Module one: open surgery


This module of the course is designed to teach you basic safe methods of performing simple surgical procedures, and to allow you to perform and practise them on the bench using 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 practised, 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 system of training is that you will work for several surgeons in the course of your training, each of whom will show you individually 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.


Handling instruments
Knots
Handling sutures
Handling tissues
Handling bowel
Abdominal incision and closure
Handling vessels

Handling instruments

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:

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.

The scalpel

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Figure 2

Figure 3

Scissors

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There are two basic types of scissors, one for soft tissues and one for firmer tissues such as sutures.

Figure 4

Figure 5

Dissecting forceps

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Figure 6

Haemostats (artery forceps) 

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Figure 7

Needle holder 

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Figure 8

View the video clip on types of needle

Exercise

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:

You will be taught and asked to demonstrate the following:

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 finger' knot and the 'middle finger' knot at the same time as the hands cross over for each throw.

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The one-handed reef knot technique

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Exercise

Figure 9a

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Figure 9g

Figure 9h

Figure 9i

Figure 9j

The instrument tie

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Exercise

Figure 10a

Figure 10b

Figure 10c

Figure 10d

Figure 10e

Figure 10f

The surgeon's knot

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Exercise

Figure 11a

Figure 11b

Figure 11c

Figure 11d

Figure 11e

Figure 11f

Figure 11g

The slip knot

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Exercise

Figure 12a

Figure 12b

Figure 12c

Figure 12d

Tying at depth

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Exercise

Figure 13a

Figure 13b

Figure 13c

Figure 13d

Figure 13e

Handling sutures

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Basic principles 

Figure 14

Figure 15a

Figure 15b

Forms of suturing

You will be taught and asked to demonstrate the following types of suturing:

Interrupted sutures (Figure 16)

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Figure 16

Exercise

Figure 17a

Figure 17b

Continuous sutures (Figure 18)

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Figure 18

Exercise

Mattress sutures 

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Exercise

Figure 19a

Figure 19b

Figure 20a

Figure 20b

Subcuticular sutures (Figure 21)

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Figure 21

Exercise

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Skin lesion biopsy 

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Exercise

Handling tissues

Haemostasis 

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Two methods of securing haemostasis by ligation will be demonstrated using vessels in small bowel mesentery. 

Exercise - single vessel ligation

Exercise - pedicle ligation

Dissection (if time and specimen allow) 

Lymph node biopsy is commonly required for histological examination.

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Exercise

Handling bowel 

Bowel anastomosis

The basic principles of bowel anastomosis will be demonstrated using a small bowel anastomosis.

The essentials for any anastomosis are: 

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

View the video clip on end-to-end anastomosis with interrupted suture

View the video clip on end-to-end anastomosis with continuous suture

Exercise 

End-to-side anastomosis on immobile bowel

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Exercise

Figure 23a

Figure 23b

The Aberdeen knot

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Exercise

Figure 24a

Figure 24b

Grasp the free end between the index finger 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).

Figure 24c

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Figure 24e

Figure 24f

Figure 24g

Figure 24h

Abdominal incision and closure 

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Exercise

Figure 25a

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Figure 25g

A simplified model for this exercise can be provided by modifying a 'lunch box' as shown in Figure 25h (courtesy of Professor E Guiney).

Figure 25h

Handling vessels

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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).

Figure 26a

Figure 26b

When suturing arterial wall it is advisable for the needle to pass from inside to out (i.e. from intima to adventitia) to fix any atherosclerotic plaques and prevent the formation of intimal flaps which may lead to dissection, embolisation or thrombosis.

Non-absorbable, monofilament 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 and the haemostat jaws should be covered with rubber (rubber shod).

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 finer the vessel, the finer the sutures required and the smaller the bites taken. Therefore, aortic sutures need large bites while femoral sutures require fine 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 

Once an artery has been dissected free and inflow and outflow 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 (e.g. endarterectomy or a graft anastomosis) a longitudinal arteriotomy provides the necessary flexibility.

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 flow and promote thrombosis (Figure 27b).

Figure 27a

Figure 27b

Exercise

Figure 28a

Figure 28b

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 difficult.

By definition, not all of the sutures can pass through both arterial walls from inside to out. Plan the placement of your stitches 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 flow is restored).

Exercise

Figure 29

Figure 30

Vein patch graft

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A vein patch is the safest way to close an arteriotomy if there is the slightest suspicion that direct closure will produce narrowing.

Exercise

Figure 32

 

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