BSS 3rd Edition Participant Handbook CD Final

This handbook was written and revised by Mr Bill Thomas, Blond surgical skills tutor and chairman of
the working party at The Royal College of Surgeons of England, with assistance from members of the
intercollegiate working party (see inside back cover).
Published by The Royal College of Surgeons of England
Registered Charity No. 212808
The Raven Department of Education
The Royal College of Surgeons of England
3543 Lincolns Inn Fields
London WC2A 3PE
Tel: 020 7869 6300
Fax: 020 7869 6320
Email: education@rcseng.ac.uk
Internet: www.rcseng.ac.uk
The Royal College of Surgeons of England 2002
First edition 1996
Second edition 1998
Third edition 2002
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or
transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise,
without the prior written permission of The Royal College of Surgeons of England.
While every effort has been made to ensure the accuracy of the information contained in this
publication, no guarantee can be given that all errors and omissions have been excluded. No
responsibility for loss occasioned to any person acting or refraining from action as a result of the material
in this publication can be accepted by The Royal College of Surgeons of England.
The establishment of the Basic Surgical Skills course has been a major educational development project
which has been greatly assisted by:
Eschmann, who kindly supported the diathermy video for the course.
Ethicon Limited, who supported the initial production of the handbook, provided materials and
equipment for the course in its pilot stage and kindly supported the production of this third edition
of the course.
Keeler Limited, who kindly supported the handbook of this third edition.
Regent Hospital Products, who kindly suppored the production of this handbook (second and third
editions).
a
company
LTD
a
company
We are particularly grateful
to Mr Nick Cheshire,
Mr Elliot Chisholm, Mr David Hay, Mrs Sue Miles and
Mr John Shepperd for their contributions to the first edition and also to Mr Chris Fowler and the minimal
access therapy training unit for permission to use extracts from the Basic Skills for Safe Laparoscopic
Surgery handbook. Additional material in the minimal access section was written by Mr George Hanna
and Mr David Smith and the new operative video footage was provided by Mr Nick Cheshire, Mr David
Hay, Mr Graham Sunderland and Mr Peter Wilson. The new orthopaedic material was provided by Mr
Nick Gilham and Mr David Large.
This handbook may be purchased from The Royal College of Surgeons of England and used in support
of courses and/or training activities other than the Basic Surgical Skills courses approved by one of the
four surgical royal colleges.
However, The Royal College of Surgeons of England takes no responsibility whatsoever for the use of its
course materials in any context, other than as part of a basic surgical skills course it has approved.
Introduction:
introduction to the course
course objectives
course programme
basic principles
xx
Module one:
open surgery
xx
Module two:
trauma and orthopaedics
xx
Module three: minimal access surgery
xx
Assessment
xx
Appendix A:
needles
xx
Appendix B:
suture materials
xxx
Appendix C:
gloves
INTRODUCTION TO THE COURSE
This handbook has been designed and written

for participants on the Basic Surgical Skills
courses, for use before, during and after
attendance on a course. From August 1996 it
has been a mandatory requirement of the four
surgical royal colleges that all SHOs entering
basic surgical training should successfully
complete such a course. This course has been
designed to introduce surgical trainees to safe
surgical practice within a controlled workshop
environment and it aims to teach, assess and
certify trainees ability to use safe and sound
surgical techniques that are common to all forms
of surgery.
The course covers three main areas:
open surgery;
trauma and orthopaedics; and
minimal access surgery.
It is not intended to provide comprehensive
coverage of all aspects of surgery, but is
designed to introduce surgical trainees to safe
and sound techniques early in their career. The
course is standardised with common objectives,
content, structure and assessment methods as
agreed by all four surgical colleges. It does
not seek to impose or promote the techniques
demonstrated as being the only safe and sound
method for performing a surgical procedure but
does endeavour to teach one safe way that
trainees may utilise. The course is intensively
taught, with an emphasis on individual tuition
and detailed personal feedback on performance.
Features of the course include:
Hands-on practice throughout the course.
High tutor to participant ratio.
Personal tuition with a maximum of 18
participants per course.
Accompanying course handbook and video
containing key points for each procedure.
Performance assessment and feedback to
identify areas of strength and weakness.
Each course will be offered under the

