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Basic Surgical Skills

Article · January 2012

DOI: 10.15766/mep_2374-8265.9292

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 BASIC SURGICAL SKILLS

FOR UNDERGRADUATE STUDENTS AND RESIDENTS

AVINASH SUPE

DEPARTMENT OF SURGERY, SETH GS MEDICAL COLLEGE AND

K E M HOSPITAL, PAREL, MUMBAI 400012.

PHOTOGRAPHS BY

GOPAL BODHE
E S MURLIKRISHNAN
 This booklet is intended for use by surgical trainees to provide

basic surgical skills through photo-guided instruction through

exercises in use of a scalpel, surgical scissors, knot tying, suturing,

tissue forceps and vascular clamps.

This booklet contains many commonly performed surgical

activities. Though this book is entirely self explanatory, Instructor

should first explain and demonstrate procedures to surgical trainees. It

is recommended that the instructor should demonstrate these activitie s

and participants should practice each task 10 times. Recommended

time is 2- 2.5 hours.

 INTRODUCTION

The meaning of the word ‘technique’ in the dictionary is ‘the method of

achieving a purpose’ and that of ‘skill’ is the ‘practised ability’ to perform the
technique or the ‘expertness’ in performing it. In other words, the development
of surgical skill through practise is a must for the attainment of surgical
techniques.
There has always been a parallel drawn between art and surgery but ev en an
art such as playing a musical instrument is refined through practice. The
development of a skill aids in the carrying out smooth and purposeful
movements at a subconscious level. Surgery is a complex skill, each step
requiring planning and execution . The basic steps should be choreographed, so
that thought processes can be directed towards complex decision -making.
Every step in surgery should be learnt with sincerity. Surgeons cannot afford
to make mistakes as even a small error, for example a badly tied ligature, can
result in serious consequences. Mistakes should be avoided in the early stages
of learning itself. Once a bad habit forms, it is difficult to get rid of. A casual
approach should be discarded as early as p ossible. A casual surgeon usually
spends many sleepless nights and faces more postoperative morbidity.
Some students of surgery live under the myth that a fast surgeon is a good
surgeon. More than speed, emphasis should be on performing a step with ease
in a relaxed, choreographed and rhythmic manner. Unless a sequence of steps is
rehearsed and is made automatic at a subconscious level, forcefully speeding
one will only break a relaxed rhythm and give rise to mistakes and repetition of
steps.
If surgery is an art then surgical instruments are the paints and brushes of a
surgeon. Each instrument is the invention of a genius with a definite purpose.
One should understand, respect and properly use them to derive maximum
advantage.
SCALPEL
An instrument with a handle and a blade. The type of blade can vary such as
no. 15, 22 and stab knife (11) etc. Number 15 blades are delicate and are used
for cosmetic and small incisions where control is more precise. Number 22
scalpels are used regularly for standard incisions. Number 11 blade (also called
as Stab knife) is different from other scalpel blades. It has cutting edge facing
towards surgeon while using it. This gives better control while taking stab
incisions while performing abscess drainage or introducing drains.
GRIPS ON A SCALPEL (15/22)
A) Pencil grip--The hand is pronated
The scalpel is held between the thumbs and the middle finger
Index finger pulp rests on the knife
The Ring and the little finger wrap around the handle
The end of the handle rests against the medial edge of the hand
Advantage:-(a) Allows sharp, precise, small incisions
(b) Hand can be rested on the patient to steady the hand
Disadvantages: -There is a 30-40 angle between the scalpel and the horizontal
surface, which decreases the contact of the blade edge with the skin

(B) Fingertip Grip (Number 15): -The scalpel is held between the thumb and the
fingertips of the hand.
Advantage: -Maximum length of the blade is in contact with the skin
Better length control.
Better depth control (As the length of tissue within the incis ed
wound on either side of the blade is more, the walls of the wound resist any
direction change)
(C) Palm grip: -Unpopular method of holding a scalpel, as precise movements
are difficult with this grip.

Steps in taking a good incision

1. Plan your incision
2. Cut along the tension lines / Langer’s lines rather than across them.
3. Mark out incision by
a) Pressing haemostat tips on the skin along the planned
incision
b) Marking inks
c) Pressing a piece of linen against the skin.
4. Cross hatching on the marked incision aid in approximation of the wound
while closing.
5. The habit of marking out the incision with the back of the blade should be
discouraged as it gives rise of bad scars, keloids etc
6. Fix the skin.
 XY - XY’ are the lines of forces
* Vectors are ZY-ZY’ and XZ - XZ’ so the skin is stretched
parallel and perpendicular to the skin
7. Keep the blade perpendicular to the skin.
8. Aim of the step is to cut the skin in a single pass, so as to achieve
- Clean incisions
- Perpendicular skin edges
- Uniform depth (Be Bold)
9. At the beginning of the inci sion use appropriate pressure. As the skin edges
begin to part and subcutaneous tissue is revealed - adjust the pressure so as to
cut the dermis and reveal the subcutaneous tissue all along
10. Towards the end of the incision, decrease the pressure again.
11. Then complete the beginning and the end, which will be simple, as the skin
edges would have separated.
12. Direction control- Go along the mark. If deviation occurs - continue along
the deviated path - to avoid a curved incision.

