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Foundations of Operative Surgery An Introduction To Surgical Techniques
Foundations of Operative Surgery An Introduction To Surgical Techniques
Foundations of Operative Surgery An Introduction To Surgical Techniques
Bruce Tulloh
Consultant General and Upper GI Surgeon
Royal Infirmary of Edinburgh
Edinburgh
UK
David Lee
Consultant General and Endocrine Surgeon
Royal Infirmary of Edinburgh
Edinburgh
UK
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v
Preface
Contents
Acknowledgements ix
Chapter 5 Retracting 31
The hand as a retractor 32
Instruments for retraction 32
Pitfalls 42
Chapter 8 Haemostasis 67
Contents
Acknowledgements
This book would not have been possible without the assistance of many others. We are
grateful first of all to the many patients who have agreed to be photographed and
filmed in the name of surgical education.The vast majority of footage in the accompanying
DVD is real live surgery, so we extend our thanks to our many colleagues who have
agreed to being filmed in action or to hold the camera. Everyone has been extremely sup-
portive of the project.
In particular we appreciate the work of Gillian Kidd at the University of Edinburgh
Medical Illustration department for the line drawings, and Alison, Lucy and Emily Tulloh for
much of the photography.
To our families we acknowledge the forbearance and support received during the long
writing process; it has been much appreciated.
Finally we would like to thank the trainees we have had the pleasure of instructing over
the years, who have been the inspiration behind writing this book, and our own teachers
from the distant past whose timeless pearls of wisdom we now find ourselves passing on
to the surgeons of the future.
Bruce Tulloh
David Lee
Edinburgh 2008
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1
Chapter 1
Preparing yourself
Pre-operative
The patient rightly expects that each member of the surgical team is well trained,
knows exactly what he or she is doing and is fit, alert and fully awake. Most patients only
have one operation in their lives, and to them it’s a very solemn occasion, even if it’s
just another gallbladder to you. Ensure you have the right patient and the appropriate
indication for surgery. Check that all the required pre-operative tests are done, with
results available. Correct any abnormalities in fluid and electrolyte balance or coagula-
tion abnormalities. Obtain informed consent (see later section). Mark the side of any
unilateral procedure to be done. Arrange adjunctive procedures such as frozen section
or intra-operative X-rays. Make sure the X-rays go to theatre if they’re needed.
Intra-operative
Whether as primary operator or assistant, your part in the operation must be performed
well.You should be familiar with the steps of the operation and be competent at perform-
ing your role. As you become a more senior trainee you will also be expected to know
about the pitfalls that may arise with each step.
Post-operative
You will be expected to know the anticipated post-operative course and the ‘usual’ com-
plications that may arise for the operation in question. You should also be aware of any
rare but serious complications that may be specific to that procedure and be able to man-
age these. You will provide the routine post-operative care and explanation and advice to
the patient and his/her family. When working for a surgeon for the first time, it is always
worth asking about post-operative care, as some surgeons have particular preferences.
No-one will be cross if you ask about post-operative preferences, but they may well be
upset if you get them wrong.
Responsibilities as a trainee
Pre-operative
Familiarize yourself with the patient and their history to understand the indication for sur-
gery and the choice of procedure. Read up the anatomy and pathology, not only to help
you understand the procedure but also to prepare for questioning from the consultant.
If you respond well, it will generate more questions and a better opportunity to learn.
Think about the steps of the operation and how they will be performed.Which bits might
you be able to do if invited?
Intra-operative
Watch and learn. Think about what your consultant says and does. Even if you don’t
admire his/her technique, there are plenty of lessons to be learned—including what NOT
to do! Ask appropriate questions but don’t do this just to show off, and don’t ask too many.
The surgeon will be impressed by your desire to learn but may be drained trying to quell
an insatiable thirst for knowledge. After all, the surgeon needs time to think and concen-
trate as well. If given a chance to operate, you should perform each manoeuvre just as the
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boss has shown you—don’t try to impress the consultant by doing something that you
think is better. Don’t be afraid to ask for help when out of your depth; this shows aware-
ness of your own limitations which is a good quality in a trainee. It also provides another
learning opportunity as the consultant shows you what to do.
Post-operative
A de-briefing is excellent, if it can be arranged, to discuss what went well and what didn’t,
and why. This is best done soon after the event. If approaching your consultant for feed-
back, be careful that it doesn’t sound like you’re fishing for compliments.
1 Preparing yourself
Recall the steps of the operation in order. Write them down—begin to construct
your own textbook of operative surgery which can be added to and edited throughout
your training.
KEY POINTS
1 Conscientiousness, diligence and reliability are qualities that surgeons love to see in
their trainees.
2 Make the most of every opportunity to learn from your experiences.
3 If you’re not sure, ask.
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5
Chapter 2
Conducting yourself
Theatre etiquette 6
Before you start 6
Sterile zones 6
Passing sharps 6
Assisting 6
Operating 7
Haste versus speed 8
After the operation 8
Record keeping 8
Speaking to relatives 10
Key points 11
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Theatre etiquette
Before you start
It is good etiquette to arrive in the theatre suite before the scheduled time of the opera-
tion and greet the theatre and anaesthetic staff. If you don’t know their names, introduce
yourself. Discuss any special needs you may have—for example, your scrub nurse will
appreciate advance warning of any particular instruments you might require, and the
anaesthetic staff and porters will happily discuss the position you’d like the patient to be in
2 Conducting yourself
on the table. If you might require intra-operative radiology or pathology, warn the
X-ray department or the laboratory beforehand.
An operation is a team effort. Everyone has a role for which he or she has been specifi-
cally trained. Remain polite. You should respect everyone else for their expertise and
welcome their input into the operative plan. In return, you can expect some respect for
your expertise.
Sterile zones
Recognize the ‘sterile zones’ in the theatre—simplistically these are in the immediate
vicinity of the operating table and all around the scrub nurse’s set-up. Once you are
scrubbed you should stay within this zone. Keep your gloved hands above your waist;
below this level (and also behind your back) is regarded as ‘unsterile’. Clasping your hands
together in front of your chest is a safe place to rest them. Crossing your arms is OK if the
hands stay out in front: don’t stick them into your armpits!
If you have to change sides of the table, it is correct etiquette to walk around the scrub
nurse’s end and not the anaesthetist’s end. When walking past another scrubbed person
you should pass back-to-back or front-to-front. If squeezing past a sterile object such as
the scrub nurse’s trolley, you should pass with your front (the sterile side) towards it and,
if passing an unsterile object such as a diathermy machine, pass with your back to it.
The instrument trolley is the nurse’s domain and he or she needs to know where all the
instruments are at all times, so don’t help yourself to instruments and equipment: ask the
scrub nurse to pass them.You should speak clearly in a firm voice.While it is acceptable to
use few words, perhaps simply stating the name of the instrument you require, it remains
good practice to say ‘please’. If the nurse is busy or distracted you may have to repeat the
request, perhaps in a louder voice, but shouting and getting angry is not helpful.
Passing sharps
It is customary for the nurse to place instruments directly into the surgeon’s hand,
oriented ready for use, in order to prevent the surgeon from taking his/her eyes off
the operative field. However, because of the risk of sharps injury, this should not be done
for scalpels.These should be placed by the nurse into a tray from which they can be picked
up by the surgeon, and returned to the nurse in the same way. Artery forceps should
be returned in the closed position, and needles should be returned mounted in the
needle-holder so they don’t get lost. Rotating the needle within the jaws to ‘hide’ the tip
before passing it back seems sensible, but bear in mind that to do so requires extra han-
dling of the needle by both surgeon and nurse, particularly if it needs to be re-mounted
for further use.
Assisting
A good assistant makes an enormous difference to the progress of the operation. The
assistant should be familiar with the steps of the operation so that the operating surgeon’s
next move can be anticipated.The assistant has several important responsibilities:
● Exposure of the operative field, which includes retraction, adjusting the light and
removing blood from the area by mopping or suction.Try to see the operative field
from the surgeon’s perspective.
7
● Streamlining the flow of the operation by holding and releasing artery forceps as knots
are tied, cutting sutures and following suture tails to maintain tension and keep them
out of the way.
● Calling for instruments—but just ask for the ones that you, the assistant, might need
such as retractors or scissors. As a rule you should not ask for something on behalf of
the operating surgeon—that is for them to do.
● Supporting the surgeon’s decision-making, rather like a caddy at golf. Having a
colleague with whom to discuss anatomy, technique and general progress is a great
2 Conducting yourself
help during a difficult operation.
If unsure of exactly what you are required to do when assisting, ask in order to clarify
this. Some surgeons like chatter across the table while others need quiet to concentrate
and would like to think that their assistant is concentrating too. Nevertheless, you are
there to learn; don’t hesitate to ask about things you see and be prepared for the surgeon
to quiz you on parts of the operation. Try not to ask what the surgeon will be doing
next—you are about to see that—and also be careful about generating conversation at
awkward times. When things aren’t going well and stress levels begin to rise, it is often
best to keep quiet and speak only when spoken to.
Occasionally you may perceive that the operating surgeon has forgotten something,
is heading in the wrong direction or has even made a mistake. You may even be right. It is
an exercise in tact to speak up in a situation like this without appearing either a fool or a
know-all, so think carefully. Asking an innocent question may be a good way to start, such
as ‘Have we got all the packs out?’ Better to do this before the error is made, so as assistant
you should be attentive to the flow and direction of the operation throughout.
Operating
It is a myth that technical skill in the operating theatre is an inborn quality that one either
has, or has not; most people can learn it if they have the dedication and will. The perfor-
mance of any task improves with practice, and rehearsal of basic surgical manoeuvres as
well as experience on the job will improve your performance. Left-handed surgeons may
struggle initially with right-handed instruments but, if well made, the instruments should
do the work themselves without the need to strain wrong-handedly on the mechanism.
For that matter, right-handed surgeons should also practise using instruments in their
left hands, as ambidextrousness is a useful trait. Applying and releasing artery forceps and
cutting sutures should certainly be mastered with both hands.
Don’t be concerned if your hands shake: no surgeon is perfectly steady. However,
some physiological tremors are more noticeable than others. Lack of sleep, caffeine and
performance anxiety certainly make things worse. It is useful to steady the operating
hand by resting it on a firm surface, thus restricting movement to the smaller joints and
neutralizing ‘sway’ of the elbow and shoulder.
In addition to knowledge of the procedure and technical skill, there are three
behavioural aspects that deserve attention if you are the operating surgeon. These are
managing your own stress response, learning to make intra-operative decisions and asking
for help.
Everybody behaves differently under stress: some become loud, others quiet; some
charge ahead while others dither; some become rude. You should learn your own stress
response and try to mould it so that you remain cool, polite and amenable to input from
others who are trying to help the situation. It takes experience, insight and a good deal of
self-control.
When something unexpected arises during the operation, certain intra-operative deci-
sions must be made on the spot. It helps to have anticipated the situation pre-operatively—
but this is not always possible—and it also helps to have been in a similar situation before,
8
which is why experienced surgeons are generally better at this. It is often a good time to
ask for advice.
Although it takes a degree of humility, asking for help does not lose you respect: in fact,
just the opposite. It’s the patient’s welfare that is at stake, and asking colleagues for help to
achieve a satisfactory outcome is in everybody’s interest. Blundering on in an attempt
to ‘save face’ may be successful, but, if not, both you and the patient will pay for it.
Speed is thought to be a good attribute for a surgeon—after all, every minute saved in the
operating theatre leaves more time for something else. However, the surgeon’s primary
aim should be to do the operation properly. To do it quickly is a bonus.
The secret to getting through an operation quickly and safely is being efficient, not
hasty. Haste is dangerous. Efficiency means getting the job done with minimum waste of
time or effort, which in surgery requires teamwork. Ward staff, porters, anaesthetic col-
leagues and theatre staff all have a role to play in getting the patient on and off the table,
while the operating surgeon, assistant and scrub nurse also need to work together if the
operation is to progress smoothly. As far as the surgeon’s individual responsibility for effi-
cient operating is concerned, the key elements are good operative planning, swift and
accurate execution of each manoeuvre, anticipation of successive steps and communica-
tion with colleagues and other staff (see Table 2.1).
Even in a ‘quick’ operation, the pace can change along the way. Experienced operators
know when they can afford to be fast and when they need to slow down and exercise
caution. They spend time on the steps that are important and don’t waste time on those
that aren’t. Trainees should note these characteristics in their seniors—the good and
the bad, the fast and the slow—and get into the habit of smooth and efficient operating
practice themselves, right from the start.
2 Conducting yourself
what went on in the theatre until the definitive report appears, which may be some days
later if it has to be typed. Remember: if post-operative complications develop when you’re
off duty, that hand-written note may be all that the covering team have to go on. An exam-
ple of such a report is illustrated.
The definitive report should contain enough detail so that another surgeon can read it
and understand exactly what was done, but should not be unnecessarily wordy. The gen-
eral structure should be as follows:
● Incision (see Fig. 2.1 for names of common abdominal incisions)
● Findings
Those of relevance, but include important normal findings such as ‘the common bile
duct was not dilated’.
Bilateral
subcostal or
rooftop
Right subcostal Upper
or Kocher’s midline
Transverse
Right lower
oblique or
gridiron
Pfannensteil
Fig. 2.1 Names of several common abdominal incisions. Others have been omitted for clarity but can be
inferred from the names, such as left upper transverse, lower midline or right upper paramedian.
10
● Procedure
What was done, step by step, in order.Writing reports in point form is acceptable, and
in some situations it is useful to draw a diagram. Intra-operative difficulties should be
described, as well as other details such as suture material and gauge, staple gun
diameter, mesh material and size, etc.These become important if there are any post-
operative complications.
● Closure
2 Conducting yourself
Material used, layers closed and technique(s) used, e.g. suture style.
While it is not suggested that operation reports be constructed with a medico-legal
defence in mind, don’t write anything that you’re not prepared to have read out in court.
The following example of a formal report for the above operation is quite succinct but still
conveys adequate detail.
Operation report
Date: 4/2/08
Operation: Emergency laparotomy & omental patch to perforated D.U.
Surgeon: Mr A
Assistant: Dr B
Anaesthetist: Dr C
Incision: Upper midline
Findings: 3mm perforation in anterior wall of duodenum just beyond pylorus.
Indurated edges. Fibrin ++. Peritoneal contamination ++ with bile and food
material. Stomach & liver normal.
Procedure Three sutures of 2/0 vicryl placed in anterior wall across ulcer. Tongue of
omentum laid between and sutures tied over. Irrigation with saline x 4 litres
incl. above and below liver, LUQ, pelvis and SB compartment. All areas
sucked dry. 32F tube drain placed to region of omental patch, brought out in
R flank.
Closure: Continuous looped 1 PDS to fascia. Staples to skin.
Signed: Dr B
S-U-R-N-A-M-E
The post-operative drug chart also needs to be written up. Often this is done by the
anaesthetist, but you need to clarify whose responsibility it is.Think of the four Ans:
● Analgesics
● Antiemetics
● Antibiotics
● Antithrombotics
The patient might not need all four, but it’s a useful checklist. It is also important to
write enough post-operative instructions for ward staff to last until you return to see the
patient again. Generally this means instructions regarding dressings, drain tubes, post-
operative oral intake and mobilization.
Speaking to relatives
Although not always practicable, it is a nice touch to speak to caring relatives after an
operation. Occasionally it is very important, such as in paediatric surgery, or after major
surgery and emergency cases when t he family are very anxious about the findings and
outcome. Remember, however, that you have an ethical obligation to the patient to
maintain confidentiality and so, strictly speaking, you should have each patient’s permis-
sion before telling others what you found at operation.
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When the relatives want to keep the operative findings a secret from the patient, the
situation is even more awkward. Such a request from the family arises out of concern,
trying to spare their loved one from bad news, but is liable to backfire when the patient
eventually finds out (which they inevitably do). The patient then feels angry about
being excluded and the family is embarrassed. It may be worth discussing all of this pre-
operatively—use your judgement and common sense.
When speaking to relatives it is important to appear calm, mature, knowledgeable
and empathic. You are the spokesperson for the whole surgical team and need to
2 Conducting yourself
instil confidence. Being cheerful and flippant may help reduce your own anxiety but is
unlikely to allay theirs. Use plain language with lay people but don’t speak down to them,
which may be insulting, and avoid euphemisms. Don’t be afraid to use medical words
where appropriate, as many educated people know a lot of medical terminology. You may
wish to establish their level of medical knowledge before you start.
Patients often want to know about the recovery process and you can be quite opti-
mistic, as most operations go well. However, be careful not to promise too much as
unforeseen complications do occur. One school of thought suggests that we should
always prepare patients and their relatives for the worst so that they will be pleasantly sur-
prised at the outcome—but that is probably taking things a bit far.
KEY POINTS
Chapter 3
Before you start
Finally, it allows the patient to vent any anxieties about their operation by asking questions.
It is therefore vital that the person obtaining consent be familiar with all aspects of the
operation and the recovery process.
The surgeon’s responsibilities during the consent process are to:
● explain the rationale for surgery, which can include a discussion of alternative
case;
● outline the steps of the procedure and the likely post-operative course;
● inform the patient of the common risks (even if they are not serious) and the serious
● invite questions. Some patients have very specific queries and these must be answered
Scrubbing up
Established in the early 1900s as an important step in the fight against infection, the ritual
of handwashing has become an iconic part of surgical practice, steeped in folklore.
Irrespective of local protocols and individual preferences about scrub technique, there
are a few principles to remember.
● ‘Scrubbing’ is a misnomer.The aim is for clean hands and, while macroscopic dirt may
require the use of a nail pick or scrubbing brush for the first scrub of the day, it is not
mandatory. Once the dirt is gone, vigorous scrubbing just damages your skin.
● The antiseptic wash will not sterilize your hands. Even if it did, more bacteria would
soon emerge from the depths of the pores, especially in the warm, moist environment
under your gloves.The best that washing can achieve is clean skin with a temporarily
reduced surface bacterial count. If some antiseptic residue remains on the surface,
so much the better.
● Make sure that you have any eye protection on and your gown and gloves laid out
too cold is uncomfortable, does not lather as well and seems harder to dry off before
gloving.You can adjust the taps as you wash, but don’t touch them with your hands
after you’ve started!
● Surgeons traditionally wash up to their elbows. Begin by washing the hands carefully
and thoroughly, taking particular care to clean between the fingers, the palmar skin
creases, around the thumb and along the ulnar border of the hand and wrist.The suds
can be then rubbed along each forearm, one at a time, remembering that in doing so
the rubbing hand is becoming progressively more ‘dirty’. Don’t go back to rubbing your
hands again.
