Basic Surgical Skill

General Surgery Department of Hasan

Sadikin Hospital/Medicine Faculty of
Padjadjaran University Bandung

The Basic Principles of Wound

Classification
Cause
Classification Comments
1. Clean

elective surgical wound e.g.hernia

surgery or breast biopsy

Low wound infection rate

approximately < 2%
Routine primary closure

2. Contaminated-tidy

low-velocity traumatic incisions

Clean and sharp with local damage
Contamination minor and brief
Minor intraoperative contamination
e.g. - kitchen knife/clean glass cut
- Small bowel or bronchial tree
opened intraoperatively

Wound infection rate 1-5%

Routine primary closure
some debridement and irrigation

3. Contaminated-untidy

Low velocity lacerating, tearing or

bursting wound
ragged and contused with gross
local damage
contamination apparent and
prolonged
major intraoperative contamination
all high-velocity injuries
e.g. crush injury
- garden tool injuries
- large bowel,infected bronchial
tree or infected urinary tract
opened intraoperatively

Wound infection rate 5-25%

May be closed after wide
debridement and copious
Irrigation or may require delayed
primary closure

The Basic Principles of Wound

Classification
4. Dirty/Infected

wound with signs of infection

such
as erythema,cellulitis or pus
grossly contaminated wound
more than 12 hours after
injury
severe tissue damage and
excessive ischaemic tissue
e.g. severe crush injury
- penetrating abdominal

trauma with hollow

visceral perforation
- war wound
- cloth,shrapnel,faeces
etc. in wound

Wound infection rate near to

50% if the wound is closed
May be closeable after total
excision or wide debridement
and copious irrigation but often
requires healing by delayed
primary closure or secondary
intention

Causative factor
Kinetic energy-closed

Kinetic energy-open

Mechanism of Wound causation

Mechanism
Ramification
Examples

direct crush or compression

shearing force
blast injury

direct penetration of tissue by

incision,tear or burst
low versus high velocity

internal disruption of tissues

haemorrhage
visceral rupture
bony fractures
occult injuries deep or
elsewhere

1. A direct steering wheel

injury to the epigastrium
result in duodenal, gastric,
splenic or hepatic disruption
2. A limb caught under a
vehicle wheel may have
skin sheared away from
deeper tissues by
rotational forces
3. A cricket ball hit into the
close fielders forehead ay
lacerate skin,fracture skull
and cause contre-coup
brain injury

Low velocity penetration

causes disruption of all tissues
in the line of the wound
high velocity penetration
causes wide internal cavitation
with little skin damage. This
may lead to major tissue
disruption, bleeding, visceral
rupture and even fractures at
some distance from the point
of entry

1. Broken beer glass to the

hand may damage digital
nerves,vessels and
tendons deep to the site
2. Stab wound to right-hand
side of chest may
penetrate lung,diaphragm
and liver
3. High-velocity bullet wound
to the thigh will disrupt
muscle widely,fracture the
femur and may disrupt
nerves and vessels
causing distal ischaemia to
the limb

The Pathology of Wound Healing

The repair of any soft tissue relies on:
The body generating capillaries and collagen on
both sides of the wound
This collagen cross-linking with wound-edge
collagen and new collagen
The wound contracting in size
The unaligned,cross-linked collagen maturing
into regularly arranged bundles (a scar) to
provide the healed wound with strength
Epithelial regrowth across the defect

Factors Affecting Wound Healing

Class

Factors

Local factors

General factors

Technical factors

ischaemia
Tension
Dead Space
Foreign bodies/contamination
Wound infection
Haematoma
Chronic tissue factors
Local trauma
Sutures
Irradiation

Age/comorbidity,e.g.diabetes,renal failure
Anaemia/blood loss
Shock hypovolaemia/hypoxia
Malnutrition-protein and micronutrient
Major infections/septicaemia
Advanced malignancy
Steroid use
Wound evaluation skills
Surgical techniques

Factors in Wound Management

Antimicrobials

Antibiotics
Tetanus prophylaxis

Anaesthesia
Haemostasis
Debridement and irrigation
Wound closure

Method
Materials

Immobilisation

Surgical instruments and Handling

Instruments
Cutting Instruments
Scalpels
Scalpel handles

 Scalpel blades

 Holding scalpel

 Scissores

 Holding Scissors

Grasping Instruments
Hand held (thumb) forceps
Tissue forceps
Toothed forceps

 Non-toothed forceps

 Holding hand-held forceps

 Ratcheted (scissor-style) forceps

Toothed forceps

 Non-toothed forceps

Vascular forceps
Crushing forceps

Non-crushing forceps

Haemostatic artery forceps

Non-toothed forceps

Toothed forceps

Vascular clamps (non-crushing)

Needle-holding forceps

Locking needle-holding forceps

Suture materials and surgical needles

Surgical needles
Anatomy of surgical needle

Shape and curvature

1/4 circle Ophtalmic and microsurgery
3/8 circle General use in all tissues
1/2 circle General use in all tissues
5/8 circle CVS and cavities (oral ,nasal ,pelvis,
umbi ,etc)
Straight General use (but discouraged as handheld)
J-shaped Similar to 5/8 (femoral hernia)

 Tip and cross-section

 Attachment to suture materials

Suture Materials

USP size code

Organic absorbable
materials

8/0
9/0
7/0
6/0
5/0
4/0
3/0
2/0
0
1
2
3
4
5
6

Nonabsorbable
materials and synthetic
absorbable materials
11/0
10/0
9/0
8/0
7/0
6/0
5/0
4/0
3/0
2/0
0
1
2
3
4
5
6
7