Model – A high-density foam or thick velvet paper can be used to demonstrate

and practice these steps.

SCISSORS
Consists of two metal parts held together at a fulcrum
Each part consists of a blade, a shank and a bow
Though one may find many sizes and shapes of scissors, th ey are basically of
two types: those with straight blades and those with curved blades. A scissor
with curved blades offers directional mobility (have 30 -40% more mobility and
visibility that straight scissors) and easily cuts tissue in a smooth curve. Cur ved
scissors are extremely useful in deeper parts of would or cavity where horizontal
cutting is desired. Straight scissors have a mechanical advantage for cutting
tough tissue.
Scissors can cut flaccid tissues effectively by stabilising tissue between
scissor blades. Scissors with thin and delicate blades can be useful for cutting
and blunt dissection. Though scissors can cut effectively, tissues can get
crushed and jagged as compared to blades. Blunt dissection can be achieved by
spreading scissor blades between tissue planes or by using scissors as a probe.

Method of use: The bow through which the thumb gets inserted is moving blade
The bow through which the finger gets inserted is the fixed
blade
GRIPS : - a) Thumb- ring finger grip
Thumb is inserted in one bow
Ring finger is inserted in other bow
index finger rests on the fulcrum
Middle finger curls around the shank (to stabilise)

b) Thumb - middle finger grip

Thumb is inserted in one bow
Middle finger is inserted in other bow
index finger rests on the fulcrum
The other two fingers curl around the fixed blade bow stabilising
the fixed blade
The above two grips - a tripod is formed making the instrument stable
The less effective grip is Thumb - index finger grip. The disadvantage being that
there is no stability, no direction control and cutting may give rise to chewing of
the tissues and ragged edges.

Bad grips - 1) Thenar eminence - finger grip

2) No fingers in the rings’ grip

The above two grips are only showmanship grips.

HAND POSITIONS
Horizontal cutting - The forearm should be in pronation because if further
supination is required- it is possible to an extent of 180 . Further supination is
possible with abduction at the shoulder joint.

Vertical cutting - The best position is with the forearm being midway between
supination and pronation.

How to use scissors:

a) For cutting tissues 1) Initiation of a cut: The tissue should be near the tip
rather than closer to the fulcrum - or there is greater chance of chewing tissues.
The blades should not be opened too wide - but just adequately. The wider apart
they are - more they will push the tissue away rather than cut the tissue. 2) For
pushing a cut: After initiati on of the cut - stop the closing action of the blade
and push the scissors forwards.
b) Suture cutting: i) Approach the knot much above it and slide the scissors
down the suture length. ii) View the knot between the blades. (No need for
clumsy position like bending, pushing the shank up and viewing the knot from
below) iii) The suture length should be cut nearer to the blade tips - nearer to
the fulcrum - results in chewing. iv) When suture cutting in a deep cavity
stabilise the scissors on the left index or against the body of the patient. v)
The suture must be cut near the knot if the suture material is likely to stay in
body and sutures are deep in tissues. If one plans to remove sutures after few
days, then suture must be cut a centimetre from knot so that it facilitates
suture removal. This also depends on type of suture material. If suture
material is monofilament (Poly propylene or Poly diaxone) or likely to swell
in post operative phase (Catgut) suture must be cut few millimetres from the
knot to prevent knot slipping.

C) For blunt dissection: Like initiating a cut- nick the tissues. Introduce the
blades into the space created. Open out the blades and thus tissue planes open
up. Whenever there are tissues that are too firm to be dissected, they ca n be
nicked and the process can be continued further.

Model- A High density foam or wooden block with a steel hook along with thick
coloured thread can be used for practicing steps.
KNOTS
A knot is an intervening of threads for joining them. Th e area of contact,
the thread surface and the tightness of knot affect secure fastening results from
friction between threads and this.
The half hitch (or single throw) forms the basis of all knots in surgery.