aegis of one of the surgical royal colleges
at a network of regional centres, so that
trainees should not need to travel too far
from their hospitals. It is an intercollegiate
course with a common content and structure
and standardised in-course assessment, so
that all trainees will have a common learning
experience, regardless of location.
The materials which accompany the course
carry the copyright of The Royal College of
Surgeons of England but have been produced
with the help of representatives of all four
surgical colleges and are available by prior
agreement between the colleges for use
on all courses. This reflects the high level
of co-operation between the colleges in
establishing this important initiative and
emphasises the intercollegiate commitment to
achieve a common standard on Basic Surgical
Skills courses.
We are particularly grateful to the many
members of faculty and the participating
trainees in the regions whose comments were
invaluable in the development and revision of
the course and its accompanying handbook and
video.
It is our intention that the courses should
not only be instructive and educational, but
also enjoyable. I trust that you will enjoy this
course and find that it provides you with a firm
foundation for your future career in surgery.
WEG Thomas
Blond surgical skills tutor, The Royal College of
Surgeons of England
introduction to the course
COURSE OBJECTIVES
Module one: open surgery

To learn safe operating techniques, gowning and gloving.
To understand that careful and sound aspects of technique are more
important than simple manual dexterity or speed.
To understand the importance of universal precautions for safe theatre
practice, especially in emergency situations.
To understand the principles of handling tissues and sound
anastomotic technique recognising differing requirements for differing
sites, eg bowel and vascular tissue.
Module two: trauma and orthopaedics

To understand the principles of assessing contaminated soft tissues,
wound debridement and primary surgical management including
drainage and appropriate closure.
To understand the principles of identifying and managing injury to
tendons, including tendon repair, handling of tissues and subsequent
management.
To understand the principles of fracture assessment, stabilisation and
plaster techniques.
Module three: minimal access surgery

To understand the basic principles governing safe preparation for
laparoscopic surgery.
To demonstrate the safe use of the open technique for port insertion
(Hassan).
To insert the Verres needle and cannulae safely.
To understand the physiological consequences of pneumoperitoneum.
To understand the use of instruments and imaging systems.
To understand the principles governing the use of the camera.
To demonstrate an ability to manipulate basic laparoscopic
instruments.
To understand the principles behind the practical use of diathermy.
To demonstrate an overall understanding of the safety issue for
minimal access surgery.
course objectives
COURSE PROGRAMME
Day 1 module one: open surgery

8.309.00
Registration (faculty meeting)
9.009.05
Introduction and statement of course objectives
9.059.25
Theatre safety (principles of safe surgery)

Gowning and gloving
Protection, visors, masks, double gloving
9.259.50
Handling instruments
Scalpel, scissors, dissecting forceps, haemostats,
needle holder
9.5010.30
Knots
One-handed reef knot, instrument tie, surgeons knot,
slip knot, tying at depth, Aberdeen knot
10.3010.45
Coffee
10.4511.30
Knots continued
11.3013.00
Handling sutures
Principles of needle and suture use, interrupted,
continuous, the art of assisting, mattress, subcuticular,
skin lesion biopsy
13.0013.45
Lunch
13.4515.30
Handling tissues
Abdominal incision and closure, haemostasis,
dissection (time permitting)
Handling bowel 1
End-to-end extramucosal anastomosis
(continuous suture technique if time permits)
15.3015.45
Tea
15.4517.15
Handling bowel 2
End-to-side anastomosis on immobile bowel
17.1517.30
Discussion and feedback
course programme
Day 2 (am) module one: open surgery (continued)

8.309.30
The Aberdeen knot

Abdominal incision and closure
Use of simulated abdominal wall and incision
9.3010.45
Handling vessels
Vascular anastomoses, arteriotomy and closure
10.4511.00
Coffee
11.0012.30
Handling vessels (continued)

Vein patch graft
12.3013.30
Lunch
Day 2 (pm) module two: trauma and orthopaedics
13.3014.10
Handling traumatised tissues

Drainage and debridement
14.1015.10
Handling tendons
Tendon repair
15.1015.25
Principles of fracture fixation

Types of fracture, principles of fixation and
complications
15.2515.40
Tea
15.4017.15
Plastering techniques
Full plaster and splitting techniques
17.1517.30
Discussion and feedback
basic surgical skills
Day 3 module three: minimal access surgery

