s ; i r t g y n e y i r d u g r o t u b u s t s o s d r o n u e M a n
c i t s a l p . ; y n g o l o i t n o e m t l e a r h ; t e r h u p s o , o y l c r e n g i k r u S s
, e r u s o l c n i k ; s c ; . i y t r a g s l a u l o l p c o s ; l a l m a v r o a h e i t n d h e r a p G c o
t r a e h r l r o f l a a i c d u e c i s s t u a r v a r e f b o o t t s o n e n e s e . d l m h s u e t s e o c v l o a h l r a S p p v
e n o N
e n o N
e n o N
e n o N
0 2 1 – 0 9
o w t e t b u t o o b n a n r a t e c f y a . l l d s a n r u u a s o e U f y
d e t a l ; u . e l s s b p e a a c u b r n s s o e i s s t b n y d a - i o n a b o m e n N r i
. r f a e o y e r t e a r p a t % a 0 2 s e 5 d 1 a r t g u o e b D a
. r f a o e y e r t e a r p a t % a 0 2 s e 5 d 1 a r t g u o e b D a
d e ; t a l e l u . b s s a p a e b r c u s o n s i s e t b s y n d a i o n a b o m e n N r i
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s y a d 1 2
l r l a a r e o y t e s n o o m t u s o e b s a o n L i
e t i n e d n I
% 0 2 – 5 r 1 a s e e y s r o e L p
% 0 2 – 5 r 1 a s e e y s r o e L p
l a i r e t a m w a R
e d i l o . c e y n l g o f t o c a r l e o m r y p l a o c p d o n C a
f o e l r k i b s y n b i e n t u o r p p s l k l . a r i u s m r t o a w a N r w
. e d a m n a M
. r e m y l o p e d i m a y l o P
. r e m y l o p e d i m a y l o P
. e n e l y p o r p f o r e m y l o P
e p y T
l o n o m e l b a b r o s b A
e l b a b r o s b d e a - i n d a o r N b
e l b a b r o s b d e a - i n d a o r N b
e l b a b r o s b l a - o n n o o N m
e l b a b r o s b l a - o n n o o N m
e r u t u S
e n o r p a c e l g i l o P
e l b a b r o s b d e a - i n d a o r N b e d i m a y l o p d e d i a r B
t n e e m d a i l m o a n l y o o M p
e n e l y p o r p y l o P
e t a r n o i t p r o s b a s s a M
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basic surgical skills
k l i S
r e t s e y l o P
e t i n e d n I
Suture materials has been generously supported by Ethicon Ltd a
company
APPENDIX C: gloves and surgical handwashing
The choice of surgical scrub and glove is critically important to a surgeon, and this point is often not fully realised or appreciated.
Surgical handwashing Surgical handwashing using approved scrub solutions is a technique which involves an initial washing of the hands and forearms to remove transient micro-organisms and reduce the count of resident ora, and then a second wash t o further reduce the level of resident colonising ora. Traditionally a sterile brush has been used for the rst application of the day, but continual use is inadvisable as damage to the skin may well occur. New alcohol-based formulations have been demonstrated to be suitable for use for surgical hand scrub and for brushless application. Alcohol antiseptics are as effective and have as wide a spectrum of antimicrobial activity as the more conventional methods using antisptic detergent solutions and are no more damaging to the skin. Therefore, scrub solutions should be chosen which: • Have substantial initial reduction of transient and resident ora. • Are effective against a wide spectrum of micro-organisms. • Have a persistent effect and will continue to work after application (in case of glove puncture). • Are not damaging to the skin.
Glove choice Given the length and complexity of many operations it is obvious that gloves must t well and securely and offer optimum sensitivity and durability without hand fatigue. They should not lose their shape or integrity during use.
Less well understood is the need for the glove to be of high quality, low in extractable latex proteins and powder-free. It is well-documented that adhesions and other post-operative complications including delayed wound healing can be attributed to glove powder which transfers latex proteins from the surface of the glove. The surface of the glove must also be low in residual accelerators used in the manufacturing process, as these can cause localised skin conditions which can occur up to 48 hours after contact. With increased latex glove usage, the incidence of latex allergy in the United States has now risen to between 28% and 67% in some high-risk healthcare workers, and is estimated at 6% in the general population. Latex allergy can often take time to develop, with exposure taking place over months or even years before any reaction occurs. Although it is recognised that latex is still the best barrier, latex-free alternatives should be considered when sensitisation to the proteins in natural rubber latex has occurred. Gloves should also be pyrogen-free, since pyrogens can induce pyrexia and misdiagnosis in some patients. This fact is also well documented. Powder-free, latex-free synthetic gloves should also be available for: • Wearers who are known to be type 1 latex allergic (and therefore prone to anaphylactic shock). • Those patients who may be at higher risk of latex allergy, such as spina bida patients, people with previous atopy, dermatitis, asthma or food allergies, or those who have undergone multiple surgical procedures. These gloves should be of the same high quality as latex gloves to allow comfort and sensitivity, and must be part of a total protocol within a surgical unit, to eliminate risk to sensitised individuals.
appendix c: gloves and surgical handwashing
73
Glove puncture is commonplace during surgery and occurs in over 50% of cases in some operative procedures. Studies show that between 50% and 88% of perforations pass undetected. Therefore for some high risk procedures, eg some orthopaedic, cardiac or gastrointestinal procedures, it may be necessary to double glove using a green under glove to ensure added protection. The use of two surgical gloves has been shown to maintain the barrier between the wearer and patient in four out of ve cases in which the outer glove has been breached. The system will allow early identication of up to 97% of all glove punctures. The inner glove is a half size larger than the outer to optimise sensitivity, dexterity and comfort. If the outer glove is punctured, uid penetrates between the two gloves and a dark green patch alerts the wearer that a puncture has occurred and the outer glove can then be replaced. In summary, therefore a surgeon should choose a glove which: • is suitable for the surgical procedure; • ts well and does not lose its shape or integrity; • offers optimum sensitivity and durability; • is powder-free; • contains low levels of latex allergens and residual accelerators and is pyrogen free; and • is powder free and synthetic for those with an allergy to natural rubber latex. The scrub solutions and gloves you are offered for your Basic Surgical Skills course meet all these stringent criteria. Powder-free, latex-free gloves should also be available for suitable emergency cases.
Gloves and surgical handwashing has been generously supported by Regent Medical 74
basic surgical skills