Sketch)  -
A half hitch may be formed in one or two ways. It can be one handed or two
handed dependent on active involvement of these hands.
Method of doing the half hitch
TWO-handed technique: Though commonly practised, it is not a very popular
method. However this is useful in certain circum stances when one is using
surgeons knot or want a secure knot and has delicate tissues. It is safest and
surest method of knot tying.
ONE handed technique: Principle - One hand (Non-dominant) holds the thread
tout while other hand (Dominant hand) does all the knot - tying manoeuvres.
For description, we have considered right hand has dominant hand and left
hand as non-dominant hand. However this can be reversible as per
individual preferences.
STEP 1. The longer end is held taut in the left hand, and the shorter end is
held with R hand between the thumb and the index fingers.
STEP 2. The longer end is looped over the middle, ring and little fingers of the
right hand.

STEP 3. Now the right middle finger go es around the short end.

STEP 4. The short end, now gets grasped between the right middle and
ring fingers and the right index and right thumb now leave the short end
simultaneously.
 STEP 5. The short end now grasped between the right middle and ring fingers
is brought out through the loop.

STEP 6. If the threads have not been crossed before ( which is preferable)
then by crossing the hands the knot gets crossed.

Half hitches can be formed in 2 ways.

A. Taking the Left end over the ri ght end.

B. Taking the Right end over the Left.

After the half hitch is formed and the end has been crossed - there can be 2
knots, which are possible.
a) Granny knots : This is formed by taking a second half hitch of the same type
as the first e.g. :- If Right over Left was taken first, then the first one is
repeated.

b) Reef knot : This is formed by taking a second half hitch of the different type.
e.g. :- First half hitch -Right over Left, Second half hitch -Left over Right.

Formation of Reef knot

After taking the half hitch the two ends are held between the thumb and the
index finger of the two hands.
STEP 1. The pronated Left hand is now supinated such that the longer end in the
Left hand is taken over the mid, index and little fing ers of the Left hand.

STEP 2. The left middle finger now loops around the longer end and the end
gets held between the left middle and left ring finger and the left thumb and
index finger let go of the end simultaneously.
STEP 3.The longer end now gets pulled through the loop by the middle and
index fingers.

The reef knot has better holding power than the granny knot.
MODEL: A High-density foam/ sponge or thermacole base covered with green
thick silk cloth with a hook fixed to it.

The Surgical Knot:

It is a knot with two half hitches taken simultaneously. Surgeons knot is
locked by reversing the direction of pull on the segments This lock stays even if
no tension is exerted on segments. An assistant does not have to put his/ her
finger on first half hitch due to this locking and therefore this is used by
surgeons for secure knotting.
Step1
Hold the long end in the left hand and the short end in the right hand.
STEP 2. The longer end is taken on the middle, ring and the small finger on the
right hand and the left middle finger pulls the short end taut thus making the
threads taut.

STEP 3. Now the longer end is held between the right ring and little finger and
looped through and then held between the left index finger and thumb.

STEP 4. The right middle finger is looped over the short end and the short end is
looped through.
 STEP 5. The hands are then crossed to cross the knot.

Model- A High density foam or wooden block with a steel hook along with thick
coloured thread can be used for practicing steps.

Taking knots in deep cavities:

In taking a knot in a deep cavity - the technique of taking the half -
hitches remains the same as with taking other knots. The principles, which make
this step easier, are
i) The longer end should be held taut in the left hand, this is the fixed end,
while the right hand does all the work of tying the ligature.
ii) After the half hitch has been taken - the left hand holds the longer end taut
and stable and the short end, after the kno t is tied, is held between the middle,
ring and little fingers and the thumb of the right hand. The index finger of the
right hand rests on the knot and slides the knot down along the straight, taut
longer end in the left hand.

iii) As the index finger approaches the tissue to be ligated in the deep cavity, it
may be necessary to wrap the end on the right hand and again progress till the
end.

MODEL: It is made out of a used Plastic can / Thick paper roll stuck on a
cardboard with a hook in the centre as shown above.

NEEDLE HOLDER and SUTURING

The use of the needle holder requires practice and patience. Most
surgeons are judged by smoothness of the suturing. Bad, shoddy suturing
consists of stuttering and stammering.
Stuttering: Repeatedly going in and out of wounds without taking a stitch, to
readjust the needle angle, point distance, the position of the hand or to change
the exposure of tissues.

Stammering: Occurs after the needle is inserted into the tissues. It includes
going in and out of the incision with the needle, multiple pushes to the needle
and multiple steps to extract the needle. It results in loss of time.