● The suds should be rinsed off under running water so that the dirty effluent runs down
off the elbows, not over your hands.The need for the hands-up–elbows-down rinse
position is why scrub sinks are so deep (Fig. 3.1).
● A good routine is to brush the nails once and then go through the above wash-and-
rinse routine three times for the first scrub of the day—it will take 2 or 3 minutes. For
each subsequent case on that list, a thorough but brief wash lasting only a minute or so
should suffice.
It is important not to undo all the hard work of hand-washing by unsterilizing yourself
when putting on the gown and gloves. If you haven’t been shown how to don these yourself,
ask for assistance. Only someone who is already gowned and gloved can help you put yours
on, although an unsterile bystander can tie your gown at the back. If wearing two pairs
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3 Before you start
Fig. 3.1 Rinsing hands: the water should wash suds and dirt off towards the elbows.
of gloves, it is common practice to put a larger size on the inside—but ultimately this
depends on what is most comfortable for you.
Changing contaminated gloves in the middle of an operation is another skill. The aim is
to keep your hands clean in order to put on a new pair, so don’t touch the dirty (blood-
stained) outer surface of your gloves with your bare skin: someone else can peel them off
you. Hold your wrists out so that the cuffs can be grasped then pulled off. You will then
need help to re-glove from someone who is already gowned-up and sterile. If you are
wearing two pairs, removing the outer pair is much easier and you can do it yourself.
The time which normally elapses between prepping and making the incision is just long
enough—so don’t hurry.
● To determine the area of skin to be cleaned, consider where the wound will be and
where the drapes will lie around that.Then aim to prep over a margin of approximately
10 cm beyond that (Fig. 3.2).You should also take into consideration the possibility that
17
Area to be
prepped
Fig. 3.2 Prepping and draping: think about the site of the wound and the area of skin you want exposed
before you start. Remember you may have to extend the wound.
your wound may have to be extended. It’s always safe to prep wider than you think
you’ll need.
● As the antiseptic-soaked swab paints the skin it becomes more and more ‘dirty’.
Therefore, you should begin to prep in the area that you plan to make the incision, and
paint in progressively larger circles or rectangles away from this. DON’T then go back
to the wound area for one last wipe.
● For the same reason, the whole skin area should be prepped twice, as above.The two
swabs provided by the scrub nurse are for sequential use.They should not be used
simultaneously to paint half each.
● Don’t use too much prep solution. Apart from splashing and being messy, it can sit in
puddles under the patient.This carries the potential for a diathermy short-circuit or, if
alcoholic prep is used, even a fire.
● If clipping the drapes in position, be VERY CAREFUL not to pick up the patient’s skin.
anaphylaxis.
● Establish the maximum safe dose (volume) that you can use before you start and don’t
exceed it. Mixing agents doesn’t necessarily give you any more leeway.Ask the
anaesthetist if in any doubt, and cancel the case if you don’t think you’ll have enough.
● Check the ampoules before filling your syringe—someone may have accidentally put
some other drugs in the local anaesthetic cupboard.
● Be wary of drawing up from a previously used ampoule—the contents may no longer
be sterile.
● Be aware of the dangers of using local anaesthetic in poorly vascularized tissue (e.g.
diabetic feet) even without vasoconstricting agents.The slight rise in tissue pressure
from the instillation of local alone may be enough to precipitate tissue necrosis.
● Be aware of the false sense of security provided by vasoconstricting agents which
reduce bleeding in the operative field. Haemostasis during these operations must be
meticulous, bordering on obsessive, to prevent post-operative haematomas
developing from the subsequent reactive hyperaemia.
Choice of agent
There are many on the market, but the two most commonly used local anaesthetic agents
are lignocaine (Xylocaine) and bupivacaine (Marcain). From a surgeon’s point of view, the
two main differences are that lignocaine has a more rapid onset than bupivacaine (1 min
versus up to 5 min) but a shorter duration (30 min versus up to 6 h). BOTH have maxi-
mum safe doses of 2–3 mg per kg and these are additive, so you can’t switch agents when
you’re approaching the maximum safe dose. Similarly, mixing the two agents together (to
provide both a rapid onset and long duration) doesn’t allow an increased dose. Prilocaine,
which behaves like lignocaine but binds to tissues better and has fewer cardiac side effects,
allows a larger volume to be used (see Table 3.1).
*The maximum safe volume can be increased either by using a lower concentration of anaesthetic
(e.g. diluting with normal saline) or by combining it with adrenaline at no more than 1:200 000.
19
Use of adrenaline
Adding adrenaline to these agents at a concentration of no more than 1:200 000 causes
vasoconstriction and has both pros and cons.
Pros:
● It decreases bleeding at the time of the operation.
● It slows the washout of the drug from the tissues, so prolongs the duration of
action.
● Because of slower absorption, it allows a higher safe maximum dose.
Cons:
How to inject
This depends on whether you are doing a regional nerve block, in which case a relatively
large volume is injected in one place, or a non-anatomical field block, in which case the
anaesthetic is distributed over a wide area.
Regional nerve block (e.g. femoral nerve block in the groin)
Consider the local anatomy: what layer is the nerve in? You may feel the needle ‘pop’
through the fascial layers. Often large vessels lie nearby—so there’s a risk of both
haematoma and intravascular injection of agent. When injecting a depot of anaesthetic, it
is imperative that you aspirate first to ensure the needle tip is not in a vessel. Then once
you’ve started to inject, don’t move the needle (unless you aspirate again to check).
Non-anatomical field block (e.g. peri-lesional infiltration for excision: see Video 3.1)
● Start your local infiltration on whichever side of the lesion the nerve supply comes
● Put it through the open wound if possible to avoid painful dermal puncture.
Video 3.1 Infiltrating local anaesthetic around a skin lesion. Start some distance away; see the skin rise
up as you inject; keep the needle tip moving at all times to avoid the need to aspirate. Fan
out the distribution of local anaesthetic from each needle puncture site. Subsequent needle
punctures should go through previously anaesthetized skin if possible. Remember to inject
deep to the lesion as well.
For peri-lesional infiltration, the needle tip is kept moving at all times so it is not necessary,
nor even sensible, to aspirate first.You will need to infiltrate beyond the planned operative
field, all around in three dimensions, and wait a minute or two for it to take effect. You
must be happy with your block before you start. Consider all the layers that have somatic
20
nerve supply and ensure that anaesthesia is delivered to them as required:
● Dermis
● Deep fascia
● Periosteum
● (Spermatic cord and mesentery: these have autonomic nerves which should be
You may need to inject more during the procedure if required, so don’t use up all your
allocation of anaesthetic on the first go.
Examples of common usage are shown in Table 3.2.
Digital ring block for 2% plain lignocaine 5–8 ml Don’t inject too much—the
ingrown toenail or raised local tissue pressure
surgery 0.5% plain bupivacaine may cause ischaemia, even
DO NOT USE without adrenaline
ADRENALINE
Chapter 4
Making incisions
● Good handling of the scalpel—holding it correctly and incising at right angles to the skin.
● Confident and precise cutting. A single smooth cut for the whole length of the wound
Video 4.1 Making a long incision.The blade is held at a shallow angle to the skin and drawn smoothly
along the whole length of the wound with firm, even pressure, pausing only to adjust the
counter-traction provided with the other hand. Several long passes with the knife like this
may be made until the desired depth is reached.
23
4 Making incisions
Fig. 4.1 The Number 3 handle and three commonly used suitable blades (left) and the larger Number 4
handle and blades.
Fig. 4.2 The conventional grip for a long incision—blade held flat and finger on top for controlled
pressure.
24
4 Making incisions
Fig. 4.4 The surgeon’s hand tensions the skin and applies lateral tension as well as counter-traction as the
blade is advanced along the wound.
For very fine work, the scalpel can be controlled with your fingers alone. When cutting
out a shape, such as an ellipse of skin, it is advisable NOT to cut right through the dermis
with the first stroke, as doing so makes it much more difficult to maintain skin traction and
hence to complete the incision neatly. It is better to make a shallow intra-dermal cut
4 Making incisions
around the whole shape first before proceeding to the deeper plane (Video 4.3).
Video 4.3 Incising around a lesion.When excising a lesion it is best to incise shallowly all around
before deepening the cut through the dermis. Otherwise it is difficult to maintain tension
and counter-traction on the skin.
Fig. 4.5 The ‘pen’ grip for short incisions, typically using a #15 blade.
Fig. 4.6 Holding the #11 blade almost vertical for a short stab incision.
Video 4.5 Using diathermy to deepen a wound. In this inguinal hernia incision, the coagulation setting
alone is used—good lateral traction helps separate the tissues and simultaneously limits
bleeding. Using just the tip of the diathermy probe concentrates the current for best
results. Cautious delicate strokes are needed as the external oblique layer is approached, to
avoid penetrating too deeply.
27
4 Making incisions
Fig. 4.7 The diathermy hand-piece with buttons to operate in either cut (yellow) or coag (blue) modes.
As the incision progresses, any uncontrolled bleeding vessels can be coagulated. This
may mean alternating between cutting and coagulation modes, which is simply a matter of
pressing a different foot-pedal or finger-button. If the coagulation setting alone is used to
deepen a wound, firm pressure on the diathermy instrument will be needed, as well as
good lateral traction to allow the tissues to separate. This will also provide a clear view of
the base of the wound. There is considerable collateral heat injury, so use it cautiously
until you become familiar with the technique. Contact must not be made with the skin
edge as this will cause a full-thickness electrical burn.
Coagulating diathermy is also commonly used for opening viscera, particularly those
that are very vascular. However, because of the inevitable associated collateral heat dam-
age, it should not be used on fine structures where there is a risk of subsequent stricture.
Thus it is used to open stomach, bowel and bladder, but not ureter, bile duct or blood vessels.
When opening into a hollow viscus, apply stay sutures or tissue forceps such as Babcock’s
to elevate the front wall and apply lateral traction, then incise (Video 4.6). Bleeding should
be minimal if the coagulation mode is used. Bowel resection performed using diathermy
seems to have no effect on the healing power of an anastomosis.
Video 4.6 Opening the bowel between Babcocks.These atraumatic grasping forceps provide the
required traction to display the tissue layers as the incision is deepened. Once into the
lumen, the incision can be extended in either direction. Coagulation diathermy is used
throughout, because the GI tract wall is so vascular.
Fig. 4.8 Plan of excision of an old scar to produce a neater result at the end of this re-operation.
The sides must be made as clean and straight as possible to ensure a neat final result, so
good skin traction is required. A relatively shallow cut should be made all around before
deepening through the dermis; a full-thickness incision on one side will make skin traction
on the second side very difficult. Once one end has been mobilized, forceps are used to lift
the old scar, and either the knife or diathermy is used to excise it entirely. It is important to
stay close beneath the scar, with what you’re cutting clearly under vision, in case some-
thing important such as a knuckle of bowel is lying just under the surface (Video 4.7).
Video 4.7 Excising an old scar.The scar has been circumscribed along the line of planned excision first,
then the wound is deepened cautiously. Good traction on the skin is important for a neat
cut, but the assistant’s fingers must be kept out of harm’s way. Firm upwards traction on the
scar with tissue forceps helps. Using the scalpel is safer than diathermy if you’re not sure
what lies beneath because the depth of incision is easier to control. Smooth sweeping
movement with the flat of the blade is better than scratching with the tip.
Once the surface scar has been removed, dissection continues down through more
fibrous tissue. Either the scalpel or diathermy must be used with care as the tissue planes
29
will have been destroyed. Progress slowly. Layers may be difficult to define and accidental
injury may occur to structures adherent beneath the scar. Good traction by the assistant
will help to avoid this. It is often useful to extend the incision at one end and then deepen
it through virgin tissue, where the anatomical planes are more distinct, before moving
back to expose the area under the scar. This is a common ploy when re-opening laparo-
tomy wounds.
KEY POINTS
4 Making incisions
2 Select the appropriate scalpel blade and handle for the task and hold it correctly.
3 Apply judicious traction to skin edges.
4 Be aware of the risks when using diathermy.
5 Beware of structures adherent beneath old scars.
PITFALLS
the original wound—it may help to take any retractors out first to help you line it
up.Think before you cut: will the extended wound be adequate?
● Consider a completely new incision: you can’t oversew a perforated duodenal
ulcer through a gridiron incision no matter how long you make it.
● In laparoscopy there is no shame in placing more ports as required to improve
vision or access.
2 There are several old scars but none is in the ideal position for you to use.
● Think very hard before adding yet another to the patient’s collection.A new
incision nearby and parallel to an old one invites ischaemia of the intervening skin,
and crossing an old scar may cause necrosis at the junction. Can you go through
(or excise) one of the old ones and extend it to suit your purposes?
3 The wound you’ve made is ragged, crooked or untidy.
● Was your scalpel blunt, forcing you to saw through the skin? Consider a new
blade.
● Initial skin traction may have been inadequate, or perhaps asymmetrical. Maybe
you used an inappropriate blade, or simply weren’t bold enough to make a sure,
straight incision.The best you can do is excise the wound edges until neat—start
with a new blade, good skin traction and a careful but confident stroke.
4 The diathermy has burned the skin edge.
● You could leave it but if the burn is any deeper than the epidermis it will scar.
Unless it’s very superficial you should excise it with a sharp blade, taking care to
blend your excision line in to the rest of the wound. Pulling the burned area
outwards with skin traction in the other direction is helpful (Fig. 4.9).
30
PITFALLS (cont.)
4 Making incisions
5 You have entered into a loop of bowel on re-opening an old laparotomy wound.
● Don’t panic. Control local effluent with suction if required.You will need to repair
this before you can go on, which means that the immediate objective of the
operation has suddenly changed.Take a deep breath, adjust the light, call for
assistance if required and prepare for tedious dissection.Your aim is to separate
the bowel loops from the overlying abdominal wall until enough length has been
exposed to perform a sound repair.
31
Chapter 5
Retracting
venient, and is sometimes the only way to expose a particular area. However, it is tiring,
and there is a risk of glove puncture, wound contamination and needle-stick injury. For
these reasons, the use of fingers and hands in wounds is generally discouraged.
Surgeons may keep their own hands out of harm’s way, but the same cannot be said for
assistants’ hands—these are at a much higher risk of injury and should stay out of wounds
altogether.
These very delicate (and sharp) instruments hook into the under-surface of the dermis
after an incision has been made, then elevate the wound edges.They are useful in fine
work such as hand surgery or excising a lesion. Be careful to avoid glove puncture.
5 Retracting
Fig. 5.2 Kilner’s (top) and Volkmann’s rake retractors.
● Larger hook-style retractors include Czerny, Langenbeck and Kocher, which can reach
a little deeper than the clawed styles (Fig. 5.3).They are commonly used in moderately
deep situations such as hernia repair or thyroidectomy.These may come in different
sizes but always maintain their characteristic and recognizable shapes.
● Doyen’s body wall retractor is even larger, with a strong handle for the assistant’s grip
and a broad, curved blade to distribute considerable force over a wide area (Fig. 5.4).
It is generally used to pull back the edges of a laparotomy wound or to elevate the
costal margin during upper abdominal surgery.Variations of this basic design have been
developed and may be used as a self-retaining third blade in a Balfour retractor
(see below).They may also be fixed to a pole or bar attached to the operating table
when firm traction for prolonged periods is required (Fig. 5.5).
● A Morris retractor has a large flat blade with a lip at the bottom end (Fig. 5.6). It is also
used to retract full-thickness wound edges and the costal margin.
34
5 Retracting
5 Retracting
Fig. 5.5 Doyen-style retractor fixed to a bar to elevate the costal margin.
Tissue-grasping forceps
These are ratcheted, ring-handled instruments with differently shaped jaws, designed
to grip tissues with different degrees of strength. Using the wrong grasper on the wrong
tissue will either fail to grip at all, or cause unwanted tissue damage.
● Lane’s tissue forceps are very strong, with the single coarse tooth in their robust jaws
providing excellent grip (Fig. 5.7).They are excellent for providing firm traction on
heavy fascial layers such as the linea alba, but can be very damaging on more delicate
tissue.
36
5 Retracting
Fig. 5.7 Allis’ (left), Littlewood’s and Lane’s tissue forceps, here displayed in increasing order of strength
from left to right.
● Littlewood’s and Allis’ forceps both have a single row of fine teeth which grip well,
although with heavy traction they can slip off and severely score the tissue being held
(Fig. 5.7). Allis’ are the more gentle of the two as the shafts are thinner and less rigid.
Both these forceps are commonly used for elevating wound edges, such as when
undermining skin flaps in a mastectomy, but when used in this way they should be
applied just to the dermis of the cut edge or the teeth may damage the skin surface.
● Babcock’s forceps are the least traumatic in this group, with delicate, smooth jaws and
a reasonably springy shaft (Fig. 5.8).They are not suitable for skin or fascial retraction
abdominal surgery to retract solid organs such as liver (Fig. 5.9).The handle is
5 Retracting
Fig. 5.9 Kelly (top) and Deaver retractors.
5 Retracting
Fig. 5.12 Travers’ self-retaining retractor.
many other retractors, some with angled shafts to allow deeper insertion, and some
with single spikes instead of claws like the Gelpi (Fig. 5.13).They are generally used for
retracting the skin and subcutaneous layers, particularly in the absence of an assistant,
such as when doing the perineal part of an abdomino-perineal resection.
● The Finochietto is a heavily built retractor designed for use in the chest. It has a levered
winding mechanism to allow it be opened against the very strong forces in the thoracic
cage (Fig. 5.16).
● Large fixed retractors have many uses in abdominal surgery.The Bookwalter is
essentially a metal ring (many sizes and shapes available) which sits over the wound,
with a number of variously shaped retractor blades clipped to it, positioned as
required. Several blades placed around the ring open the wound very widely. Others
such as the Omni-tract (Omni-tract Surgical, St Paul, Minnesota) involve one or more
metal arms fixed to the operating table, to which a variety of retracting blades can be
attached (Fig. 5.17).These retractors take some time to set up correctly, so are only
used in long procedures where complex retraction may be needed, such as abdominal
aortic aneurysm repair or liver resection.
41
5 Retracting
Fig. 5.15 The Balfour abdominal retractor (with third blade attached).
Fig. 5.17 The Omni-tract apparatus in place. Note also Balfour retractors on either side, fixed to poles
under the drapes with linen tapes.
PITFALLS
1 Retractors can damage skin edges, either by excessive pulling on a hook-style retrac-
tor or by tissue-grasping forceps slipping across the skin. Care should be taken with
the force of retraction at all times—you should pull just hard enough to provide ade-
quate exposure, and no more. Grasping forceps should be applied to strong subcuta-
neous layers (Scarpa’s fascia, platysma, dermis) rather than the skin surface.