8.308.45
Introduction to minimal access surgery

Ergonomics and safety principles
8.459.20
The laparoscopic stack

Rapid flow insufflator, light source, video camera,
laparoscopes, monitors
9.2010.30
Safe induction and maintenance of the

pneumoperitoneum
Open method of port insertion, closed method of
creating pneumoperitoneum, insertion of the umbilical
trocar and laparoscope, safe port management,
camera handling
10.3010.45
Coffee
10.4511.15
Minimal access surgery instrumentation

Introduction to basic laparoscopic instrumentation
11.1513.00
Grasping and manipulation skills

Multiple exercises to demonstrate manipulative skills
13.0014.00
Lunch
14.0015.15
Advanced dexterity skills

Clipping and loop ligation (simulation of
appendicectomy)
15.1515.30
Tea
15.3016.45
Diathermy
Video and discussion
(This may be shown at any time on the final day
depending on local resources)
Diathermy skills exercises
Chicken skin peeling
16.4517.00
Summary and feedback
END OF COURSE
course programme
BASIC PRINCIPLES
Preparation for the course

There is little essential preparation for the
Basic Surgical Skills course apart from
reading this handbook and watching the
video.
All participants will preferably be on a basic
surgical training scheme.
It is preferable that all participants have had
some, if only limited, experience of suture
techniques and handling instruments.
Any practise of the techniques demonstrated
in the video prior to the course will help the
participant to progress more rapidly with the
exercises.
Theatre safety (principles of safe

surgery)
Exercise
The following procedure for putting on sterile
theatre gowns and gloves is essential to the
overall approach of operative sterile technique:
Wash your hands thoroughly with appropriate
antiseptic soaps.
Dry your hands from the hands down towards
the elbows and then discard the towels.
Pick up your gown and fold it so that the
inside faces towards you.
Put on the gown without touching the outside
of the gown, keeping your hands inside the
cuffs.
Get an assistant to tie up the gown from the
back.
Open the glove packet.
Use a closed gloving technique to put on your
gloves.
Hand your assistant the tab of the posterior
gown tie so that they handle only the red tab
end and not the tie itself. Turn around and
then pull the tie out of the tab and tie it so
that the posterior aspect of the gown is now
closed.
10
Other important principles

Always wear gloves of the correct size and
choose appropriate gloves to suit the surgical
procedure. See Principles of glove usage
Appendix C.
Never directly handle sharps.
Never handle a needle with your fingers.
When opening a needle packet, be careful to
take the needle out of the specially designed
packet using the needle holder and without
touching the needle yourself.
When changing the position of the needle
in the needle holder, always use the forceps
to change the orientation of the needle as
demonstrated in the video. Once again, do
not use your fingers.
Always keep any needle in use in your direct
sight at all times. When using a long suture
length on your needle, utilise the middle finger
of your right hand to control the long length,
as shown in the video, and do not simply pull
the needle out of view to tighten the suture
material, as you can contaminate the needle
or even injure your assistant.
Always hand sharp instruments to assistants
in a manner such that they cannot be injured
preferably in a kidney dish or suitable
container. The safety of any assistants is the
surgeons responsibility.
When changing the blade of a scalpel, be
careful to handle the blade with forceps or
haemostats. The blade is extremely sharp and
should not be handled with your fingers.
Always dispose of used needles or blades in
the sharps container provided.
Always dispose of excised tissue in
appropriate containers.
Always keep the operative field tidy without
extraneous instruments or equipment lying
around.
Always check the integrity of instruments
before use and do not always rely on
assistants or scrub nurses. This is particularly