For smooth, purposefulness needle holder - movements the important steps are:

i) Position of the needle on the needle holder : Perpendicular position, 2/3 rd

from the point. 1/3 rd from the eye. The further he needle holder is form the
point ( Closer to the eye) more force will have to be applied and closer the
holder is to the point, more difficult it will be to take the opposite edg e of the
wound for adequate needle tip to be brought out from the opposite edge. In
tough tissues the needle may be grasped nearer the point so that the needle
enters with more force. Varying angles are necessary depending on the depth
of tissue intended to be included in stitch. Deeper wounds require more
tangential penetration resulting into more amount of tissue included in stitch.

ii) Grip on the Needle holder:

a) Palm grip : Advantages 1) Strong grip 2) Controlled needle
movement 3) More degree of moveme nt form pronation to
supination. Disadvantages: 1) For re -grasping the needle for
withdrawal, the grip will have to be changed.
 b) Thenar grip: Advantages 1) No need to change grips from
insertion
to extraction of the needle. 2) It has as much as mobility as the
palm grip. 3) It has as much as direction control as the thumb
index grip.

c) Thumb - Index grip: Ideal for fine suturing. Advantages: 1) Better

direction and force control. 2) As the clasp between the handle can
be smoothly released and reapplied the needle will not jump out of
the holder when released.

iii) Positioning the free end of the suture. Proper positioning avoids tangling of
the free end when the knot is tied.
iv) Placement of the needle point : The needle should be placed on the edge at a
pre-decided point and precise movements should direct the needle to that
point. Precision at this step will avoid stammering and stuttering.

v) Position of the Hand : The hand should be in pronation. From the pronation
to supination - a 180 movement - the surgeon is stable and insertion &
extraction of the needle can be done in one s mooth motion. It is better to
come towards oneself while suturing. Going away from the body will push the
elbow against the chest wall cramping the needle movement.

vi) Following the curve of the needle : While pushing the needle through the
tissues it is important to push along the curve of the needle.

vii) Needle extraction: If the needle has been sufficiently brought out across the
opposite side of the incision/ wound then the needle holder can be released
and supinated arm is then pronated and the needle is h eld again. The pronated
arm is then gradually supinated and as this motion is carried out the needle is
gradually extracted along the curve of the needle. If sufficient length of the
needle has not been pushed through or if there is chance that the needle might
slip back in the wound then the tip of the needle can be held with the tissue
forceps. After the tissue forceps has stabilised the needle, the needle holder
can be released and the needle is re -grasped for extraction.
viii) In routine circumstances most s urgeons rarely grasp needle with tissue
forceps. Grasping of needle with tissue forceps is acceptable and used in rare
circumstances when the needle cannot otherwise be retrieved.

viii) Drawing sufficient length of suture material : The required amount of the
suture material has to be drawn through the wound. Once the suture is drawn
out, the suture can be wrapped around the palm of the left hand or the suture can
be left long and the suture is tied.

ix) Repositioning for next stitch.

Model- Two blocks made from high-density foam or wooden block (Covered
with thick velvet cloth fixed on cardboard can be used for practicing steps.

Tissue forceps
Grasp:
1) Palm Grip: Too much of stress comes on the wrist, so the grip is not
too preferred.
2) Pencil Grip: One blade acts as the extension of the thumb and the
other as the extension of the fingers.

How to use the tissue forceps:

1. The tissue forceps holds the tissue to be sutured and thus stabilises the tissue
or The tissue forceps can be used t o retract away the tissue that is above the
layer to be sutured.
2. The tissue forceps retracts the edge of the wound away, so that the needle can
be seen to exit into the wound.
3. The tissue forceps grasps the needlepoint and stabilises the needle till the
needle holder is reapplied to aid extraction.
4. The forceps holds the opposite end of the wound edge and retracts it away so
that the deeper layers are exposed to judge the entrance point of the needle
on the other side of the wound.
5. After the needle is pushed through, the forceps again grasps the needlepoint
to stabilise and then extraction follows.

Artery Forceps.

How to hold vessels : The curve of the artery (Concavity) should be towards the
bleeder to be held. The vessel should be held with the tip of th e artery forceps.

Artery forceps as a clamp . If the artery forceps are to be used to clamp a

structure. They should be used in such a way that the concavities face each
other.
To take ties around the clamp.
STEP 1. The tie is taken around the cla mp with I) The finger tip II) A tie on the
feeder (A long artery forceps with a piece of suture material held at one end.)

STEP 2. The tie is taken around and to the convex side of the clamp.

STEP 3. The clamp is then turned slightly so that the back of the clamp (i.e. the
convex side) faces the person who is tying the knot.
 STEP 4. The half hitch or any other knot is then tied around the stump.

STEP 5. As the knot is being tightened the clamp is slowly released so that as
each tooth is released the tie keeps taking tissue and the stump cannot slip away.

STEP 6. The clamp is then slowly removed in a direction away from the clamp.

Models used in this booklet. Models used in this booklet are made form
easily available material such as green si lk thick cloth, sponge, foam,
hooks, Thick paper roll or plastic can.

References:
1. Anderson and Romfh. Techniques in use of Surgical skills. Appleton
Century Crofts. New York. 1980.
2. R M Kirk. Basic Surgical Skills. 4 t h Edition. Churchill Livingstone.
Edinburgh. 1994.

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