2 A burn injury may occur if the metal retractor makes contact with the diathermy
instrument.
3 Nerves and vessels are subject to traction injury if they happen to pass near a
wound which is being forcibly retracted open. They may also be directly injured
by the sharp tips of some designs.
4 Bowel may be damaged to the point of pressure necrosis if caught behind a
retractor blade for any length of time. Care must be taken when positioning
retractors near delicate structures.
5 Retraction on a major vessel where a tributary has been tied may avulse the knot
and cause bleeding, although it may only become apparent when the retractor is
released.
6 The tips of deep retractors may dig into soft organs such as liver or spleen if the
assistant is positioned such that they cannot see what they’re doing. A straight
even pull, avoiding the temptation to lean on the retractor or rotating it against
the wound margins to gain purchase, reduces the risk. Supervision, checking and
reassurance from the surgeon regarding position is essential.
7 Retractors may move out of position. The forces may be too great, the blades
may not be deep enough or too gentle, or the assistant may be falling asleep. Do
not hesitate to inform the surgeon if your hand is tiring and you think your grip
may soon slip.
43
Chapter 6
Separating tissues
Blunt dissection 44
Using instruments 44
Using fingers 46
Sharp dissection 48
Using scissors 48
Using the scalpel 49
Using the diathermy 50
Key points 50
Pitfalls 51
44
The secret to separating tissues is to identify and stay in the correct plane. This relies on
sound anatomical knowledge and good assistance. An understanding of local anatomy is
important not only from the point of view of recognizing landmarks but also to help select
the appropriate technique for dissection, and good assistance is necessary not only to
ensure adequate display of the operative field but also to provide traction on the tissues
to be separated.
Sometimes keeping to the plane may be difficult, such as when operating in an
obliterated congenital plane or in one destroyed by inflammation and scarring. In these
cases, good assistance is vital, and knowing the anatomy is even more important, as
6 Separating tissues
the only clue to the fact that you’ve drifted into the wrong plane may be seeing something
you shouldn’t.
For any given tissue-separating task you will need to choose between blunt and sharp
dissection. As a general rule, blunt dissection is appropriate in virgin planes to separate
loose areolar connective tissue. Inflammatory adhesions can sometimes be separated this
way too, particularly ‘young’ adhesions that are only a few days old. Blunt dissection should
begin with gentle force, gradually escalating as required, with great care taken not to tear
tissues or vessels.
Fibrous adhesions, obliterated tissue planes and those that do not separate easily with
blunt dissection require division with the scalpel, scissors or diathermy (sharp dissection).
Blunt dissection
Using instruments
Closed scissors pushing sideways
Blunt-nosed scissors (such as Metzenbaum’s) are closed and held like a pen (Fig. 6.1).
Loose areolar tissue can be pushed away, generally parallel to any vessels or important
structures that you suspect lie beneath; in this way they won’t be damaged.Traction needs
to be applied in one direction so that the closed scissors can push in opposition to this.
Quite wide spaces can be opened up this way (Video 6.1).
Video 6.1 Pushing closed scissors sideways to expose the neck of a small epigastric hernia.
Video 6.2 Pushing closed scissors longitudinally to prepare a narrow space for incision with one blade
behind—in this case, opening the external oblique during an inguinal hernia repair.With the
tips of the scissors facing upwards, deeper structures are pushed away as the scissors are
gently advanced.
Spreading scissors
The closed scissors are inserted into the correct plane and then opened, carefully but
with some force, to separate the tissues widely.This opens loose areolar tissue rapidly and
is useful when there are no other important structures nearby (Video 6.3). The scissors,
already in the surgeon’s hand, can also be used to cut tough strands if required. However,
the forceful spreading may damage nearby structures such as nerves, or avulse small
vessels and cause bleeding.
45
6 Separating tissues
Fig. 6.1 Closed scissors pushing sideways.
Video 6.3 Spreading scissors to open up a plane.This is quite forceful and should only be used in
avascular planes where the tissues will separate easily, such as here mobilizing a lipoma in
the subcutaneous fat layer.
Video 6.4 Spreading with artery forceps to open a plane, in this case to encircle a vascular pedicle within
the mesentery. Repeated opening and closing is required to separate the areolar tissue
rather than forceful pushing to pop the tips through, which risks injuring whatever lies behind.
Mounted swabs
These include a swab-on-a-holder (large) or peanut swab (small), sometimes called a
mounted pledget (Fig. 6.2).
46
6 Separating tissues
Fig. 6.2 Swab on a holder (top) and a peanut swab (mounted pledget).
Their successful use relies on three things: friction which is distributed over a relatively
large surface area and therefore reasonably gentle; tissue that will tear easily (i.e. loose
areolar connective tissue); and a firm surface behind it to push against (Video 6.5). Too
much pressure will tear the firm underlying layer as well, so take care and switch to sharp
dissection if it’s not working.
Video 6.5 Pushing with swab on a holder. Here moblizing the sigmoid colon, the peritoneum is divided
with scissors before being pushed away. Counter traction on the sigmoid is vital.Watch the
layers separate and adjust the force and pressure used accordingly, or else bleeding will
result from small vessels being torn. Sharp dissection (e.g. scissors or diathermy) may be
required when resistance to moderate force is encountered.
Specific dissectors
The Watson–Cheyne dissector is specifically designed for blunt dissection on a small
scale, separating plaques of thickened atheromatous intima from the underlying media in
an endarterectomy procedure. Its flat blade is designed to slip in between layers and its
broad surface is ideal for pushing layers apart (Fig. 6.3).
Using fingers
In general, surgeons are advised to keep their hands and fingers out of the wounds to
avoid contaminating their gloves in a dirty case and to reduce the risk of glove perforation.
However, there is a time and a place for everything. The index finger is soft and blunt and
provides immediate tactile feedback to the surgeon.
Stretching
One finger can be used to assess and dilate a small hole such as a hernial defect which, in
an emergency procedure for incarceration, may need gentle and controlled dilatation to
allow reduction of the hernial contents. It is generally safe, as nearby nerves and vessels
47
6 Separating tissues
Fig. 6.3 The Watson–Cheyne dissector.
are simply pushed aside. Two or more fingers are commonly used to dilate the fascial
defect made in the abdominal wall when creating a colostomy.
Pushing/pulling/sweeping
Broad expanses of loose areolar conective tissue are suitable for pushing with the
finger, but only in virgin planes where they separate easily. Structures to be pushed
apart by hand need to be fairly large, as the fingers are fairly large ‘instruments’, but care
must be taken to avoid tearing blood vessels which often cross these planes (Video 6.6).
Extra friction can be applied by pushing over a dry swab, and this can be useful for more
focussed dissection such as isolating a peritoneal hernia sac from within the spermatic
cord (Video 6.7).
Video 6.6 Separating layers with the fingers, here elevating the anterior sheath off the rectus muscle
as part of a Pfannensteil incision. Diathermy is used as required to divide blood vessels tra-
versing the plane or when tougher tissue is encountered that does not separate readily.
Video 6.7 Using fingers over a gauze swab for extra friction, here teasing apart the spermatic cord to
isolate the sac of an indirect inguinal hernia.
Displaying layers
Using the finger can also be very helpful to spread and display tissues as a precursor to
scissor dissection, such as separating loops of bowel from the undersurface of the peri-
toneum to allow sharp dissection to proceed more safely (Fig. 6.4). Care must be taken to
avoid glove perforation.
Pinching
Simply compressing the space between two adjacent tissues with thumb and index finger
can help them to separate. This is a very useful technique for inflammatory adhesions,
which generally give way unless they are too ‘old’ (and have thus become fibrous). In fact,
one way to tell the difference between inflammatory and malignant adhesions is how eas-
ily they separate with pinching. Like sweeping, it is useful for separating adherent small
bowel loops as a precursor to dividing adhesions.As with all blunt dissection, only a mod-
erate amount of force should be used: if things are not progressing, switch to another
technique.
48
6 Separating tissues
Fig. 6.4 Using the finger can be very helpful to display tissues as a precursor to scissor dissection.
Sharp dissection
The tissue to be cut must be clearly displayed: blind cutting is very dangerous. Cutting onto
a gloved finger is also risky as it invites glove perforation with or without skin penetration.
Critical to sharp dissection is the principle of traction and counter-traction. If the sur-
geon and assistant provide adequate traction on the tissue to be divided, it will separate
readily upon cutting and immediately display the next layer of tissue beneath.
Using scissors
End-on (small snips)
This is an ideal technique for dividing a thin membrane when you need to control your
depth of cut, such as dividing the peritoneum as it reflects onto the abdominal wall. Blunt-
nosed scissors such as Mayo’s or Metzenbaum’s are required.Approaching the membrane
surface at right angles, numerous small snips are made and, provided the scissors are in
good condition and cut at their tips, no more than the overlying membrane will be divided
(Fig. 6.5). Traction on the membrane to be cut, as well as a degree of bold pressure on the
scissor tips, is vital for success (Video 6.8).
Video 6.8 Dividing adhesions around the liver, and later between gallbladder and small bowel, via a
subcostal incision. Blade-behind cutting is quick, but only safe when the rear blade is in view.
End-on snipping with the scissor tips is more cautious and generally safer for controlling the
depth of cut.
6 Separating tissues
Fig. 6.5 Approaching a membrane at right angles for end-on snips.
Fig. 6.6 Blade-behind cutting. Ideally the rear blade should be in view.
Video 6.9 Elevating the abdominal wall from the underlying rectus sheath using the scalpel. Note the
flat angle of approach, the counter-traction and the endeavour to stay in the correct plane.
Small vessels traversing the plane are divided and bleed.
Video 6.10 Elevating an abdominal skin flap with diathermy.Traction is the key, with sweeping strokes
to minimize local burn injury and control depth. Small vessels crossing the plane to be sep-
arated can be dealt with as they are encountered.
KEY POINTS
● Finger dissection and pinching can easily disrupt delicate tissue layers, so take
great care.
● Inflamed and ischaemic tissues are particularly prone to rupture with what you
might regard as only ‘reasonable’ force. If the bowel is perforated you will need to
6 Separating tissues
stop, expose and repair before continuing, and it may mean that an alternative
technique for dissection is required.
● Pulling and stretching—with the fingers, retractors or the scissor blades opened
somewhere else and approach the troublesome area from a different angle.
3 While dividing bowel adhesions the lumen is breached and faecal soiling occurs.
● Were you too bold or too hasty with the dissection? Did you lose the plane? An
acute perforation with minimal soiling can generally be repaired straight away and
then the operation can continue. If there are plans to insert foreign material later
(e.g. mesh for a hernia repair), then soiling from a large bowel perforation may
preclude this, and the objectives of the operation may have to change.
4 You accidentally cut a nerve.
● Depending on its importance, such nerves can either be cut short (to avoid the
proximal end being caught up in the operation and the development of a painful
neuroma) or be repaired with fine perineural sutures.This may require
microsurgery. If unsure, ask for advice.
5 A vessel crossing the plane of dissection has been cut, with resultant trouble-
some bleeding.
● Such vessels are best controlled with ties or diathermy before they are divided—
otherwise there is a risk that the cut end will retract. If it does, further attempts at
diathermy may cause more harm than good unless the vessel can be grasped and
brought into view with forceps so that diathermy can be applied accurately.
● Under-running the retracted vessel with a figure-of-8 suture is often best, taking
Burn marks on the bowel or other internal organs should be carefully assessed
and may be left if superficial, or excised/oversewn.
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53
Chapter 7
Knots
(a) (b)
Fig. 7.1 (a) The index finger throw and (b) the middle finger throw.
}
● save suture material
}
● stitching distracting tissues together,
7 Knots
The reef knot should be considered a ‘doublet’: two complementary, different throws
tied in succession. It looks neat, lies flat, and the suture tails emerge parallel to the axis of
the knot (Fig. 7.2a).
(a) (b)
Fig. 7.2 (a) The reef knot and (b) the granny knot.
It is produced by rolling one thread-end around the other in one particular direction,
and then rolling the same ed back in the opposite direction to complete the knot.
Irrespective of whether you are tying with instruments or by hand, the important step is
to carry each thread-end from one side of the knot to the other, back and forth, with each
successive throw.
When hand-tying, you must not only lay down the threads in opposite directions
with each throw, but also perform the two different throw manoeuvres in succession.
These two aspects to a successful hand-tied reef knot are critical, as without both it won’t
work. For subsequent throws—whether by hand or instrument—laying the thread ends
in opposite directions across the wound continues to be important.
If it’s not done correctly, i.e. if the thread ends are laid down in the wrong directions,
or if two like throws are done in succession, you’ll end up with a granny or a slip knot.
You may get away with it, but these knots do not hold under tension and can loosen. Your
tie may slip off! Reef knots and granny knots look different too: the suture tails lie parallel
to the knot in a reef knot but stick out sideways in a granny (see Fig. 7.2).
Slip (or sliding) knots are made by applying continuous traction to one thread end as
the knot is made. These knots slip because one thread is kept straight as the other is
wound around it. As long as the passive thread is kept taut, the knot will still slip no matter
how many throws are made (Fig. 7.3). This can be used to advantage, particularly when
56
7 Knots
Fig. 7.3 As long as the passive thread is kept taut (dark colour), the knot will still slip no matter how many
throws are made.
tying a knot in a cavity, as the first two throws can be slid into position. However, such a
knot must still be finished off with a reef knot ‘doublet’ to lock it (see later section).
Do not develop the habit of continually throwing granny knots then sliding the knots
down to where you want them to lie. Beware: they may not slip. Rather, practise accurate
knot placement and locking with reef knots.
7 Knots
(a)
(b)
Fig. 7.4 (a) RIGHT: hands should move towards and away from your body as a knot is thrown on the flat.
(b) WRONG: hands crossing over, side to side.
4 Now you are up and running.The next throw should be the opposite one to that with
which you started, laid down in the opposite direction.This creates a reef knot (Fig 7.5b).
Index finger throws are ALWAYS laid down towards yourself, and middle finger throws
are ALWAYS laid away from you. If you started correctly and follow this simple rule,
your knots will ALWAYS be right.
5 Having now done two throws and tied a textbook reef knot, you should apply a third
throw for security—opposite in both type and direction to the second (in other
words, the same as the first) (Video 7.1).
58
7 Knots
(a)
Fig. 7.5a Starting a reef knot.The thread that begins ‘near’ to the surgeon (dark colour) is laid down in the
‘away’ direction.
Video 7.1 Tying a three-throw square (reef) knot, starting with both the index- and middle-finger
throws. Note the way the thread ends are carried from one side of the knot to the other
with successive throws, irrespective of which manoeuvre is used to begin.
In a good knot, the first throw positions the knot and establishes the correct tension.
The second throw holds the position—but be careful not to pull down too hard, or you
may overtighten the whole knot. The third throw locks the knot, and a fourth may be
added for security. Third (and fourth) throws can be tightened quite firmly—if the first
two throws were done properly, it won’t slip.
A ‘surgeon’s knot’ is similar to a reef knot except that the first throw (and occasionally
the second) is a double throw, i.e. thread ends are wound around each other twice before
the throw is laid down (Fig. 7.6).
59
7 Knots
(b)
Fig. 7.5b The reef knot.The dark thread, originally lying ‘near’ and carried to the ‘far’ position after the first
throw, is laid down back towards the surgeon with the second. Compared with Fig. 7.5a, the surgeon’s
hands have changed position.
Video 7.2 Tying a surgeon’s knot, starting with both the index- and the middle-finger throws. Finally,
a double throw can also be tied by simultaneously creating complementary throws with
each hand.
7 Knots
The Aberdeen knot is popular for finishing off a continuous suture, as it involves han-
dling a loop of thread rather than the needle.Three ‘passes’ through the loop are generally
all that is required to produce a secure knot that won’t slip, and four should be very
secure—even for heavy monofilament material (Video 7.3).
Video 7.3 Tying an Aberdeen knot at the end of a continuous suture line. Four ‘passes’ are thought to
be adequate even for heavy-gauge material.
Fig. 7.7 A double throw with instruments—two winds around the needle-holder.
61
3 Grasp the short end and pull it through. Remember it must end up on the opposite
side of the knot to where it started, so if it began ‘far’ from you, it will be pulled towards
you as the throw is laid down.Your other hand will simultaneously carry the long end
in the other direction.
4 You now have half a knot. For the next throw, place the needle-holder between the
threads again.Wind the long thread around it—again making a circle with the
threads—then grasp the short end and pull it through.The same as before, except this
time all the directions are reversed.The short and long ends must change sides again
(Video 7.4).
Video 7.4 Instrument ties, here in the subcutaneous layer following an inguinal hernia repair. Attention is
paid to setting the tension on the first throw, then laying subsequent throws down
7 Knots
correctly, alternating side to side, to ensure a square knot.
5 As many subsequent throws can be made as you wish, each time beginning with the
needle-holder between the threads and making sure both threads alternate sides as
they are laid down.
Video 7.5 Locking a knot in a cavity by running down the opposite thread after the first two throws.
It will not slip because, at the end, neither thread runs straight.
Fig. 7.8 Tying in a cavity: the index finger must be inserted down beyond the structure to be tied and
forces applied to thread ends at 180° to each other.
Keep the tension on that first throw as the assistant releases the forceps: this allows it
to tighten just a little more. The tightening of the tie and release of the forceps occur
simultaneously and the surgeon should direct the assistant when to release, and how
slowly (Video 7.6).
Video 7.6 Tying around artery forceps.Tension on the first throw should be maintained until after the
artery clip has been released to allow it to tighten a little more.
Remember to pull the two thread ends at 180° to each other, or the tie may slip off.
They should also be pulled in a plane parallel to the artery forceps so that the knot lies flat
(Fig. 7.10a and b).
Once the first throw is firmly in place, it goes without saying that the next two throws
must also be laid correctly to secure the knot.
63
7 Knots
(a)
(b)
(c)
Fig. 7.9 Locking a knot in a cavity. (a) The first throw is run down; (b) after a second like throw, the third
locks it by running the other thread down; (c) the fourth is laid by swapping hands again.
64
(a)
7 Knots
(b)
Fig. 7.10 Tying around an artery forceps. (a) RIGHT: threads must be tightened in a plane parallel to the
artery forceps. (b) WRONG: the same throw pulled in the wrong direction does not produce a knot at all,
and may cause the threads to break.