EP size codes (mm)

Organic and synthetic
absorbable material.
Nonabsorbable
materials
0.1
0.2
0.3
0.4
0.5
0.7
1
1.5
2
2.5
3
4
5
6
7
8
9
10

Suture diameter ( mm)

Min.Max

0.01-0.019
0.02-0.029
0.03-0.039
0.04-0.049
0.05-0.069
0.07-0.099
0.10-0.14
0.15-0.19
0.20-0.24
0.25-0.29
0.30-0.39
0.40-0.49
0.50-0.59
0.60-0.69
0.70-0.79
0.80-0.89
0.90-0.99
1.00-1.09

Suture selection

Size

Comparasion

Uses

12/0(to 7/0)

Four times smaller than

human hair

Exclusively microsurgical

6/0

Human hair size;

generaly the smallest
suture used with naked
vision

Face, blood vessels

5/0

Face,neck,blood vessels

4/0

Mucosa,neck,hands,limbs,tendons,blo
od vessels

3/0

Limbs,trunk,gut,blood vessels

2/0

Trunk,fascia,stomach,viscera,blood
vessels

0-1

Small pencil lead

Abdominal wall closure and other

heavy fascial uses

Properties of Common Suture Materials

Catgut (Softgut)
Natural,multifilament and absorbable

Sheep gut submucosa/beef gut serosa

Digested by proteolytic enzyemes in 80-120 days
Common use

Subcuticular and subcutaneous sutures

Liver sutures
Appendiceal stump/oversew
Urinary tract
mesentery

Properties of Common Suture Materials

Polyglycolic acid (PGA) (Dexon II)

Synthetic,multifilament and absorbable

A polymer of glycolic acid

PGA hydrolyses from the 10th to 90th day
Common uses

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

Properties of Common Suture Materials

Polyglactin 910 (Vicryl)

Synthetic,multifilament and absorbable

Copolymer of glycolide and lactide

Absorption at around 20-40 days and is
complete by 60-90 days
Common uses

GI anastomosis
Muscle and fascial
Subcuticular skin closure

Properties of Common Suture Materials

Trimethylene/Glycolic acid (Maxon)

Synthetic, monofilament, absorbable

The monofilament polymer

Hydrolisis is generally completed between the
180th and 210th day.
Common uses

GI anastomosis
Fascial closure
Caesarean section

Properties of Common Suture Materials

Polydioxanone (PDS II)

Synthetic,monofilament and absorbable

The polyester polymer

Absorption by hydrolisis starts at 90 days and
complete by 6 months
Common uses

GI anastomoses
Fascial (abdominal) closure
Subcuticular (skin) closure

Properties of Common Suture Materials

Poliglecaprone 25

Synthetic, monofilament and absorbable

Copolymer of glycolide and caprolactone

Fully absorbed between 91 and 119 days)
Common uses

Subcuticular (skin) suture

Ligation
Subcutaneous suture

Properties of Common Suture Materials

Polybutester (Novafil)

Synthetic,monofilament and nonabsorbable

Polymer
Common uses

Skin closure (plastics)

Ophtalmology
Fascial closure (general)

Properties of Common Suture Materials

Polyvinylidene (Vilene)

Synthetic,monofilament and nonabsorbable

Minimally reactive monofilament suture

Common uses

Fascial (abdominal closure)

Skin closure
Hernia surgery
Vascular surgery
neurosurgery

Properties of Common Suture Materials

Polyether (Dycloc)

Synthetic, monofilament and nonabsorbable

Minimally reactive stretchable monofilament suture

Common uses

Skin closure (plastics)

Opthalmology
Fascial closure (general)

Properties of Common Suture Materials

Polyamides (Nylon)
Synthetic,multi/monofilament and nonabsorbable

Common uses

Fascial (abdominal)
Skin closure
Hernia surgery
Vascular surgery
neurosurgery

Properties of Common Suture Materials

Polypropylene (surgilene,prolene)
Synthetic,monofilament, and nonabsorbable

Non-reactive polymer
Minimal tissue reaction
Common uses

Fascial (abdominal closure)

Vascular anastomoses
Subcuticular (skin) closure
Tendon repairs
opthalmology

Properties of Common Suture Materials

Polyester
Synthetic,multi/monofilament and nonabsorbable

High and permanent tensile strength

Common uses

Cardiac valve surgery

Tendon suture
Othopaedics
Opthalmology

Properties of Common Suture Materials

Silk/Cotton/Linen

Natural,multifilament and nonabsorbable

Common uses

Skin closure
Vascular ligation
GI anastomosis
Opthalmology
Cardiac surgery

Basic Suturing Techniques

Basic Suturing Techniques

Basic Suturing Techniques

Simple suture

Basic Suturing Techniques

Basic Suturing Techniques

Basic Suturing Techniques

Vertical matterss suture

Basic Suturing Techniques

Basic Suturing Techniques

Horizontal matterss suture

Basic Suturing Techniques

Continuous suture

Basic Suturing Techniques

Subcuticular suture

Basic Suturing Techniques

Subcuticular suture

Basic Suturing Techniques

Barron suture

Basic Suturing Techniques

Three-corner suture

Surgical Knot tying

Surgical Knot tying

Surgical Knot tying

Instrument knot

Surgical Knot tying

Surgical Knot tying

Instrument knot

Surgical Knot tying

One-handed knot

Surgical Knot tying

One-handed knot

Surgical Knot tying

One-handed knot

Surgical Knot tying

Two-handed knot