important for electrical equipment such as
diathermy and laparoscopic equipment.
Operate with the table at the correct
height whether sitting or standing the
height of the operative field should be
approximately horizontal to your forearm
(Figure 1). Operating at any other height is
likely to cause tiredness and stress.
Throughout the course always wear aprons
and gloves when handling tissues.
Always dispose of gloves, theatre gowns and
drapes in the appropriate manner.
Principles of magnification
The benefits of using magnification during
surgical procedures are obvious. A clearer,
sharper working view is provided that enables
you to clearly visualise the structures that
require your attention. Head-mounted optical
systems (loupes) are often ideal to wear during
surgery as they allow you more freedom of
movement than microscopes and are individually
adjusted to fit the user. There are two types of
loupes available.
The Galilean system consists of three lenses
and is often considered the easier to use. This is
because it provides an increased working depth
and a wide field of view allowing you to move
more freely while the image remains in focus. It
is usually available in up to 3X magnification.
The prismatic loupe provides a more
complicated optical system and, because of
the increased number of lenses and the prism,
is heavier than a Galilean loupe. However,
it provides superb colour rendition and an
extremely flat field, which makes it particularly
useful for vascular surgery and fine detailed
work. The clarity of the image requires you to
maintain an exact working distance. Prismatic
loupes are usually available in magnifications of
up to 5.5X or 6X.
When selecting your magnification, bear the
following in mind:
Glass lenses. These are optically superior
and will provide a sharp clear image with little
or no distortion.
Comfort. You will often have to wear your
loupes for extended periods of time, so
ensure they are comfortable and practical to
wear. There is usually an option to wear them
on a spectacle frame or headband. For ease
of use a flip-up design may be preferred as
Basic principles has been generously supported by Keeler Ltd
Figure 1
they provide magnification when needed and

an unrestricted view when magnification is not
required.
Fitting. Ensure that your loupes can be fitted
to suit your eyes. An individual interpupillary
adjustment is normally required to prevent
eyestrain. A well-fitted pair of loupes can also
help improve your posture and help avoid
back problems, maintaining your comfort
during surgery.
Optical advice. Before deciding to purchase
loupes, contact your local optician. The
correct prescription will ensure your loupes
are comfortable and easy to wear helping
you to maintain your chosen working distance.
Contrary to popular belief, loupes are not
simply something that is required as you
grow older, as magnification will improve your
working view regardless of whether you are
normally a spectacle wearer or not. While your
eyes will not become reliant upon them, you
may well find that you rely on your loupes to
see the finer detail in your work and, like many
wearers, prefer working with them.
basic principles
11
MODULE ONE: open surgery
This module of the course is designed to teach

you basic safe methods of performing simple
surgical procedures, and to allow you to perform
and practise them at the bench on prepared
animal tissue, simulations and various jigs. We
aim to provide you with an enjoyable hands-on
experience and the opportunity of practising vital
and fundamental techniques in a less stressful
atmosphere than the operating theatre.
The module aims to introduce you to some
of the manipulative skills you will require in
your career. Complex manoeuvres will need to
be assiduously practised, preferably under critical
observation, so that you do not acquire bad
habits. The aim of this course is to help you
acquire good habits early in your career, as it is
so much harder to unlearn bad habits later in life.
The techniques chosen for this course by all four
surgical royal colleges are those which are simple
and safe, but we make no claim that these are the
only simple and safe techniques. They have been
chosen as being simple and proven. An advantage
of the British system of training is that you will
work for several surgeons in the course of your
training, each of whom will show you individually
preferred techniques from which you will be
able to select those which suit your needs best.
However, the techniques taught on this course
have been standardised and are recommended for
their simplicity and safety.
In order to achieve maximum potential from any
surgical instrument, it will need to be handled
correctly and carefully.
The basic principles of all instrument handling
include:
safety;
economy of movement;
relaxed handling; and
avoidance of awkward movements.
We shall demonstrate the handling of
scalpels, scissors, dissecting forceps,
haemostats and needle holders. Take every
opportunity to practise correct handling using
the whole range of surgical instruments.
The scalpel
Handle with great care as the blades are very
sharp. Practise attaching and detaching the
blade using a haemostat. Never handle the
blade directly.
For making a routine skin incision hold the
scalpel in a similar manner to a table knife,
with your index finger guiding the blade. Keep
the knife horizontal and draw the whole length
of the sharp blade, not just the point, over the
tissues (Figure 2).
Figure 2
12
For finer work the scalpel may be held like a

pen, often steadying the hand by using the
little finger as a fulcrum (Figure 3).
Use the index finger to steady the scissors by

placing it over the joint.
When cutting tissues or sutures, especially at
depth, it often helps to steady the scissors
over the index finger of the other hand
(Figure 5).
Figure 3
Figure 5
Always pass the scalpel in a kidney dish.