KEY POINTS
1 The knot slips off as you tie it. This may be because
● the artery clip was released too fast—you should control your assistant’s timing as
● you let the first throw slacken as you made the second throw—keep tension on
the suture with your passive hand as your active hand makes the knot
2 The knot pulls the tissue off. This may be because:
● the thread end were not pulled at 180˚ to each other as each throw was
tightened—make sure you position your hands so that the thread is tightened with
no tension on the tissue itself
7 Knots
● you pulled the knot too hard, cutting through the tissue—learn to be gentle but
toothed dissecting forceps to push the knot down over the tip.
● Mount a tie in the jaws of another instrument and pass it down.
4 The tissues keep springing apart and you cannot get a tight tie.
● Are you trying to bring together tissues under too much tension? Think what you
less likely to undo. Having laid the first throw square and flat, it may help to pull
both thread ends over to one side of the wound with a jerk—this causes the
threads to bunch up, producing even more friction and grip.
● Deliberately place a slip knot with the first two throws to set the tension right
ask your assistant to hold the first throw with fine non-toothed forceps. It should
be held in such a way that the forceps do not get tied in! (Fig. 7.11). Pinching the
threads between finger and thumb is an alternative, as the next throw can be run
down between them into place before the assistant lets go.
5 Your thread keeps breaking.
● The suture may be too fine for the job: ask for a larger size, or perhaps just don’t
pull so hard.
● Are you trying to approximate tissues under too much tension?
● Make sure your knots are all landing flat. If a throw is laid down in the wrong
direction, one thread is forced to turn 180° around the other and will simply cut
through if pulled hard (Fig 7.12a and b).
66
PITFALLS (cont.)
7 Knots
Fig. 7.11 Holding the first throw with forceps to maintain the tension until the second is in place.
(a)
(b)
Fig. 7.12 The same throw as in (a) but laid down in the wrong directions (b) is likely to cause the
thread to break as it is pulled against itself.
67
Chapter 8
Haemostasis
During the operation, try to anticipate bleeding before it occurs rather than relying
on your ability to control it after the event. Knowledge of the vascular anatomy in and
around the operative field is essential, as this will allow vessels to be exposed and
controlled before they are divided. Several haemostatic techniques are available, each
with pros and cons for a given situation.
Diathermy coagulation
This is suitable only for small vessels. Larger vessels conduct the heat away too quickly—
or, if they do coagulate, are at greater risk of later re-bleeding.
1 As soon as it is exposed—and before it bleeds—the vessel can be diathermied. Bipolar
forceps may be used, or the vessel may be grasped with forceps (dissecting or artery)
and the monopolar diathermy probe just touched on the metal of these. It doesn’t
matter whether the diathermy is applied to the top or the bottom of the forceps—
whichever will not obstruct the surgeon’s view.The current will travel down and cause
coagulation along the vessel in both directions, after which the vessel can be cut.To
make good electrical contact, the diathermy probe must be clean. Ensure that the
forceps are not touching any other tissue such as the wound edge or a loop of bowel,
or a short-circuit may occur and cause an unwanted burn injury (Fig. 8.1).
2 The exposed vessel may be clipped twice with artery forceps and divided, then
diathermy applied to each artery clip separately.This forces the current to run
unidirectionally along each half of the vessel, which results in a relatively long segment
of dessication and coagulation (Video 8.1).Again, care must be taken to avoid
unwanted electrical contact.
Video 8.1 Clipping and cutting a small vessel, then diathermying each end. All the current is delivered
to each end of the vessel separately. Artery forceps must be held clear to prevent acciden-
tal burn injury to the wound edges.
8 Haemostasis
Fig. 8.1 Touching the diathermy on forceps which are grasping a vessel. Here there is unwanted contact
with the skin edge, which will cause a local full-thickness burn.
The Liga-sure device is similar but actually uses diathermy to generate the heat instead
of ultrasound. As with the ultrasonic shears, tissue is both compressed and heated
between the jaws of the grasping instrument, sealing it together and causing it to separate
centrally (Video 8.2). Both devices are useful for dividing very vascular tissue and, as very
little collateral heat is produced, are arguably safer than conventional diathermy. They can
also control larger vessels than diathermy. However, both the ultrasonic and Liga-sure
generators, as well as the (disposable) hand-pieces, are quite expensive.
Video 8.2 Using the Ligasure device, similar to the harmonic scalpel (ultrasonic shears). Patience is
required until the tissue within the jaws separates spontaneously.
Metallic clips
These are V-shaped titanium clips which are bent together by the application device to
compress and occlude the vessel lumen (Fig. 8.2). Useful for controlling vessels in inacces-
sible areas where hand-ties would be difficult, they are also common in laparoscopic sur-
gery. They are quick to apply but may slide off and dislodge, so two are usually placed for
security.
Clip and tie
If it’s too large for diathermy (or ultrasonic shears) then it’s safer to divide between artery
forceps (clips) and tie each end.This applies to wads of tissue such as omentum or mesen-
tery, as well as individual vessels. Two artery forceps are applied across the tissue to be
divided, leaving enough space in between to cut. Curved artery forceps are most com-
monly used and should be placed with the concavities facing each other—then, when
divided, each tip will kick up for easy encirclement with a tie (Fig. 8.3a and b). It is also wise
70
8 Haemostasis
Fig. 8.2 A loaded clip applicator. Multi-fire disposables are also available.
(a)
(b)
Fig. 8.3 (a) Clipping a vessel before dividing: the curved artery forceps should be appled with their concave
surfaces facing each other so that the tips sit up for easy encirclement with a tie once the vessel has been
divided (b).
71
to leave a small cuff of tissue protruding from the artery forceps—if you cut too close to
the instrument the tissue might slip out.
To tie around an artery clip:
● Pass the thread around the tissue in the jaws and run the first throw down close
behind the artery clip—this is to minimize tissue necrosis (everything distal to the
ligature will die).
● Pull to tighten and hold firm as the assistant slowly releases the artery forceps. Doing
8 Haemostasis
Video 8.3 Tying around an artery forceps.The first throw is laid square and flat to reduce the risk of
thread breakage, and subsequent throws are also laid flat to produce a secure knot. Note
that the threads are tightened in a direction parallel to the plane of the artery forceps – that
is, at right-angles to the pedicle itself – to ensure that the knot forms correctly.
● As always, the threads must be pulled at 180° to each other as each throw is tightened
to neutralize net forces on the tissues.
The assistant’s role is very important here: if the artery clip is removed too rapidly, the
ligature may slip off and, if the artery clip is wobbled or tugged too much, the tissue may
tear and bleed. Generally the assistant should wait for a cue from the surgeon before
releasing.
You should become adept at applying and releasing artery forceps with both left
and right hands. A popular technique for left-handed release is shown (Fig. 8.4a), but it is
difficult to re-apply artery forceps accurately this way if required. The ‘conventional’ grip
with the left hand should be practised too (Fig. 8.4b).
Double-clip and tie
Placing two individual ties on the proximal end is commonly done for safety if the vessel to
be divided is large but short (e.g. the inferior mesenteric artery in a left hemicolectomy)
or in danger of retracting out of sight when the artery clip is released (e.g. the superior
thyroid artery in a thyroidectomy).Three artery clips are applied initially—two proximally
(parallel to each other) and one distally (facing the other way). After the intervening tissue
has been divided, the ligature is placed around the rear-most of the two proximal clips,
and tied (Fig. 8.5). The rear-most artery clip is removed first. A second ligature is passed
around the remaining clip to complete the double-tie. This ensures control of the vessel
throughout the process.
Transfixion
This ensures that a ligature will not slip off, and is useful for bulky vascular pedicles such
as thickened mesentery or the splenic hilum. A suture on a needle is passed through the
tissue immediately behind the artery forceps and tied to one side, then to the other,
ensuring full encirclage of the pedicle (Video 8.4).
Video 8.4 Transfixing a bulky pedicle, in this case containing a sizeable mesenteric vessel.This
technique is also known as a ‘stitch-tie’. For very wide pedicles, two passes with the needle
through the tissue can be made before tying.
72
8 Haemostasis
(a)
(b)
Fig. 8.4 (a) A popular technique for left-handed artery forceps release. (b) The ‘conventional’ left-handed
grip should be practised too as clips can be more accurately re-applied this way.
Fig. 8.5 Double-clip and tie: the first ligature is placed around the rear-most artery forceps.
73
Ligation in continuity
Ligation in continuity, then division
This technique is even safer than clip-and-tie as the vessel is securely ligated before it is cut.
The risk of artery forceps being released too soon is thus eliminated, which may be impor-
tant where the vessel might retract out of sight, such as the inferior thyroid veins in the
neck. It is also useful when the vessel to be tied is so short that there is no room for artery
forceps, such as in the small bowel mesentery. However, it is a little more time-consuming.
The vessel to be divided is clearly isolated. A pair of curved artery forceps—right-
angled or Lahey forceps are ideal (Fig. 8.6)—is passed behind the vessel and the jaws
opened, ready for a thread to be passed down into them.
8 Haemostasis
Usually the thread is passed down with another instrument rather than with the assis-
tant’s fingers. If held tight like a ‘bow-string’ and passed beyond the waiting jaws (Fig. 8.7),
the thread is easy to grasp, but it does not have to be done this way.The artery forceps are
then withdrawn, pulling the thread around the vessel. It may or may not be tied at this
stage.
A second ligature is then passed around the vessel in the same way and each is tied,
leaving an appropriate length of vessel between them to allow division with a small cuff of
vessel beyond the knot. Great care must be taken not to pull the ligatures off as the vessel
is divided, as they are each subjected to a significant ‘tug’ when this happens. The tied
threads are then cut a few millimetres long—just enough length to prevent the knots
undoing spontaneously (Video 8.5).
Video 8.5 Tying in continuity before dividing. It is useful to keep the ends of the first tie long initially, to
provide traction to aid placement of the second one. Ensure enough space between
ligatures for subsequent cutting of the vessel. Different scissors are used for cutting the
tissue (Metzenbaum) and the suture material (straight Mayo scissors).
Fig. 8.6 Right-angled forceps. Laheys are very similar, except that the grooves in the jaws run longitudinally—
arguably for better grip on suture material.
74
8 Haemostasis
Fig. 8.7 Passing a thread down to artery forceps around a vessel. If held taut like a bow-string and passed
beyond the waiting jaws, the thread is easy to grasp.
Fig. 8.8 An aneurysm needle. A thread is passed through the eye at the tip and passed around a vessel to
be tied.
75
Ligation in continuity without division
On occasion, vessels may be defined proximally, cleaned and simply tied without division.
Cutting more distal branches during the course of the operation should then cause mini-
mal haemorrhage. This technique is sometimes used on the inferior thyroid artery during
a thyroidectomy.
Other techniques
Tourniquets
These are commonly used in limb surgery to provide a temporary avascular field. The
proximally placed limb-encircling cuff is inflated to above systolic pressure. Most of the
8 Haemostasis
blood volume sits within the veins and these may be emptied first by simple limb elevation
prior to cuff inflation, by winding the limb with a rubber Esmarch’s bandage or rolling it
inside a pneumatic sleeve. During any operation done under tourniquet control,
haemostasis must be meticulous, even though the operative field is dry, because of the
reactive hyperaemia that follows release of the tourniquet.
Tourniquets and compression devices in general should not be used in patients with
pre-existing limb ischaemia.
Vascular clamps
These are for temporary control of regional vascular inflow and particularly for surgery
on the vessels themselves. They can be considered as gentle artery forceps, designed to
compress but not traumatize the vascular walls. A wide variety of sizes and shapes are
available, and three frequently used types are illustrated (Fig. 8.9).
Fig. 8.9 Derra (top), curved DeBakey and Bulldog vascular clamps.
Vascular slings
These are slender rubber or linen tapes placed around large blood vessels in prepara-
tion for applying vascular clamps, and are passed in the same way as a ligature in prepara-
tion for tying. They are not tied. They may be placed just as a precautionary measure
to allow rapid proximal vascular control in the event of sudden major bleeding during
the operation. Different coloured slings are often used to identify different structures
(Fig. 8.10).
76
8 Haemostasis
Fig. 8.10. Slings placed around the branches of the femoral artery in a groin dissection.
Control of haemorrhage
Minor bleeding
This is usually from a small vessel inadvertently—or inevitably—cut during dissection.
Immediate control may be obtained with simple pressure with a swab. Dab firmly; do not
wipe—this may dislodge other nearby clots and cause other vessels to start bleeding.
The swab can be gradually withdrawn or rolled back to reveal the bleeding point, which
will usually be apparent. It may be dealt with by application of the bipolar diathermy for-
ceps, or grasped with an instrument for application of monopolar coagulation diathermy
(Video 8.6).
Video 8.6 Picking up bleeders in a wound and applying the diathermy.The assistant applies pressure
then gradually rolls it back to reveal the bleeding point. After diathermying the area it is
dabbed and inspected again to ensure control.
Major bleeding
A patient may present in an emergency situation with traumatic bleeding, or during careful
elective surgery a ligature may slip or an unexpected vessel may be damaged. It is vital in
this situation not to leap in and plunge forceps blindly into a pool of blood which may be
masking the underlying anatomy. Remain calm. The key is local pressure, then accurate
visualization and control which may be aided by adjusting the light, suction and good assis-
tance. Pressure may be applied with the fingers—directly or by pinching, with packs or
with instruments. Beware that suction may not remove clotted blood and may block eas-
ily; scooping out large clots and mopping with packs is usually a better way to clear the
operative field. Continued suction near an ongoing bleeding source may also mask the
severity of the bleeding—a litre or more can be removed before it is noticed that any loss
has occurred at all.
77
Once the bleeding vessel has been identified, a number of options are available for
definitive control.
Artery forceps
These should be applied precisely, leaving the tips of the forceps clear to allow the passage of
a suture behind the clips. The two-clip technique may help: one applied end-on to grasp and
elevate the bleeding vessel, then the other to clamp it in preparation for tying (Video 8.7).
Video 8.7 The two-clip technique for regaining control of a bleeding vessel. If one end is lost
and retracts, it may be grasped end-on with forceps, pulled out and re-grasped with another
pair.
8 Haemostasis
Repairing a torn vessel
A vessel which has torn along one side wall—usually a vein—can often be repaired with a
continuous suture of fine, non-absorbable monofilament material. Injuries to important
arteries may also require repair: options include end-to-end anastomosis, vein patch or an
interposition graft to restore continuity. As a general principle, any vascular repair requires
proximal and distal control of the vessel first, with slings and/or vascular clamps. For large
and important vessels such as the vena cava which you don’t want to occlude, side-binding
clamps alone such as a Derra, or the larger Satinsky, may suffice (Fig. 8.9).
Under-running of a vessel
Bleeding from a vessel that is short, has retracted or is barely visible and is thus not able to
be grasped or ligated easily may be best controlled by simply under-running.This technique
is commonly used to control bleeding from the gastro-duodenal artery in the base of a
duodenal ulcer, or mesenteric vessels that have retracted into the fat. Use local pressure
and suction initially as required to determine the precise bleeding point. Then, using an
appropriate suture on a curved needle, take a good bite of tissue to one side of the bleeding
point and another bite, in the same direction, on the other side. This is known as a ‘figure-
of-8’ suture because of the shape the suture traces through the tissue (Fig. 8.11a, b and c).
If it’s a side-hole in a vessel, the bites can be placed to encircle the vessel above and
below the bleeding point where possible (Fig. 8.12). Individual proximal and distal sutures
may be necessary.The choice of needle, suture and depth of bite depends on the situation
but, as a rule of thumb, always take a deeper bite than you think.
Oversewing a raw surface
Bleeding from the raw area following partial removal of an encapsulated organ such as
thyroid, ovary or kidney can often be dealt with by careful oversewing with a continuous
suture. Care must be taken to ensure that suture bites incorporate the fibrous capsule.This
is not applicable for large raw areas in thinly encapsulated organs such as liver or spleen.
Thrombogenic agents
If copious oozing persists despite prolonged local pressure from a raw surface such as the
gallbladder fossa or a decapsulated area of spleen, topical application of thrombogenic
agents may be useful. These may come as a powder, woven material or sponge-like pad
depending on the substance. Some are designed to be left in situ while others will need to
be removed eventually. Whatever the agent, it relies on the patient’s innate coagulation
mechanisms to work. It also requires careful and accurate placement, continued local
pressure on top, and—most important of all—patience on the part of the surgeon.
Packing
Heavy bleeding from multiple sites within a relatively confined space such as the pelvis,
retroperitoneum or substance of the liver may be tamponaded by the insertion of firm packs.
These can be left in place for up to several days, then cautiously removed at a subsequent
operation. Bleeding is then frequently surprisingly minimal.
78
8 Haemostasis
(a)
(b)
(c)
Fig. 8.11 The process of under-running a bleeding vessel.
Other techniques
Vasoconstricting agents such as adrenaline can be injected in the vicinity of bleeding
vessels to reduce flow and allow natural clotting to occur. This method is widely used via
the endoscopic approach for bleeding peptic ulcers, but they can also be injected locally
for troublesome wound edge and peri-stomal bleeding. Topical silver nitrate is very effec-
tive for small raw areas such as the tonsillar fossa, stomal margins and general granulation
tissue. Alginate dressings liberate calcium ions and facilitate the clotting cascade, and are
thus useful for packing into bleeding open wounds.
79
8 Haemostasis
Fig. 8.12 Under-running a bleeding side-hole in a vessel.
Uncontrollable haemorrhage
No matter how large the vessel or wide the tear, arterial bleeding can always be over-
come with local pressure. It may be possible to pinch or compress the bleeding vessel
directly with your fingers; if not, rapidly take several surgical swabs and apply them firmly
to the area.These can be held for 5 minutes. Make sure that blood is not continuing to accu-
mulate and adjust your pressure if required. This gives you time to think, to call for more
swabs, to set up a reliable sucker, to prepare instruments and sutures which may be neces-
sary and to call for more senior assistance.
Do not be too quick to remove your packs to see what is happening; count five minutes
against the theatre clock before moving. The longer you wait, the more likely the vessels
are to have sealed spontaneously, particularly if cut right across. Vessels bleeding through
side-defects tend not to stop, however, and active steps such as ligation or repair may be
needed to control them. Proximal vascular clamping or ligation in continuity may also be
useful.
(a)
(b)
Fig. 8.13 (a) The Yankauer sucker concentrates the suction at the tip. (b) The Poole sucker.The multiple
side-holes distribute the suction making it safe to use near bowel.
For clearing large volumes of blood rapidly, a sump sucker is best, while for focal expo-
sure of a bleeding point the fine-tipped style is preferred. Either way, be careful not to
dwell for too long near a bleeding point as blood will disappear straight up the sucker and
not be seen. Large amounts of blood can be lost in this way.
