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 clips.
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 clips 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.

Other important principles

View the video clip

Always wear gloves of the correct size and choose appropriate gloves to suit the surgical procedure. See 'Glove choice' Appendix C.
Never directly handle 'sharps'.
Never handle a needle with your fingers. 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 fingers.
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 finger 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 assistant 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 fingers.
Always dispose of used needles or blades in the sharps container provided.
Always dispose of excised tissue in appropriate containers.
Always keep the operative field 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 field 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 magnification

The benefits of using magnification 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 fit 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 field of view allowing you to move more freely while the image remains in focus. It is usually available in up to 3X magnification.

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 flat field, which makes it particularly useful for vascular surgery and fine detailed work. The clarity of the image requires you to maintain an exact working distance. Prismatic loupes are usually available in magnifications of up to 5.5X or 6X.

When selecting your magnification, 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 flip-up design may be preferred as they provide magnification when needed and an unrestricted view when magnification is not required.
Fitting. Ensure that your loupes can be fitted to suit your eyes. An individual interpupillary adjustment is normally required to prevent eyestrain. A well-fitted 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 magnification 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 find that you rely on your loupes to see the finer detail in your work and, like many wearers, prefer working with them.

Figure 1

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