BASIC SURGICAL SKILLS AND ANASTOMOSIS Dr Zaeem Fezea

BASIC SURGICAL SKILLS AND ANASTOMOSIS Dr. Zaeem Fezea Dahla Consultant General surgeon

LEARNING OBJECTIVES To understand � � � The principles of skin and abdominal incisions The principles of wound closure To know the principles in performing: Bowel anastomoses Vascular anastomoses �To � be aware of: The principles of drain usage , diathermy, ligasure and harmonic scalpel Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 2

INCISIONS Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 3

Factors considered when planning askin incision 1) Skin tension lines (Langer s lines) Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 4

Anatomical structure � Incision should be avoid bony prominences, and crossing skin creases if possible, and take care of underlying structures , such as nerves and vessels. �Cosmetic factors. �Adequate access for the procedure. Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 5

Abdominal incisions � As for skin incisions, all abdominal incision should be planned in advance of surgery and taking into consideration access to the abdominal organs , surface anatomy, pain control and cosmetic outcome. Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 6

WOUND CLOSURE There is no ideal wound closure technique that would appropriate for all situation. Thursday, December 3, 2020 The suturing for any incision or wound need to take into consideration Site , tissue involved , & technique of closure Basic surgical skill & anastomosis Dr. zaeem dahla 7

suture materials Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 8

Types of wound healing Healing by primary intention (clean wound) � Healing by secondary intention (infected unclean or contaminated wound) � Healing by tertiary intention ( skin grafting or delayed closure) � Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 9

Suture characteristics There are five characteristics: 1. Physical structure (monofilament or poly filament) 2. Strength (depends on constituent material , thickness , how it is handled in tissue ) Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 10

suture characteristics � Tensile behavior : what occur in the tissue � Absorbability � Biological behavior Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. Zaeem dahla 11

Suture techniques � Interrupted Thursday, December 3, 2020 sutures. Basic surgical skill & anastomosis Dr. zaeem dahla 12

� Continuous Thursday, December 3, 2020 sutures Basic surgical skill & anastomosis Dr. zaeem dahla 13

� Mattress sutures. either vertical or horizontal Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 14

� Subcuticular Thursday, December 3, 2020 suture. Basic surgical skill & anastomosis Dr. zaeem dahla 15

Needle types Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 16

Knotting techniques � Knot tying is one of the most fundamental techniques. � The general principles in knot tying include 1. 2. 3. 4. 5. 6. 7. The knot must be tied firmly without tension or strangulation The knot must be unable to slip The knot must be as small as possible to minimize the amount of foreign body No tension During tying the suture must not be sawed as this weakens the thread. The suture material must be laid square. The standard surgical knot is the reef knot Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. Zaeem dahlia 17

Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. Zaeem dahla 18

The tensile strength of suture material can be expressed as the force required to break it when pulling the two end apart. This depend on whether the material used for synthesis are absorbable or non absorbable. Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 19

Alternative to sutures Skin adhesive strips. v Tissue glue v Staples v clips v Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 20

THE PRINCIPLES OF ANASTOMOSIS � Bowel anastomosis ü Ensure good blood supply to both bowel ends before and after anastomosis. ü Ensure the anastomosis not under tension. ü Avoid risk of mesenteric vessels not involved by suture or clamps. ü Use atraumatic bowel clamps to minimize contamination ü Interrupted or continuous single layer suture technique is adequate and safe. ü Stapling devices are an alternative when speed is required or access is a major factor. Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 21

Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 22

VASCULAR ANASTOMOSIS Need to be extremely accurate closure and immediately watertight at the end of operation when vascular clamps removed , � Knots security is important. � Use monofilament and a traumatic needle. � Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 23

DRAINS Drains are inserted to allow fluid or air that might collect at an operation site or in wound to drain freely to the surface. � Three basic principles apply in the use of drains; 1. Open drains work in gravity principle. 2. Semi open work in principle of capillary effect. 3. Closed system drains work in principle of siphon or negative suction. � Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 24

Advantages and Disadvantage of using drains To remove any intraperitoneal or wound collection � Act as signal for any postoperative internal hemorrhage or anastomotic leakage � Provide track for later diagnostic and therapeutic options. � Thursday, December 3, 2020 � � � Increase chance of infection(FB) Increase chance of anastomotic leak Increase abdominal pain Increase hospital stay. Decrease pulmonary faction. Basic surgical skill & anastomosis Dr. zaeem dahla 25

Specialist use of drains � Chest drains Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 26

� T-tube drain Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 27

The principles of diathermy � This one of way used in surgery to cut tissue or to coagulate site of bleeding to do hemostasis in surgical site. � The heat produced depend on: Ø The intensity of the current Ø The wave from the current Ø The electrical property of the tissue through which the current passes Ø The size of two electrodes Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 28

Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 29

Complication of diathermy Electrocution q Explosion q Burns q Channelling this can happened when the q intensity of current is great, for examples § Coagulation of the penis if use diathermy. § Coagulation of spermatic cord when the electrode applied to the testis. q pacemakers Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 30

The principles of ligasure & harmonic scalpel � Ligasure use fusion technology is a vessel sealing system that is used in open and laparoscopic surgery, it was a combination of pressure and energy to create vessel fusion. � Harmonic scalpel ; use ultasound technology to cut tissue while at same time sealing them Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 31

THANKS FOR ATTENDENCY Thursday, December 3, 2020 Basic surgical skill & anastomosis Dr. zaeem dahla 32