81
KEY POINTS
1 Be prepared: know your anatomy before you start and control vessels before you
divide them.
2 Don’t cut anything until you know what’s in it.
3 Don’t panic if bleeding occurs: apply firm pressure, clear the area of clot, identify the
bleeding point precisely and choose the appropriate technique to control it.
4 Never hesitate to call for help.
8 Haemostasis
PITFALLS
● Is there a short circuit? Ensure that the forceps holding the vessel are not touching
the vessel. Sparking may occur. Clean the diathermy probe and try again.
● Perhaps the diathermy setting is simply too low—but be aware that turning up the
current could be dangerous if all of the above options have not been considered.
2 A ligature pulls off as you tie it.
● Did your assistant release the artery forceps too soon? Try to re-grasp and start
again.
● Consider the vector forces on the threads you were pulling as the knot was tight-
ened: were they being pulled at 180° to each other so that there was no net force
on the tissue pedicle?
● Were the artery forceps—and hence the ligature—too close to the end of the
pedicle? You should leave a small cuff of tissue beyond the artery forceps jaws.
● Is the pedicle too bulky? Maybe it would be better to be transfixed.
clip it for ligation using the two-clip technique (see Video 8.7).
● Oversewing with a figure-of-8 stitch is likely to be effective as long as care is taken
Chapter 9
Approximating tissues
blood supply and minimal distracting forces are also important. The surgeon has a role to
play as well: delicate tissue handling, control of instruments, control of tissue tension and
accuracy of tissue apposition are also required to achieve a ‘perfect’ end result.
The quality of tissue union is related to the accuracy of alignment. Alignment is helped
by recognition of layers, which need to meet accurately for a sound join. They may need
to be opposed separately (as in a gridiron incision where peritoneum, muscles and exter-
nal oblique aponeurosis must all be identified individually), but often tissue layers align
themselves automatically if carefully placed full-thickness sutures are used (e.g. mass
closure of the abdominal wall or bowel anastomoses).
Some layers within a particular tissue are stronger than others. In skin, the strength lies
in the dermis, and so sutures must pick up this layer to hold distracting wound edges
together. In the bowel wall, the strength lies in the submucosa, so any technique used for
anastomosis must incorporate this layer. Many surgeons omit the mucosa altogether.
In blood vessels, the adventitia is the strongest layer; however, the intima must also be
included to prevent it from lifting as this could result in an intramural dissection and/or
thrombosis.
As far as choice of technique for tissue approximation is concerned, several
methods are available. For skin, the simplest include adhesive tapes (e.g. Steristrips) and
tissue glues. Across the whole range of general surgery, the two main techniques for tissue
approximation are suturing and stapling.
Tissue glues
These are made from cyanoacrylate (the same as ‘Superglue’) and are applied externally
on top of the wound to both hold the skin edges together and provide an impervious
dressing. As with adhesive tapes, there is limited tensile strength.They are useful for clean,
shallow skin wounds or where the deeper layers have been firmly repaired and the skin
edges lie together without tension. Because there is no need for dressings on top, this
technique is useful in day-case surgery and, since it does not require any form of wound
anaesthesia, it is popular for use in children (Video 9.1).
Video 9.1 Applying tissue glue.The delivery ‘pen’ is held vertically for a few seconds until the liquid
glue has run into the tip.The skin must be clean and dry.The glue is then spread lightly over
the wound, which has been held in approximation – by forceps in one case and deep dermal
sutures in another.A second layer is applied a minute or so later, after the first has dried.
85
9 Approximating tissues
Fig. 9.1 Using adhesive tapes to close a hernia wound in the groin.The skin edges have been approximated
with deep dermal absorbable sutures first.
Suturing
Suturing is a complex manual task that requires training and skill. As a trainee, you must
become familiar with a variety of suture materials, needles, instruments and suture style
to be able to select what you need for each occasion (see Table 9.3).
Choice of suture
Theatres have a bewildering array of sutures and needles, and often there’s a choice of
alternatives for a given situation (Table 9.1). Individual surgeons develop favourites and
tend to stick with these. In time you will select what seems most comfortable and success-
ful for you.The important considerations are:
1 gauge (or thickness) which reflects the tensile strength
2 absorbable versus non-absorbable
3 monofilament versus braided
4 biological versus synthetic
5 coloured versus uncoloured.
*Biological material.
86
Gauge
The heaviest gauge you will find these days is a No. 2—almost like string. A little finer is
No. 1, still a very robust thread, followed in descending order by sizes 0, 00 (2/0), 000 (3/0),
0000 (4/0), and so forth. Note that there’s no size ‘1/0’: that’s just size 0. A metric system is
also in use, based on the thread diameter in millimetres: metric size 1.5, for example, is
0.15 mm in diameter.This corresponds to a 4/0 suture.
Choice of gauge depends on the tissues involved, the suture material needing to be
9 Approximating tissues
strong enough to retain the tension placed upon it. As a rule, one should use the finest
suture appropriate to the task. The finer the suture, the less tissue trauma as it passes
through. Numerous small sutures placed close together distribute tissue tension more
evenly along a suture line, and the smaller gaps between sutures will leak less compared
with fewer sutures of a heavier gauge placed further apart. However, fine sutures are
harder to tie and easier to break. As a general guide, No. 1 is commonly used to close
abdominal fascia, 3/0 is often used to suture skin and 6/0 may be used to anastomose
blood vessels. A microsurgical nerve repair might use 10/0.
Absorbable versus non-absorbable
The choice between absorbable and non-absorbable sutures can be vital.
Non-absorbable sutures retain their tensile strength indefinitely and are thus useful
wherever tissues may be slow to heal, or where strong forces are permanently at play,
such as with hernia repairs and vascular anastomoses. However, as foreign bodies, deeply
placed non-absorbable sutures retain the potential to harbour infection indefinitely, with
the risk of persistent wound sepsis and suture sinuses over many years. If absorbable
sutures become infected, the sepsis will clear as they eventually dissolve away, and so most
surgeons prefer to use absorbable materials internally where possible.
Understanding that different materials resorb at different rates is the key to suture
selection, recognizing that tensile strength is lost well before these sutures dissolve com-
pletely. Rapidly absorbable sutures (several weeks) are satisfactory for well-vascularized
tissues such as bowel anastomoses which heal quickly, but heavy, slowly absorbed material
(several months) is required for tough, relatively avascular tissues such as the fascia in
abdominal wall closure.
Non-absorbable material is still preferred for interrupted suturing of the skin, as early
suture removal is associated with less scarring and improved cosmesis. Absorbable
sutures provoke an inflammatory response during their dissolution which can lead to
increased scar formation, but are often used when suture removal is anticipated to be
awkward (e.g. the nail bed) or if cosmesis is not a high priority (e.g. scrotum). Absorbable
subcuticular sutures, being entirely under the surface, are much less problematic, but
these still dissolve by inciting an inflammatory reaction and so tend to promote more
collagen deposition (scar) in the long run.This is more of an issue with braided rather than
monofilament sutures, perhaps because of the larger surface area of material exposed to
the body’s defences.
Monofilament versus braided
Compared with braided sutures, monofilament sutures cause less friction and thus less
tissue trauma during insertion and removal. They also incite less tissue reaction and have
fewer interstices in which bacteria may hide, so are favoured for suturing the skin.
However, they are rather stiff and can be difficult to tie securely. Knots with braided
threads are less likely to slip and are generally more reliable, which is why this material is
favoured for ligating tissue pedicles and vessels.
Biological versus synthetic
Biological materials tend to exhibit a variation in tensile strength throughout their length
compared with modern synthetic threads which are uniform and therefore more reliable.
Because of this, synthetic materials are tending to replace the older forms, although silk,
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linen and catgut remain popular owing to their excellent handling and knotting character-
istics. Silk is still widely used for tying in drain tubes, and many surgeons still favour it for
delicate ties in difficult situations because of its handling properties. Catgut—made from
the submucosa of sheeps’ intestines and nothing to do with cats—is useful for tying liga-
tures and for subcutaneous tissue closure, although it is no longer used in the UK because
of concerns about its animal protein content. As a rule, biological materials are signifi-
cantly cheaper than their synthetic counterparts, which is an important consideration in
9 Approximating tissues
some parts of the world.
Coloured versus uncoloured
Darkly coloured material stands out against the red-and-yellow tissues of the body,
making it easy to see where sutures and ties have been placed. This can be very helpful.
However, colourless material should be chosen for sutures to be placed just under the
skin, because suture dyes may stain and tattoo.
Choice of needle
Needles come as:
1 straight or curved
2 with a cutting edge or round body.
Straight needles are designed to be hand-held, particularly for placing subcuticular
sutures. In line with current recommendations to minimize the risk of needlestick injury,
their use should be avoided. They are also useful in certain laparoscopic applications as
they can be passed readily through the abdominal wall from inside the peritoneal cavity to
outside, or vice versa.
Curved needles are generally for instrument use. Large hand-held curved needles are also
available for use on the skin but, for the reasons outlined above, are potentially dangerous—
although they can be used with a needle-holder. Curved needles may have cutting edges
or round bodies and may be further subclassified according to the radius of curvature and
the degree of arc. A half-circle needle is designed for deep bites such as when under-running
a bleeding vessel, as the tip will emerge readily from the tissues and can then be picked up
using forceps. For shallow bites, such as placing a subcuticular suture, a 3/8-circle needle is
preferred. Whatever the arc and radius, however, it is important when driving the needle
through tissues to follow the natural curvature of the needle. This is best done using a
combined arm and shoulder movement; supination of the wrist alone is likely to bend the
needle.
Cutting edge needles are designed to penetrate very tough tissue such as skin.The sharp
end of the needle has a triangular cross-section and literally slices its way through.
Standard curved cutting edge needles have the apex of the triangle facing towards the
concavity of the needle, while in ‘reverse’ cutting edge needles it faces the other way. In
practical terms this makes no difference.
Round-bodied needles are used in almost all other applications, where tissues are easier
to penetrate. It’s surprising how difficult it is to pass a round-bodied needle through the
skin! Tapering to a point, these needles spread the tissue fibres when passing through with-
out cutting. The hole then closes snugly against the thread, which is important if there is a
potential risk of leakage as with vascular or bowel anastomoses.
Other special needles are available, such as round-bodied needles with cutting tips
designed to penetrate calcified plaques in arterial walls, large blunt-tipped needles for
suturing the liver, and J-shaped needles for suturing fascia in the depths of small incisions.
As with a wine bottle, all the information you need is provided on the label—provided you
know what it means (Fig. 9.2).
Choice of instruments
If given the task of approximating tissues with sutures, you will need to select a
needle-holder and dissecting forceps. Not surprisingly there is a vast array of each,
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9 Approximating tissues
Fig. 9.2 All you need to know is on the label, provided you know what it means.
most with eponymous names, although the majority represent variations on a few common
themes.
Needle-holders
The common needle-holder is a Crile–Wood, designed to be handled with the thumb and
fourth fingers through the rings (Fig. 9.3). Larger needle-holders can also be held using the
alternative ‘palmar grip’ which allows the instrument to be rotated within the surgeon’s hand
with ease (Fig. 9.4). This is very convenient when placing a continuous over-and-over suture.
9 Approximating tissues
Fig. 9.4 The alternative palmar grip.
The needle should be grasped about two-thirds of the way along the shaft, where the needle
is square in cross-section and thus won’t rotate in the jaws of the needle-holder (Fig. 9.5).
Needle-holders can also be used in the left hand, a skill that right-handers should
develop for suturing in awkward situations, although working the ratchet mechanism
takes practice. Simply mounting the needle ‘backhand’ is an alternative (Fig. 9.6).
Fig. 9.5 The needle should be grasped about two-thirds of the way along the shaft.
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9 Approximating tissues
Fig. 9.6 The ‘backhand’ grip for a needle-holder, helpful for right-handers in some awkward situations.
Needle-holders come in a range of sizes to suit the needle and the task, and your
choice will largely depend on which is the most comfortable to use. Some, readily identifi-
able by their gold handles, have tungsten-carbide inserts within the jaws to reduce wear
(Fig. 9.7). This is generally a sign of quality. Similar inserts (and gold handles) can be found
in scissors and dissecting forceps.
Fig. 9.7 Tungsten-carbide inserts in the jaws to reduce wear, a sign of quality.
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Double-action needleholders such as the Naunton–Morgan are useful when a long
reach is needed, such as in the chest or pelvis, as the hand-grip doesn’t have to be opened
as far to ensure good opening of the jaws (Fig. 9.8). The Gillies needle-holder has no
ratchet, asymmetrical rings and scissor blades incorporated into the jaws (Fig. 9.9).
A spring-loaded handle is seen in microsurgical needle-holders such as the Castroviejo,
designed to be held in the fingers like a pair of tweezers (Fig. 9.10).
9 Approximating tissues
Fig. 9.8 The Naunton–Morgan double-action needle-holder (top) with a standard 7′′ Crile–Wood.
Dissecting forceps
These are held in the non-dominant hand in the same way that you might hold a pen to
write—NOT like you might hold a knife to cut (Fig. 9.11).
They are used to manipulate tissues and/or the needle while suturing. Forceps may be
described as light or heavy, fine or broad, toothed or non-toothed (plain). Commonly used
toothed forceps include Lanes’s (heavy), Gillies’ (medium) and Adson’s (fine) (Fig.9.12), and
9 Approximating tissues
Fig. 9.12 Lane’s (top), Gillies’ and toothed Adson’s forceps.
non-toothed include broad plain dressing forceps, McIndoe’s and Adson’s (again)
(Fig. 9.13). Note that Adson’s—like other named forceps you may come across—may be
either toothed or plain.
Fig. 9.13 Broad plain (‘dressing’) forceps, McIndoe’s and non-toothed Adson’s.
● Light, fine forceps are made for delicate work while heavy forceps suit bulkier tissues.
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● Heavy forceps such as Lane’s may be used with care on delicate tissues, but the
converse does not apply. Fine instruments such as Adson’s will be damaged if you ask
too much of them.
● Teeth aid traction and thus reduce the squeeze pressure required for grip, but can
crush and perforate fragile tissues.Toothed forceps are reserved primarily for skin and
fascia, and can still cause tissue damage if used roughly.
● Because of their low surface area and poor grip, fine non-toothed forceps such as
9 Approximating tissues
McIndoe’s are difficult to use on skin.They may even cause damage from the high
squeeze pressures required. Broad, non-toothed (‘dressing’) forceps distribute the
squeeze pressure over a relatively large surface area and handle needles well, so are
useful for suturing skin.
● It is easier to grasp and manipulate a needle with plain forceps than with toothed
forceps.
● The multiple fine teeth on a De Bakey’s forceps (Fig. 9.14) make them relatively
atraumatic with good grip.These are a popular choice for handling bowel and blood
vessels, and are good for skin too.
The common uses of the forceps illustrated are summarized in Table 9.2.
Fig. 9.14 The multiple fine teeth on DeBakey’s dissecting forceps make them relatively atraumatic with
good grip.
stretch, which is important for suture lines crossing joints and for bowel anastomoses.
It also allows partial opening of a wound, which is very useful if an infection or
haematoma needs to be drained.
● Continuous suturing is very quick and produces a more ‘watertight’ closure, which can
9 Approximating tissues
be used to advantage such as when closing the abdomen in a patient with ascites.
However, there’s a danger that it can be made too tight and, if a continuous suture
breaks, the whole suture line fails.
There is a wide range of suturing styles to choose from, each suited to a purpose.
Several common examples will be discussed here.
Interrupted sutures to skin
The aim is to produce perfect apposition of skin edges, neither inverting nor overlapping.
A tendency to eversion is acceptable as this ensures the subcutaneous tissues are
opposed and reduces dead space under the skin. This is achieved by creating, at least in
your mind’s eye, a wider bite in the depths of the bite than at the surface (Fig. 9.15).
Fig. 9.15 To achieve eversion with a skin suture, aim to take a wider bite in the depths than at the surface.
● Evert the skin edge with dissecting forceps and insert the needle, penetrating
perpendicular to the skin (Fig. 9.16a).The depth of each bite should be about the same
as the width of the completed suture at skin level.
● Follow the curve of the needle to create a U-shaped path through the wound.The
needle can be watched, or even brought out, in the wound itself to ensure that the
depth of the bite is the same on each side (Fig. 9.16b).
● As the needle tip approaches the surface on the other side on its way out, use your dis-
secting forceps to help it exit at a right angle again. Simply pushing down on the skin
just beyond the emerging needle is one way to achieve this (Fig. 9.16c).
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9 Approximating tissues
(a)
(b)
(c)
Fig. 9.16 (a) Begin the suture with plenty of pronation to enter the skin; (b) observe the needle tip in the
wound to match up the depth of bite on the other side; (c) pushing down on the skin just beyond the
emerging needle will help it to emerge perpendicular to the surface.
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When considering suture spacing, think of a cube—the distance between adjacent
sutures should be about the same as both the depth and the width of each one.
To achieve a good cosmetic result, sutures should be:
1 as fine a gauge as suits the task
2 preferably monofilament
3 evenly spaced, each crossing the wound at right angles
4 close enough together to prevent gaping between adjacent sutures
9 Approximating tissues
5 tension-free
6 loose rather than tight (to allow for post-op swelling)
7 removed at the earliest opportunity.
Tying can be done by hand or with instruments (see Chapter 7). Just be careful not to
pull the sutures too tight, and watch that subsequent throws don’t overtighten the first one.
It looks neat if the knots all sit along one side of the wound in a row of sutures, but the
choice of side depends on how the skin edges lie. It often makes a subtle difference, so for best
results each knot should be sided on its merits. See how the completed suture looks; the
knot can usually be moved from one side to the other as required when you’ve finished.
Vertical mattress sutures
The aim of these sutures is to ensure eversion—or at least absolutely to prevent inver-
sion. These are very useful when suturing thin skin with a tendency to invert, such as
the dorsum of the hand. Vertical mattress sutures have two components: a conventional,
deep bite through the subcutaneous tissue and a small back-bite incorporating dermis
only (Fig. 9.17). The smaller the back-bite, the more accurately the skin edges can be
opposed—but there is a limit, as a really tiny bite will just pull through. Aim to cross the
wound margin at a 45° angle and make sure you pick up some dermis.
Fig. 9.17 Vertical mattress suture.The small back-bite incorporates dermis only.
Pull the thread through in a forwards direction to minimize the risk of cheese-wiring out
(Fig. 9.18a and b).
Corner sutures
Where an angulated wound comes to a point, especially if it is less than 90°, it is important
not to place a suture across the point of the ‘V’ as the blood supply is precarious
and necrosis may result. Placing sutures either side nearby is just as risky. Instead, start
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9 Approximating tissues
(a) (b)
Fig. 9.18 (a) RIGHT: with a vertical mattress suture, pull the thread through in a forwards direction.
(b) WRONG: pulling backwards risks the thread cutting out of the delicate dermis.
some distance from the tip on the other side and emerge in the dermis near the apex; run
horizontally across under the point of the’V’ in the subcuticular plane and re-emerge back
on the opposite side near where you started, then tie (Fig. 9.19).
Subcuticular sutures
This is a popular technique with two great advantages over interrupted suture repair:
1 No stitch marks are visible, so it can be very neat.
2 The suture can be removed very quickly if monofilament material is used.This is vital in
urgent situations (e.g. decompressing a neck haematoma after thyroid surgery).
However, as for all continuous suture lines, the whole suture line may unravel if the
suture breaks or is cut. Thus it is difficult to drain localized subcutaneous collections by
opening part of a wound. For this reason, many surgeons prefer interrupted sutures to
close wounds at risk of infection, e.g. after a nasty appendicectomy.
A subcuticular suture is confined solely to the dermis and each bite is placed horizon-
tally within that layer (Video 9.2). Strong eversion of the skin edge with forceps is required
Fig. 9.19 Placing a corner suture.The needle entry and exit points are within the dermis.
99
to see what you are doing. Bites are spaced so that each run of suture material crosses the
wound gap at right angles. If several are placed before pulling the wound edges together,
the threads are seen crossing in parallel like rungs on a ladder (Fig. 9.20).
Video 9.2 Placing a running subcuticular suture. Eversion of the wound edge is required to display
the dermal layer. Plain forceps are used here, making it easier to grasp and handle the nee-
dle than if they were toothed. Horizontal bites are placed with care to ensure equal spacing
and depth on each side of the wound. By placing several in succession before pulling them
9 Approximating tissues
tight, the threads can be seen to cross the wound at right angles.As the thread is pulled, the
wound edges can be squeezed together to reduce friction.
Fig. 9.20 Subcuticular suturing: the threads are seen crossing the wound in parallel like rungs on a ladder.
To achieve this, it often helps to enter the dermis each time a little further back than
you think … this is because there is a natural tendency to place each bite too far forwards
along the wound. Just thinking about back-tracking slightly will make it end up just right.
Also, attention must be paid to the suture depth of each side of the wound to avoid a ‘step’
as the edges meet: watch carefully where the needle emerges with each bite, then line up
the entry point on the other side accordingly.
There are many ways to start and finish a subcuticular suture; no doubt your senior will
show you his or her favoured technique. Once underway, it helps to take small bites initially
and lengthen these towards the middle of the wound before making them smaller again as
the far end is approached. If using braided material, only place two or three bites in succes-
sion before pulling the thread to oppose the skin edges because of the friction it develops.
You can manage more with monofilament material, but there is a limit. Don’t pull the suture
too tight either, as this causes bunching of the skin.Take particular care with curved wounds,
where one side of the wound appears longer than the other. Individual suture bites must
be spaced carefully, with slightly longer bites on the concave side (Fig. 9.21).
Fig. 9.21 A subcuticular suture in a curved wound requires longer bites on the concave (long) side.
100
Continuous sutures
The common, continuous over-and-over suture has many applications. It is not difficult but
must be done with care, taking into consideration both the distance back from the edge and
the spacing of bites. These generally depend on the tissue being closed. Too near the edge
and they may cut out; too far back and they cause too much tissue overlap and wound tension.
In suturing aponeuroses, where all the tissue fibres are parallel, the distance back from the
edge should be varied with each bite to prevent a linear tear. However, the biggest danger
9 Approximating tissues
with a continuous suture is to pull it too tight: you should aim to approximate the tissues
comfortably and no more. A tight continuous suture brings several problems.
● The overall length of the suture line is shortened. In a circular suture line such as an
Fig. 9.22 Following.The assistant maintains the tension on previously placed sutures and keeps excessive
thread out of the surgeon’s way.
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9 Approximating tissues
Fig. 9.23 A continuous suture look neat if the threads cross the wound at right angles (with the oblique
component under the surface).
Remember, in a continuous suture line the thread is always advancing along the wound
and thus must lie diagonally at some point.The diagonal section of each bite can be placed
either on the outside or under the surface. In the latter case, the threads cross perpendi-
cular to the wound and arguably look neater (Fig. 9.23).
Particular cases
Closing a laparotomy (linea alba)
The suture must retain its strength for many weeks until a firm fibrous union has occurred.
A heavy material is required, and some surgeons prefer something non-absorbable such
as 1-nylon, although a slowly absorbable suture such as 1-PDS is also very popular and has
the advantage that uncomfortable subcutaneous knots or chronically infected stitch
sinuses will eventually resolve spontaneously as the suture disappears. Good strong bites
of fascia should be placed at least 1 cm back from the edge and about 1 cm apart to pre-
vent bowel loops herniating in between. Great care must be taken not to injure underlying
bowel loops as the facia is closed; use of a folded abdominal pack, a rubber ‘fish’ or even
the copper spatula retractor may help (Video 9.3). Surgeons often use their own hands
as well. This is potentially dangerous, but blunt-tipped needles have been introduced to
minimize the risk of needle-stick injury. These are effective but can be very hard to drive
through the tissues.
Video 9.3 Closing the posterior and anterior rectus sheaths in a right subcostal (Kocher’s) incision.
A looped 1-PDS suture is used with Lane’s forceps. Note the copper retractor to help
protect the underlying viscera, and also the important role of the assistant in following to
maintain tension on the suture line and keep excessive suture length out of the surgeon’s
way. Bites are about 1.5 cm apart and well back from the fascial edge. Care is taken not to
pull the suture too tight. As the needle emerges from the fascia, the surgeon re-grasps it in
such a way that, by rolling the needle-holder over in the palmar grip, he is ready for the next
bite.
Suturing bowel
Inversion rather than eversion is the aim here, whether a continuous or interrupted
suture is used. A continuous suture may be quick, but interrupted sutures allow for
stretch and thus are less likely to cause a stenosis. Good bites of the important seromus-
cular layer must be obtained, with or without any mucosa; 5 mm back from the edge and
5 mm apart is about right. A round-bodied needle is used. Monofilament suture material is
favoured by many as it pulls easily through the tissues, but braided material is easier to
knot. Most surgeons use an absorbable suture with a gauge of 3/0. Interrupted sutures can
be tied as they’re placed, or cut long and held up in artery forceps for tying at the end—
the latter technique may help suture alignment and placement, but it takes longer.
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Vascular anastomosis
Even though the strength lies in the adventitia, it is vital to pick up the intima as well to pre-
vent this lifting and causing a dissection or thrombosis. Bites should be taken, wherever
possible, with the needle passing from within the lumen to outside (Fig. 9.24).
9 Approximating tissues
Fig. 9.24 The fine vascular suture is being passed from inside the arterial lumen to outside.
Stapling
Staples are very reliable and hold the tissues together extremely well, but only if you’ve
9 Approximating tissues
lined the tissues up correctly in preparation. It takes time to do this properly. Staplers fired
hastily can lead to very poor results.
Stapling skin
Compared with suturing techniques, skin stapling is faster but can be very uncomfortable
for the patient, particularly during removal. Great care must be taken to ensure that the
skin edges are well everted; the assistant is important here, using a pair of toothed forceps
in each hand to align them accurately as the stapler is fired (Fig. 9.25 and Video 9.4).
Stapling tends to force the edges to roll in or overlap. While this can look very neat from
above, it leads to a poor cosmetic result and so eversion must be ensured not only as the
stapling proceeds but also before the final dressing is applied.
Video 9.4 Stapling skin.The assistant holds the skin edges together and ensures eversion as the
stapler is applied. It is useful to hold the skin up with the stapler before releasing to help the
assistant re-grasp in preparation for the next bite. Spacing between staples depends on
how well the edges lie, but about 1 cm apart is a good starting point.
Stapling viscera
A line of staples can be fired across a hollow viscus to close it (linear stapler) or used to
make an anastomosis (linear or circular staplers). Visceral staples are different from those
Fig. 9.25 Skin stapling: everting the wound edges ahead of the skin stapler.
104
used for skin. They are also different from those used to staple sheets of paper together,
which are flattened by the anvil; visceral staples are folded into a ‘B’ shape to allow blood
vessels to pass through and ensure viability of the join (see Fig. 9.29).
Broadly speaking there are three types of visceral stapler. Each comes in a variety of
sizes and lengths.
Linear stapler (Fig 9.26)
A double (or triple) row of staples is laid to seal off a hollow organ (Fig. 9.27). They are
9 Approximating tissues
generally more reliable than a row of sutures. An example is closing the bronchus in a
Fig. 9.27 The linear staple line—two staggered rows to seal an artificial ‘hollow viscus’.
105
pneumonectomy, or the rectal stump in a Hartmann’s procedure. If the organ is to be
divided as well, it should be cut with a scalpel immediately adjacent to the stapler—a
groove is provided in which the knife blade can be run.
Linear cutting stapler (Fig. 9.28)
Two double-rows of staples are fired and, at the same time, a blade within the device is
advanced between them (Fig. 9.29). Note that the staple lines extend a little further
than the cut.
9 Approximating tissues
This stapler is useful for dividing bowel, especially if it is unprepared, because both cut
surfaces are automatically stapled over to prevent soiling (Video 9.5). It is also used for
Fig. 9.29 The linear cutting staple line: two double rows, cut between by the advancing blade.
106
creating side-to-side anastomoses: the device is separated into two halves, each arm is
inserted separately into the adjacent bowel loops and then reconnected. On firing, a slit-
like join is created with a row of staples on each side.
Video 9.5 Firing the linear cutting stapler. In this partial gastrectomy, the jaws are initially slid into posi-
tion across the duodenum and locked together.With the stapling device held firmly in one
hand, the knob is advanced with the other to fire the staples and simultaneously advance
the cutting blade.The staples fire for a short distance beyond the reach of the blade, so scis-
9 Approximating tissues
sors are required to compete the tissue division.When subsequently dividing the body of
the stomach, a second firing of the (reloaded) stapler is required to traverse the distance.
9 Approximating tissues
Fig. 9.31 The circular stapler.Two concentric rows of staples emerge from the main body (yellow).
The circular blade is visible in the centre.
PITFALLS
1 The skin won’t close without tension. Did you excise too much skin? Perhaps
there is too much swelling under the surface, or maybe the skin does not have
the elasticity you expected.
● Undermine the skin edges to allow them to advance. Make sure you do this in a
strain.This works like a pulley system and gives 2:1 purchase in dragging the
wound edges together. Remove it later after others have been placed along the
wound to distribute the tension widely.
● If it remains too tight to close despite the above measures, leave the wound open
above.
● Place a double throw to begin with, which increases friction between threads and
across to the opposite side (so both thread ends are now on the same side of the
wound), then give it a tug.This distorts the knot and locks it. Subsequent throws
can be placed as normal.
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PITFALLS (cont.)
3 The skin edges tend to invert. It may look neat from above but if the skin edges
fold into the wound it won’t heal well.
● If sutures or staples have already been placed, the skin edges may be able to be
manually everted with forceps. If this fails in a stapled wound, staples will have to
be removed and carefully re-applied with an assistant holding the skin in
9 Approximating tissues
edge up and correct the problem. Remember, the smaller the back-bite, the more
finely the wound margin can be controlled.
● Take all your sutures/staples out and start again if you have to. Just remember that
the final result won’t be as good as it would have been if you’d done it properly the
first time!
4 There’s a step at the wound edge.
● This occurs because the sutures don’t take bites of equal depth on each side.
Sutures must be placed with particular attention to this. It is an easy trap to fall
into, particularly with wounds that enter the skin obliquely.
● Don’t hesitate to bring the needle out in the middle of the wound to check the
short. Dog-ears can usually be avoided if the wound length:width ratio is 4:1 or
more, so careful planning should prevent this. Dog-ears won’t go away by
themselves and so should be sliced off carefully, but the wound is lengthened in
the process.
6 The wound sides are of unequal length.
● This can be a true problem or an apparent one. If the wound sides are truly of
unequal length, it is helpful to start suturing in the centre, then in the centre of
each half that is left, then keep ‘halving the distance’ between placed sutures to
distribute the length inequality along the whole wound.
● The halving technique also works well for anastomosing bowel ends of unequal
diameter.
● Apparent wound side discrepancy arises with curved wounds, and when one side
‘sags’ or slides laterally relative to the other.The potential for this to happen
should be recognized before suturing begins. Line things up carefully and take care
to place the early sutures accurately, or else the problem will worsen as wound
closure progresses.
7 The completed subcuticular suture line is puckered.
● Perhaps the thread was just pulled too tight. Just slackening off the suture may help.
● Did each bite cross the wound at right angles? You must decide if it’s bad enough
to warrant removing the suture and starting again. It may be possible to remove
one or two suture bites by simply pulling the needle backwards through the
dermis.
● Applying adhesive strips on top may pin a local skin fold down, but they are no
usual culprit.The needle bends at the level of the needle-holder jaws (Fig. 9.32).
9 Approximating tissues
Fig. 9.32 A bent needle, caused by excessive supination of the wrist. Bending it back weakens the
needle further.
● To prevent this, follow the curve of the needle as it is driven through the tissue—
the correct movement involves the whole shoulder and arm. It should be
effortless—resistance implies that incorrect forces are being applied.
● Bending the needle back into shape may succeed but fatigues the metal, and it may
snap it in half. Repeatedly bending and re-shaping will certainly break it. Also,
handling the needle in this way risks personal injury.
● If you can, leave the needle bent and carry on. Grasp it with the needle-holder in
front of the bend to prevent it from worsening with subsequent bites.
● If continuing this way is impossible or if the needle breaks, cut it off. Find all the
needle pieces, hand them back to the scrub nurse (safely!) and start again.
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111
Chapter 10
Manoeuvres in laparoscopic
surgery
Equipment 112
The stack 113
Camera and cables 113
Ports and trocars 113
Setting up 114
Where to stand 114
Port positioning 115
Instruments 115
Creating the pneumoperitoneum 115
Inserting subsequent trocars 117
Holding the camera 118
Operating 119
Orientation 119
Separating tissues 119
Suction and irrigation 120
Clearing diathermy smoke 120
Clipping, suturing and stapling 121
Knot-tying 125
Haemostasis 127
Decision to convert 127
Key points 128
Pitfalls 128
112
Laparoscopy is no more than an alternative approach to an operation that could other-
wise be done open.A decision should be made for each case as to which approach is bet-
ter, as both have their pros and cons. If laparoscopy is chosen, the possibility of conversion
10 Manoeuvres in laparoscopic surgery
to open must be discussed as part of the consent process. Furthermore, since conversion
to open is the ultimate way to get out of trouble, you should be capable of performing the
operation open before you attempt it laparoscopically—or at least have rapid access to
someone who can help you if necessary.
Equipment
A lot of specialized equipment has been developed over the past 20 years in parallel with
the boom in popularity of laparoscopic surgery. Kit will vary from place to place, but the
basic set up requires a camera, a telescope, various laparoscopic instruments and a stack
nal organs as the sharp tip penetrates the peritoneum (see later section).
Setting up
Where to stand
A key principle is that the surgeon, the organ of interest, the line of view of the camera and
the screen should all be set up in straight line (Fig. 10.3). This is important not only for
Fig. 10.3 The surgeon, organ of interest (in this case, a midline incisional hernia) and screen are aligned to
maximize orientation. Note the camera placed between the two working ports.
115
comfort but to ensure left–right orientation. The assistant should stand wherever is con-
venient to hold the camera without getting in the surgeon’s way.The scrub nurse is usually
across the table from the primary operator. Bilateral screens are useful if someone has to
● The ideal position will change according to each patient’s body habitus.
● Make your skin incision further back if you are deliberately planning an oblique path
Instruments
Most have evolved from open-surgery instruments and often share their names, such as
Babcock’s tissue forceps or Metzenbaum’s scissors. Others have been developed specifi-
cally for laparoscopic surgery, such as the diathermy hook, Petelin’s dissectors and fan
retractor. A huge variety of graspers and other specialized instruments are available, and
most will have eponymous names.A selection is shown in Fig 10.4a and b. They can come
with locking or non-locking handles, which are generally interchangeable, and some have
the facility for diathermy attachment. These will have insulated shafts: be wary of causing
short-circuits and inadvertent burn injuries when any non-insulated part comes into contact
with tissue.You will soon become familiar with the ones in use at your own institution.
sutures.A cone-shaped sleeve attachment over the port is commonly used to help
maintain a gas-tight seal if the opening is wider than the port.
Use of a ‘bladeless’ trocar with a hollow centre, down which the camera is inserted to
watch it progress through the layers of the abdominal wall, is another option.This is a pop-
ular technique for use in obese patients, or if the insertion site is somewhere other than
the umbilicus where an otherwise long, deep cut-down incision would be required.
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10 Manoeuvres in laparoscopic surgery
(a)
(b)
Fig. 10.4 Common laparoscopic instruments. From the left: (a) Maryland dissectors, bullet-nosed grasp-
ing forceps, Metzenbaum scissors and parrot-beak or hook scissors; (b) Serrated graspers, diathermy
hook, three-pronged grasper and DeBakey atraumatic grasping forceps.
It is wise to commence insufflation at a low flow rate until you can be certain that the
gas is going into the right space. This can be confirmed by observing low intra-abdominal
pressure, progressive distension of the abdomen, percussion resonance over the liver, or
by simply inserting the camera and having a look. A lot of gas inadvertently run into the
extraperitoneal space will make subsequent intraperitoneal laparoscopy more difficult.
Also, watch the insufflation pressures: high intra-abdominal pressures can impair venous
return (affecting cardiac function and increasing the risk of deep vein thrombosis) and
117
push up on the diaphragm (restricting the patient’s ventilation). Inflation pressures set to a
maximum of 10–12 mmHg are generally safe.
● Use caution! Trocars should ALWAYS be watched on the screen as they come through
the peritoneum.
● To insert an 11 mm port, the incision should be about 15 mm long.Work it out: the
circumference of the port is 11 × π = 34 mm, and your linear incision must open out
into a circle to accommodate the port—thus its length must be this circumference
divided by two.That’s 17 mm. However, the skin does stretch a little and you want
the ports to fit snugly through the skin wound to prevent gas leakage, so you can afford
to make the incision a little shorter. For a 5 mm port, the incision should be about
7 mm long.
● A good technique is to place your index finger on the shaft to prevent the trocar from
suddenly going in too deeply (Fig. 10.5).Twisting the port as you push will give more
control as you drive it through.
● Watch the screen and stop every so often to check how close the tip is to penetrating
the peritoneum. In order to emerge in the right place, only angle the trocar away when
the tip has passed right through the muscle layers and is immediately extra-peritoneal.
Fig. 10.5 Placing one finger on the trocar shaft may prevent it going in too far.
118
● Watch your angle of entry: this can easily bring you through in the wrong place.Think
about where you want the port to emerge on the inside, and the direction you’d like it
to point in.This should be towards to operative site, particularly in obese patients
10 Manoeuvres in laparoscopic surgery
whose thick abdominal walls allow relatively little trocar ‘waggle’. In these cases, the
skin incision should be made further away than you think and an oblique path should
be taken through the abdominal wall. Make sure you have trocars that are long enough
to get through!
Fig. 10.6 The angled telescope always looks away from the direction that the light cable enters.With the
light cable entering from above, the scope is looking slightly down.
119
● Often just wiping the end of the scope on the intra-abdominal organs nearby will
clear it—but don’t wipe where there is any blood.
● If all else fails, pull the scope out and clean it properly.An alcohol solution usually
gives the best results. Just check with the surgeon first—don’t pull it away without
warning!
● Check what the surgeon wants when instrument changes occur. Some like you to
follow the instrument out as it’s withdrawn and to follow the new instrument in
laparoscopically, while others prefer you to remain focused on the operative field
throughout.
Operating
Orientation
● Check your stance, the position of the monitors, the camera angle and the horizon on
the screen: if these are not set up correctly right from the start, you’ll struggle throughout
the procedure.
● Depth of field is hard to perceive on a two-dimensional video monitor. It helps always
to use two instruments, one in each hand, so that your own proprioceptors tell you
where you are in space.
● If you are ‘lost’ and your instrument is off-screen, look away from the monitor and
instead look at the patient’s abdomen.With your external view, advance your
instrument towards the relevant quadrant, keeping to the ‘ceiling’ inside the abdominal
cavity, and it will soon come back into view on the screen.
Separating tissues
● Metzenbaum scissors (Fig. 10.4a) are ideal for dividing adhesions, particularly thin
transparent ones.Traction with another instrument helps too, not only displaying them
better but also putting them under tension, which makes cutting easier (Video 10.2).
Video 10.2 Diving adhesions. Here mobilizing the sigmoid colon from the abdominal wall, a combination
of gentle snips with the Metzenbaum scissors and traction downwards on the colon helps
to separate the tissues and display what is to be cut.
● They may be used with diathermy attached, but care must be taken to avoid
inadvertent electrical contact with other tissues. If the diathermy doesn’t appear to be
working, it may be short-circuiting. It is advisable to avoid diathermy altogether when
dividing adhesions close to bowel.
● The diathermy hook (Fig. 10.4b) can be used to push or to pull. Either way, it works
best when the tissue to be separated is stretched or under tension—traction from
another instrument is very important here.
● Pushing with the heel is useful when a ‘frenulum’ of tissue is on view, but is danger-
ous on the flat because the depth of penetration of the current is hard to control.
● Hooking behind a strand of tissue and pulling is slower but certainly safer, as long as
you can see exactly what lies within the hook before it is burned through.While not
always possible, you should try to see the tip of the hook before applying the
diathermy current (Video 10.3).
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Video 10.3 Using the diathermy hook. Judicious use of both the ‘heel’ and hook, as well as simple push-
ing with the side of the instrument, separates the gallbladder from the undersurface of the
liver. It only works when the tissue to be separated is under tension.The position of the
10 Manoeuvres in laparoscopic surgery
● Hot forceps can also be used if local tissue destruction is not a concern. Forceps such
as dolphin-nosed or Marylands work well as their fine grasping tips concentrate the
current (Fig. 10.4a).Tissue is grasped firmly in the tips, burned until clearly coagulated,
then pulled/stripped away (Video 10.4). Don’t take too much with each bite as this will
not burn or separate well; the tissues will tear and bleeding will result.Again, care must
be taken to avoid a short-circuit with neighbouring tissue.
Video 10.4 Using hot forceps.The thickened and fatty peritoneum overlying the cystic duct in this
case is stripped downwards after initial pinch-diathermy with Petelin’s forceps. Care must
be taken to grasp and burn only peritoneum. Spreading the jaws of the instrument also
opens tissue planes, and the cystic duct can be isolated fairly readily with blunt dissection
alone and minimal bleeding.
● Blunt dissection can be done by spreading with forceps; this is an excellent way to
expose a duct or blood vessel (see Video10.4). Gentle pushing with any of the above
instruments can open up areolar spaces widely, as in preparing the pre-peritoneal
space for an extraperitoneal hernia repair (see Video 10.5).
Video 10.5 Blunt dissection.Two blunt instruments, kept closed, are used simply to open up the
areolar tissue in the extraperitoneal space in preparation for an inguinal hernia repair.
clear a puddle of fluid, ensure that the sucker is completely underwater.To remove
blood clots, apply suction in short bursts as these break up the clot and help
prevent the sucker blocking.The omentum also blocks the sucker with annoying
regularity, so use another instrument to keep this out of the way whenever
possible.
● Irrigation can wash off fresh clots and actually encourage bleeding from a raw surface.
disposable, and the clips themselves are available in several sizes.Think about what
you’ll need before you ask for it.
Fig. 10.7 Both jaws of the loaded clip-applicator are clearly seen around the structure to be clipped
before firing.
● Owing to the lack of 3-D vision and the possibility of catching something unwanted
within the clip, it is vital that both jaws of the loaded clip-applicator are clearly seen
around the structure to be clipped before firing (Fig. 10.7).
● As the trigger is squeezed, the tips of the clip come together first, encircling the
structure you want.This allows the clips then to be slid into position before flattening
completely as it is fired fully (Fig. 10.8a, b and c).
● Clips can easily be dislodged, so double-clipping important structures is advisable
(Fig. 10.9).
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10 Manoeuvres in laparoscopic surgery
(a)
(b)
(c)
Fig. 10.8 Firing the clip-applicator (a).The tips of the clip come together first (b), allowing it to be partially
closed around a structure and then slid into position before it is flattened firmly (c).
123
Laparoscopic suturing
● If suturing of bowel or omentum is required, consider delivering it outside the
threads have a tendency to get caught in the hinge mechanism, so proper laparoscopic
needle-holders are required (Fig.10.10). It is preferable to have two, one in each hand,
so that the needle can be passed from one to the other as you work.
● Choose a curved needle that’s small enough to fit down a port if possible. If not, the
becomes tedious to handle inside the abdomen, but remember to leave enough to tie
off at the end.
● Use the ratchet of the needle-holder to lock the needle securely in its jaws so that
driving the needle can be done with a gentle grip. Follow the curve of the needle as it
passes through the tissues.This is not the same as simply rotating the needle-holder
along the axis of its shaft, which can produce abnormal forces and tear the tissues or
cause the needle to bend and break.
● Pull the thread through as far as needs be before placing the next suture to minimize
Video 10.6 Laparoscopic suturing.As short a length of suture material as possible is used and the
thread is pulled through with each suture to reduce the risk of tangling.A standard ‘square’
knot is tied at the end by alternating needle-holders for successive throws and laying the
threads down in alternate directions, as in open surgery.
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10 Manoeuvres in laparoscopic surgery
Fig. 10.10 Laparoscopic needle-holder.The fine serrations help prevent needle rotation within the jaws
and the hinge mechanism is hidden to prevent suture material from catching.
● Take great care not to stick the needle into something you shouldn’t during the
suturing process, or to lose it inside the abdomen at the end.
Laparoscopic stapling
● The linear cutting stapler is the model that has been adapted for laparoscopic use. It
fires a total of six rows of fine staples and cuts between to leave a triple row of staples
on each side of the divided tissue.The security of the triple row means that
oversewing the staple line is not required.
● Before introducing a stapling device, chose the port placement carefully so that the
angle of approach to the tissues is suitable, i.e. parallel to the line of stapling you have in
mind (Video 10.7).
Video 10.7 Laparoscopic stapling. Right at the start, the port positions were chosen to ensure a suit-
able angle of approach for the stapler. In this gastro-jejunostomy, the stapler enters from
the left flank. Once each jaw has been positioned within each lumen the device is closed
and fired. Second and third firings with staple-cartridge reloads are possible to create a
longer anastomosis.
● In contrast to open surgery, it is difficult to check the rear-side of a staple line made at
laparoscopy.Thus you should double-check that the stapler is positioned properly,
with nothing but the correct tissue in the jaws, before you fire it.
● It is still worth inspecting the interior of a laparoscopically fired anastomosis staple line
for bleeding, just as it is in open surgery. Bleeding points may need to be oversewn
before the enterotomy is closed.
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Knot-tying
Knots can be tied intra-corporeally with instruments, or extra-corporeally by hand and
Video 10.8 Alternative technique for tying an intra-corporeal knot. Here suturing the diaphragmatic
crura together in a fundoplication, two similar throws are created in succession. Sustained
traction on one thread creates a slip knot which can be tightened as desired.A third
throw, with a change of thread and direction, locks it in place.
Extra-corporeal knots
Several knots have been described, all similar in construction to a hangman’s noose. They
are designed to slide when one thread end is held taut but to lock when the direction of
pull changes as the knot lies in place. One way to tie extra-corporeal knots is described
here (Video 10.9).
Video 10.9 Tying an extra-corporeal knot.The cystic duct is being ligated here because it was deemed
too wide for a metal clip.The suture material is passed around the duct, entering and leaving
the abdomen via the same port.An assistant’s finger over the port not only prevents gas
leakage but also keeps the thread ends apart for ease of tying. One of several methods for
tying a sliding knot is shown: the short end is wound around itself three times; a small loop
is preserved at the top; the end is then passed between the threads as they emerge from
the port, then back through the preserved loop.The knot is tightened with care taken to
maintain longitudinal tension on the long thread, so that the knot can be slid down with a
pair of grasping forceps and snugged firmly into position.
● Both thread ends are brought out through one port, and the assistant’s finger is placed
across the hole to prevent gas escape. Doing this also separates the threads for ease
of tying.
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10 Manoeuvres in laparoscopic surgery
(a)
(b)
(c)
Fig. 10.11 Tying an intra-corporeal knot. (a) One needle-holder is laid across the ‘C’ and one or two winds
are made around it (b). For the second throw, the letter ‘C’ is reversed, as are the roles of each needle-
holder (c).
127
● One is wound around the other a minimum of three times, with a small loop preserved
at the top.
● Irrigation may obscure important anatomy and may encourage further bleeding.
The situation can spiral out of control unless you act promptly.
● You must identify the exact bleeding point to allow precise control—this may require
● Even accurately placed diathermy may not work, especially on omental or mesenteric
vessels, in which case clipping, suture ligation, snaring with pre-tied loops or under-
running with a suture may be needed.
● If you cannot see clearly, call for help early.
● If bleeding continues and help is not immediately available, convert to open. Struggling
in this situation may compromise an otherwise fit patient’s condition very rapidly.
● Use a generous incision to obtain the exposure you need. Bleeding should be
appendix mass).
128
● Organ injury or bleeding which requires open surgery to repair (e.g. inadvertent bile
duct injury).
10 Manoeuvres in laparoscopic surgery
● General condition of the patient (e.g. anaesthetist does not want a prolonged
operation).
If conversion is inevitable, the earlier it’s done the better. The trick is to realize that it’s
inevitable, or at least highly likely; this takes experience. If you are struggling laparoscopi-
cally and the possibility of conversion enters your mind, it’s probably time to call for more
senior assistance.
KEY POINTS
1 The surgeon, the organ of interest, the line of camera view and the screen should be
in a straight line.
2 Keep the camera steady, in focus and with the horizon horizontal.
3 Trocars should always be inserted under direct vision.
4 Consider carefully the position and angle of each port’s insertion.
5 Beware of high abdominal inflation pressures.
6 Be wary of diathermy short-circuits outside the field of view.
7 Anticipate and avoid blood vessels where possible.
8 Convert early if in trouble.
PITFALLS
1 You have difficulty finding the peritoneal cavity in order to start insufflation.
● Are you still extra-peritoneal? Use the open cut-down technique if not already
doing so. Enlarge your incision and identify the layers one by one until the
peritoneum is found and opened under vision.
● There may be local adhesions—if they cannot be swept away with gentle finger
the patient’s relaxation may have worn off. Speak to your anaesthetist.
● With low pressure there may be a gas leak: check the taps on your trocars and the
seal at skin level around your first port.A wet swab packed in around the port may
improve the seal, or a purse-string suture in the skin. Have you put a 5 mm
instrument down a 10 mm port without a reducer? Perhaps a diaphragm valve is
torn inside a port—this can happen as needles are passed in and out of the
abdomen.
● Has the cylinder run out of gas?
● Be prepared to move the camera too, as your view dictates. Inserting another
is half the battle—you need a high index of suspicion. So if you get to the point of
contemplating repair, you’re doing well.
● Minor seromuscular tears can often be left, but mucosal breaches must be
repaired.
● Small bowel can often be delivered to the outside through a port wound and
and further instrumentation which may not be readily available. Don’t struggle;
convert to open if concerned.
● Colonic injuries are associated with a much higher incidence of infection,
or suture until you can see the bleeding point clearly in order to allow precise
control.
● Some time can be bought by grasping the bleeding point with an atraumatic
instrument and just holding until extra equipment or personnel are available.
● If bleeding cannot be controlled, convert to laparotomy. Don’t wait until the
The patient will not begrudge you an extra small incision or two if it improves the
situation. Remember: if the operation is easier for you, it’s safer for them.
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131
Chapter 11
Drains and dressings
Drains 132
Rationale and indications 132
Types of drain 132
Inserting a drain 135
Removing a drain 136
Post-operative dressings 137
Choice of dressing 137
When to take down the dressing 138
Pitfalls 139
132
Drains
Whether or not to use a drain at the end of an operation is often a matter of personal
preference.While there may be widespread agreement that a chest drain is indicated after
a thoracotomy, there is little evidence to support routine drainage in many other
situations such as after thyroidectomy, cholecystectomy or bowel resection. It is sensible
to make a considered decision in each case.
Rationale and indications
11 Drains and dressings
These drains can be brought out through the end of a wound, or more commonly
through a separate stab incision. It is important to suture open drains to the skin to prevent
them from falling out, and also traditional to place a safety-pin through them at skin level
to prevent them falling ‘in’.
Closed drains
These are single hollow tubes that are, by definition, connected to a sealed collection
system. Thus the drain contents remain sterile. They may or may not have continuous
suction applied.
● Closed non-suction drains, commonly used after abdominal surgery, are
dead spaces and prevent blood or serous fluid collections.They typically comprise
a fine-bore tube with an end hole and multiple side perforations, attached to a
pre-vacuumed hard plastic bottle (Fig. 11.3).
134
11 Drains and dressings
very rapidly.
● Don’t lift the collection bottle above the level of the patient’s chest.This may siphon
tubing.
Of course there are exceptions—for example, the tubing may need to be clamped
when moving a patient in case the collection bottle is tipped over or lifted up.These
will be encountered during a thoracic surgery post. In the meantime, just remember
the rules.
Inserting a drain
Non-suction drains (open or closed)
A short incision must be made through the skin—just long enough for the drain tubing to
fit snugly. If it is too long there will be leakage around the drain. A #11 blade is ideal and the
incision should be in line with the natural skin creases. A strong artery forceps such as a
Mayo is pushed through all the layers of the abdominal (or chest) wall, using your other
hand to protect the internal organs from injury. The tip of the drain tube is then placed
within the jaws of the forceps and pulled back through (Video 11.1). There is often a
black mark on the tubing to indicate where it should sit at skin level, but it is just a guide.
Once positioned correctly, the drain should be sutured in place so that it is not dislodged
subsequently.
Video 11.1 Inserting a non-suction drain. A small incision is made along Langer’s lines. Artery forceps
are pushed through, and the drain is grasped and pulled out again to the correct position.
Using a similar technique, drains may be pulled from outside to in.
Video 11.2 Inserting a closed suction drain tube.The sharp metal introducer is stabbed through the
dermis from within and pulled through until the desired position is reached.The
introducer is cut off.The drain is tied in place and subsequently connected to the
vacuumed bottle, then switched on.
11 Drains and dressings
Video 11.3 Suturing in a drain tube. Heavy silk is an easy material to handle and popular for tying drains.
The suture is passed through the skin and tied down comfortably. Each end is wound
around the drain several times in opposite directions.The ends are then tied, firmly
enough to indent the tubing.
● Take a bite of skin adjacent to the drain as it emerges—if the skin wound is long
enough, place the suture across the wound as if you were planning to suture it closed.
This will help to snug the wound against the drain and reduce leakage.
● Tie a proper locked knot down onto the skin. Leave both suture tails long at this stage.
● Wrap one suture tail around the tubing in a clockwise direction for two or three turns,
and the other one in an anti-clockwise direction similarly. Make sure they are
reasonably tight against the tubing and all bunched down together.
● Tie the suture tails together, firmly enough so that the thread indents the tubing, but
tubing, remains popular, but is prone to slip. For this to hold firmly, a half-hitch (single
throw) must be placed each time the threads cross as they wind around the tubing, and
pulled tightly enough to indent the tubing with each throw (Video 11.4). If they are not
tight enough, the encircling loops will slide down the tubing and become loose.
Video 11.4 ‘Roman sandal’ technique. After the suture has been tied down to the skin, each end is
wound once around the drain and tied again.With the drain tube held up by an assistant,
the thread ends are wound around the tubing, advancing up its length with each wind. At
each half-turn, when the threads cross, they are tied with a single throw, and these must be
pulled tightly to indent the tubing.After several winds and over several centimetres of
length, the tubing will be forced into a tortuous shape. Failure to achieve this means it has
not been secured tightly enough and is likely to slip.
Removing a drain
The optimum time for removal depends primarily on the reason for insertion in the first
place, but also on both the character and the volume of the fluid in the drain.
● A closed suction drain placed prophylactically to prevent accumulation of serous fluid
could be removed when the volume of fluid is judged low enough to be resorbed
spontaneously.This is often 3–5 days but may be longer.The nursing staff will be
recording daily volumes carefully.These drains may never cease drainage altogether—
partly because of the suction, but also because the plastic drain itself can cause a degree
of tissue irritation.The risk of retrograde infection developing increases the longer the
drain is in; many surgeons are reluctant to leave them in for longer than a week.
137
● A closed non-suction drain placed in the gallbladder fossa after a difficult
cholecystectomy, placed only to detect any leaking bile, might be removed after
just 24 h if the effluent is clear, regardless of the volume.
● A drain to the duodenal stump after a gastrectomy will generally be left in for at least a
week, as stump blow-out typically occurs around the fifth to seventh day
post-operatively. If enteric content appears in the drain it will be left in place for as long
as it takes to dry up completely, which may be several weeks.
Post-operative dressings
These serve several basic functions.
1 To prevent blood and other fluids from seeping to cause contamination of clothing
and bedclothes.
2 To prevent infection from entering the wound.
3 To prevent the raw wound rubbing on clothing, thus improving comfort.
4 To apply pressure in order to prevent serous fluid collection or haematoma.
5 To support the wound and help hold it together.
Choice of dressing
Your choice of dressing will depend on which qualities you want.
● Transparent
Typically these come as a thin adhesive sheet with a paper backing which is peeled off
as the dressing is applied.Their advantage is in immediately showing up any early signs
of wound complication, such as skin edge necrosis or infection.They are also
waterproof. However, wound discharge accumulates beneath them and a sizeable
‘blister’ may form.This may need to be drained (using a needle and syringe under strict
aseptic technique) before it leaks out from under the side.
Spray-on forms are available which coat the skin with a thin transparent and
waterproof film that wears off after several days.They remain tacky for a few moments
before they dry and can be covered with light gauze at this time to provide an
absorptive layer as well. Spray-on dressings are convenient in children and in awkward
areas such as the perineum.
● Absorbent
These are commonly used in anticipation of the inevitable post-operative early wound
bleeding and discharge.These dressings should be changed if the discharge shows
through.There are numerous forms of such dressings, and local purchasing policy
tends to dictate which brands are available in your hospital. Some patients may be
allergic to certain adhesives and it is important to enquire about this before the
operation.
138
● Waterproof
Apart from the transparent adhesive films mentioned above, thicker opaque dressings,
like plastic-coated sticking plasters, may also be used.Their main advantage is in
allowing the patient to bathe/shower without having to change the dressing if it gets
wet.This is convenient for children and also in ambulatory day-case surgery. Patients
may be allergic to these dressings too.
● Padded
11 Drains and dressings
These are useful in wounds where a lot of exudate is anticipated, such as over an open
drain tube, where pressure is required to prevent seroma/haematoma, or to help pad
out an irregular surface prior to bandaging, such as the ankle or the hand.They are also
useful in perineal wounds as they afford a degree of cushioning as well. Gamgee gauze
(a thick layer of highly absorbent cotton wool enclosed in an absorbent gauze cover)
or simply multiple layers of absorbent gauze swabs, opened out and ‘fluffed’ if desired,
are commonly used.The padding is laid over the wound and then covered with a broad
adhesive plaster or bandage.
● Supportive
Paper tapes are often used to aid skin approximation and may be left as a definitive
dressing. Broad strips of adhesive tape are sometimes used for wound support after
repair of large ventral herniae or when an abdomen is closed under tension. Care must
be taken not to apply too much tension in such circumstances, as continued traction
on the epithelium can cause a shearing separation of the skin layers with subsequent
blistering.This iatrogenic problem is often mistaken for a dressing allergy.
Remember to extend the pre-operative shave zone far enough beyond the planned
incision area to allow for the adhesive dressing. It will always overlap the wound by several
centimetres.
When to take down the dressing
The policy of wound dressings and their removal varies enormously from unit to unit, and
it is difficult to be dogmatic, but a few principles apply:
● Almost all wound sepsis is from the patient’s intrinsic organisms introduced at the time
of surgery, and wounds are generally well sealed after just a few hours.Wound
dressings therefore cannot be relied upon to prevent wound infection.
● Dressing should be removed or changed if they soak through or become wet, as
bacteria can then translocate from outside and thrive in the warm moist environment
underneath.
● Clean gloves should be worn for dressing removal; sterile gloves are required for
there are clues to the possibility of a wound complication such as malodour suggesting
skin edge necrosis, fever suggesting wound infection (rarely visible before the fourth or
fifth post-operative day anyway), or pain and swelling suggesting haematoma. Routine
inspection of the wound within 48 h of surgery is hard to justify.
● From the point of view of infection, dressings are probably unnecessary after 48 h, by
which time a sutured or stapled wound will have sealed with fibrin and dried exudate.
However, their continued use undoubtedly makes the patients more comfortable for
the first 4–5 days, depending on the location of the wound.
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PITFALLS
● Perhaps it was not stitched in properly—or not at all. Make sure the encircling
suture material indents the tubing so it can’t slip. Don’t rely on tape alone.
● Did it actually fall ‘in’? If the drain had a radio-opaque line it will be visible on X-ray.
● The patient may have to return to theatre if the drain is that important.
and placing a colostomy bag over it to collect the fluid from within and around
the drain.
● Could the drain be removed altogether?
subcutaneous bleeding.
● Major haemorrhage within a drain may be serious, depending on the rate of
bleeding and where the drain tip lies. It may have eroded into a vessel. Resuscitate,
replace lost blood and consider the need to return to theatre urgently.
4 The drain is stuck in and won’t come out.
● Check the operation note to see that it wasn’t deliberately stitched in place deep
inside. In these cases you will have to wait for the absorbable suture material to
dissolve, which could be up to several weeks, depending on the material.
● The drain may just have been in for so long that tissue has grown into it, or
perhaps tissue has been sucked into the side-holes. Simply pulling hard is painful
and may cause internal damage. A better strategy is to just twist the drain on its
axis: that way force is applied only to the tissues immediately adjacent to the drain.
It releases with a sudden ‘give’ and then comes out easily.The torque will dislodge
the tissue attachments more safely than if you just pull hard.
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Chapter 12
Putting it all together
procedure itself.
The margins of the swelling and proposed line of excision are defined clearly using a
waterproof marker pen prior to infiltration with the local anaesthesia since the lesion
will then become more difficult to feel with certainty.
The skin is prepped using an alcohol-soaked wipe prior to infiltration of local
anaesthetic. Many would argue that this step is unnecessary. Note that care is taken to
wash around the marked area and not to wash the marks away.
● Infiltation of local anaesthetic
The skin is washed with an iodine-based antiseptic solution. Note that the wash is
started over the lesion and works away from the lesion.Two preps are performed, one
after the other, and not simultaneously.The area is then draped with a single
fenestrated sheet.
● Incision
An elliptical incision is made with the long axis in the direction of the skin Langer’s
lines, which here run transversely. Note the ‘15’ blade on a small handle used for this
operation and the ‘pencil-like’ grip.The thumb and index finger of the opposite hand
stretch the skin equally to allow a smooth, even cut along the lines marked.The initial
incision encircles the whole lesion but does not penetrate the dermis, allowing
a clearly defined wound margin before starting the excision proper.
Dissection is then continued more deeply into the subcutaneous tissue through the
wound margins previously marked by the initial incision.The tissue to be excised is
grasped with fine-toothed forceps on the attached skin rather the lesion itself, allowing
firm traction without the risk of perforating the cyst.
● Haemostasis
The skin flaps are raised first, to define the margins of the cyst and identify the plane
just outside the capsule of the lesion. Once the correct tissue plane has been entered,
143
tissue separation is continued using knife or scissors, but remains sharp dissection as
there is considerable fibrosis following a previous excision of this cyst. If there were a
nice areolar plane, blunt dissection might be an alternative. Dissection moves to different
points around the lesion as better areas come into view.When the dissection becomes
deeper, scissor cutting is preferred as the knife tip would be less easy to see clearly.
● Wound closure
Wound closure is commenced by insertion of deep interrupted fine absorbable
taken at varying distances back from the fascial edge to prevent shearing and that the
assistant follows to maintain suture tension.
Finally the wound is approximated with several more interrupted polyglactin sutures
to Scarpa’s fascia and a subcuticular suture of 4/0 undyed polyglactin to the skin. Note
that the needle is handled with instruments throughout and grasped with the needle-
holder in preparation for the next bite as soon as it emerges from the wound edge.An
Aberdeen knot finishes the suture and the knot is buried at the end.
● Dressing
After a final wash of the wound area a sterile dressing would be applied.
Open appendicectomy
● Preparation
The patient is lying in the supine position and has already had antiseptic skin
preparation applied. Note the extent of the prep, which covers almost the whole
abdomen, not just the right iliac fossa.This allows a freedom of incision should the
wound require to be extended during the procedure.Also note that the drapes are
applied to expose the area of intended surgery only, with the anterior superior iliac
spine (ASIS) exposed in one corner and the umbilicus in the other. Care must be taken
when applying clips to the drapes not to pick up skin, as this can cause severe skin
damage which can be extremely painful post-operatively and may take many days
to heal.
● Incision
Prior to making the incision, two swabs are placed on the patient for use by the
surgeon and the assistant.
The position of the incision is carefully planned.The ASIS is clearly shown.The classical
grid-iron incision, at right angles to McBurney’s point, crosses Langer’s lines and is
placed high in the right iliac fossa.A more cosmetic incision is placed lower and runs in
Langer’s lines which in this position cross the abdominal wall in a gentle curve, almost
transversely. It is most important, however, that the cut is made such that the wound
can be extended either to the right or the left, should the operation require.The
wound is therefore placed such that the right end is just above the level of the ASIS and
can therefore be extended into the loin region without impinging on bone.
The skin incision is made. Note the grip on the scalpel handle and the single smooth
cut for the entire length of the wound.Also note the position of the thumb and index
finger of the opposite hand, spreading the skin evenly to both sides of the wound.
Bleeding is minimal and easily removed by dabbing with the swabs provided.
The assistant now retracts the wound edges using Volkmann’s rake retractors and the
wound is deepened using coagulation monopolar diathermy—lateral traction on the
tissue is necessary for this to be effective.When the external oblique aponeurosis
appears, the tissue plane is defined by finger dissection using a swab. Note that the full
length of the incision is utilized.Avoid the wound becoming narrower as you descend
downwards.
145
A small nick is made in the aponeurosis using a scalpel blade tip. Scissors are inserted
closed to develop the plane, and the aponeurosis is then cut in the direction of the
fibres.The next layers, the internal oblique and transversus abdominis muscles, are
then simply split along their fibres using a blunt scissor spreading technique
supplemented by the insertion of two deeper retractors which are then firmly
separated. In this situation, the rakes are replaced by Langenbeck retractors which are
better for retracting deeper tissue planes.The peritoneum is now clearly visible.
The right iliac fossa and pelvis are irrigated with saline and sucked clean, this process
being repeated until the suction fluid is clear.
● Closure
The caecum is now replaced into position in the abdominal cavity.The two original
artery forceps are still in position on the peritoneum and are complemented by two
other clips placed at the apices of the peritoneal incision.The peritoneum is closed
using a continuous absorbable suture.The internal oblique and transversus layers are
closed together with a loose figure-of-8 suture, applied with just enough tension to
oppose the muscle edges but without causing tissue strangulation. Rakes are now
re-inserted to retract the subcutaneous tissue and skin to expose the external
oblique aponeurosis, which is now closed with a continuous absorbable suture.
The membranous layer of the superficial fascia is now closed using interrupted
absorbable sutures obliterating the deep layer prior to application of staples to
the skin. Note the careful application of the staples with slight eversion of the skin
edges and no overlapping of one side over the other, the edges meeting exactly
edge-to-edge.
Laparoscopic cholecystectomy
● Creating the pneumoperitoneum
One open cut-down is made at the umbilicus to insert the first blunt port.
A transverse fold of skin is elevated using Kocher’s forceps—toothed artery
clips—and an oblique incision made.This becomes a neat curve lying along Langer’s
lines when the clips are released.The fibrous umbilical tube is exposed and incised
vertically. Large, blunt artery forceps are inserted to gain entry into the peritoneal
cavity.The blunt port is then inserted and gas flow commenced (low flow initially until
the camera confirms correct positioning).
● Initial inspection
The camera is inserted. Immediately apparent is the liver, the antrum of the stomach
and the hepatic flexure of the colon. Note how the camera has steamed up on
entering the intra-abdominal cavity. Rather than remove the telescope, the end is
simply wiped gently on the liver surface to de-fog it.
A 360° inspection of the intra-abdominal contents is performed. Starting down the
right paracolic gutter into the pelvis, the camera then looks back up beneath the
falciform ligament, visualizing the whole of the anterior surface of the stomach and left
lobe of the liver before passing down the left paracolic gutter to the pelvis again.The
exploration is normal. No tissues are displaced to try to visualize any other organs.
Note that on return to the right upper quadrant, the fundus of the gallbladder is just visible.
● Inserting subsequent ports
Trocars are inserted under direct vision with an intermittent pushing and twisting
motion, their sharp tips being observed as they enter the peritoneal cavity.
● Exposing structures at the gallbladder neck
When all ports are in, one instrument from the epigastric port is used to elevate the
free edge of the liver and expose the gallbladder, while another through the right
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lateral port grasps the fundus of the gallbladder.This second grasper has a locking
mechanism to retain its hold on the gallbladder throughout the operation.The
gallbladder and liver are now elevated with this grasper high into the right upper
quadrant of the abdomen.
Further instruments are inserted.Through the subcostal port site is inserted a
non-locking grasper held externally in the surgeon’s left hand, and through the
epigastric port site is now inserted diathermy scissors held by the right hand.
together with the port. In this case it was retrieved without having to dilate or enlarge
the incision.A second video (from another case) shows extraction of the gallbladder
via the epigastric port using a retrieval bag, chosen in this case because the gallbladder
had been perforated (note the bile staining).
Returning to the original case following gallbladder removal, the camera is reinserted
to allow a final inspection of the gallbladder fossa, ensuringe that this is dry, the clips
are intact and that there is no free fluid that needs to be removed. Heavy washing with
saline at this stage is to be avoided as this may simply dislodge clot and cause bleeding.
Judicious suction is simply all that should necessary.
● Closure
The gas is deflated. Ports should be removed under direct vision, the final port being
that of the camera.The umbilical tube/linea alba at the umbilicus would be closed with
a heavy, slowly absorbable suture such as 1-PDS, and the skin wounds could be closed
with fine absorbable subcuticular material, tissue glue or just adhesive strips.
After wide antiseptic skin preparation and draping to expose a rectangular area of skin
from below the umbilicus to above the xiphisternum, a confident smooth incision is
made using a #23 blade held in the ‘knife’ grip, at a low angle to the skin surface.The
scalpel is turned more vertically to finish in order to ensure a vertical wound margin at
the end of the incision.
The assistant and surgeon place packs over the wound edges to compress dermal
bleeders and to allow lateral retraction over a wide zone as the incision is deepened
with another pass of the knife as before. Packs and traction are adjusted as the
diathermy is selected to take the incision down further. Smooth confident strokes
continue but, as the linea alba is divided, the strokes become more cautious, to control
depth.The peritoneum is carefully opened between Crile forceps (having picked up
just extraperitoneal fat first).After the peritoneal cavity has been entered, the surgeon
inserts two fingers to spread the tissues and protect the underlying viscera as the
peritoneal incision is extended—diathermy is commonly used as the peritoneum and
extraperitoneal fat is quite vascular. Once there is enough room, the assistant and
surgeon can insert a finger each to continue the process up and down.
● Closure
Looped 1-PDS is used here, beginning with a simple looped ‘knot’. Note the use of the
blunt-tipped needle which means the surgeon can place her fingers beneath the
margins of the wound safely. Later, a pack is placed over the viscera and the surgeon
uses heavy toothed forceps to elevate the fascia and manipulate the needle. Deep,
wide bites are taken, well back from the wound margin.The assistant follows to
maintain tension, but is careful not to pull this running suture too tight. Note the
careful use of the dissecting forceps and needle-holder, working together to hand the
149
needle from one to the other in a no-touch technique.Also note the use of the
surgeon’s finger placed under the wound while tightening each suture to ensure that
no loops of bowel or any other tissue are caught in the stitches on the under surface.
In the lower part of the wound, the anterior and posterior sheaths are each taken
individually on one side because the initial incision wandered off the midline.The
surgeon is deliberately avoiding including the rectus muscle in these bites to maintain
its function and prevent strangulation.
Index
Index
backhand grip 89, 90 internal organs 37
double-action 91–2 self-retaining retractors 37–42
laparoscopic 124 right-angled forceps 73
palmar grip 89
tungsten-carbide inserts 90 scalpel 22–6
needles 87 dissection 49–50
bent 109 grip 23, 24, 25, 26
curved 87 handles and blades 23
cutting edge 87 long incision 22–4
round bodied 87 short incision 24–5
straight 87 stab incision 25–6
non-anatomical field block 19 scissors 44–5, 49–50
scrubbing up 15–16
old wounds, re-opening 27–9 sebaceous cyst, removal of 143–4
Omni-tract apparatus 40, 42 serrated graspers 116
open drains 132–3 sharp dissection 48–50
operating 7–8 scalpel 49–50
Operation reports 9 scissors 48–9
brief 9 sharps, passing 6
definitive 9 shaving 14
oversewing raw surface 77 skin hooks 32
skin lesions, excision of 143–4
packing 77 skin stapling 103
padded dressings 138 slip knots 55–6
Parks’ anal retractor 38 speaking to relatives 10–11
parrot-beak scissors 116 spreading artery forceps 45
patient positioning 15 stack 112, 113
patient preparation 14–15 Staplers 104–107
Penrose drain 133 circular 106, 107
Petelin dissectors 115 linear 104, 105
pneumoperitoneum 115–17 linear cutting 105–106
Poole sucker 80 stapling 103–7
ports 113–14 laparoscopic 124
positioning 115 skin 103
post-operative dressings 137–8 viscera 103–7
post-operative drug chart 10 sterile zones 6
post-operative responsibilities 2, 3 stress response 7
pre-operative responsibilities 2 subcuticular sutures 98–9
154
suction 79–80 suturing 85–103
laparoscopic surgery 120 tissue glues 84
sump drains 132 tissue glues 84
supportive dressings 138 tissue-grasping forceps 35–42
surgeon’s knot 58 tissue separation 43–51
suturing 85–103 blunt dissection 44–8
absorbable vs non-absorbable 86 laparoscopic surgery 119–20
biological vs synthetic 86–7 sharp dissection 48–50
coloured vs uncoloured 87 tourniquets 75
gauge 86 transfixion 71
instruments 87–94 transparent dressings 137
laparoscopic 123–4 Travers’ self-retaining retractor 39
materials 85–7, 102 tremor 7
Index