Never pass the scalpel point first across the
table.
Scissors
There are two basic types of scissors, one for
soft tissues and one for firmer tissues such as
sutures.
Insert the thumb and ring finger into the rings
(or bows) of the scissors so that just the distal
phalanges are within the rings (Figure 4). Any
further advancement of the fingers will lead
to clumsy handling and difficulty in extricating
the fingers at speed.
Cut with the tips of the scissors for accuracy

rather than using the crutch which will run
the risk of damaging tissues beyond the item
being divided and will also diminish accuracy.
Dissecting forceps
Hold gently between thumb and fingers,
the middle finger playing the pivotal role
(Figure 6).
Figure 6
Figure 4
Two main types of forceps are available,

toothed for tougher tissue such as fascia or
skin, and non-toothed (atraumatic) for delicate
tissues such as bowel and vessels.
Never crush tissues with the forceps but use
them to hold or manipulate tissues with great
care and gentleness.
open surgery
13
Haemostats (artery forceps)

Hold haemostats in a similar manner to
scissors.
Place on vessels using the tips of the jaws
(the grip lessens towards the joint of the
instrument).
Secure position using the ratchet lock.
Learn to release the haemostat using either
hand. For the right hand, hold the forceps
as normally, then gently further compress the
handles and separate them in a plane at right
angles to the plane of action of the joint.
Control the forceps during this manoeuvre
to prevent them from springing open in an
uncontrolled manner. For the left hand, hold
the forceps with the thumb and index finger
grasping the distal ring and the ring finger
resting on the under surface of the near ring
(Figure 7). Gently compress the handles and
separate them again at right angles to the
plane of action, taking care to control the
forceps as you do so.
Figure 6
Needle holder
Grasp the needle holders in a similar manner
to scissors.
Hold the needle in the tip of the jaws about
two-thirds of the way along its circumference
(Figure 8), never at its very delicate point
and never too near the swaged eye (see
Appendix A).
Figure 7
Select the needle holder carefully. For

delicate, fine suturing use a fine short-handled
needle holder and an appropriate needle.
Suturing at depth requires a long-handled
needle holder.
Most needle holders incorporate a ratchet
lock but some, eg Gilles, do not. Practise
using different forms of needle holder to
decide which is most applicable for your use.
There are a wide variety of needle and suture
materials available and their use will depend
on the tissues being sutured and the nature
of the anastomosis. For a full description of
needles and suture materials see Appendices
A and B.
Exercise
Practise the correct handling of each of
the instruments (scalpels, scissors, dissecting
forceps, haemostats and needle holders) as
demonstrated.
14
Knots
Knot tying is one of the most fundamental
techniques in surgery and is often performed
very badly.
Take time to perfect your knot tying technique
as this will stand you in good stead for the
rest of your career. Practise regularly with spare
lengths of suture material.
General principles of knot tying include:
The knot must be firm and unable to slip.
The knot must be as small as possible to
minimise foreign material.
During tying do not saw the material as this
will weaken the thread.
Do not damage the suture material by
grasping it with artery forceps or needle
holders except at the free end when using an
instrument tie.
Avoid excess tension during tying as this
could damage the structure being ligated or
even cause breakage of the suture material.
Avoid tearing the tissue being ligated by
controlling tension at bedding down of the
knot very carefully using the index finger or
thumb as appropriate
You will be taught and asked to demonstrate
the following:
the one-handed reef knot;
an instrument tie reef knot;
the surgeons knot;
a slip knot (the granny knot); and
tying at depth.
The standard knot used in routine surgery is
the reef knot with a third throw for security. This
is usually tied using the one-handed method
and this technique should be mastered and
practised regularly during the course.
The principles of the reef knot are the
alternating ties of the index finger knot and the
middle finger knot at the same time as the
hands cross over for each throw.
open surgery
15
The one-handed reef knot technique

Exercise
Hold the end of the short end of the suture
between the thumb and middle finger of the
left hand with the loop over the extended
index finger (Figure 9a). Hold the remainder of
the suture material with the right hand.
Use the distal phalanx of the left index finger

to pass under the thread held in the left hand
in preparation for pulling it through the loop
(Figure 9c).
Figure 9c
Figure 9a
Pull the thread through and complete the

throw by drawing the left hand towards the
operator and the right hand away from the
operator (Figure 9d).
Bring the remainder of the suture material in

the right hand over the left index finger by
moving the right hand away from the operator
(Figure 9b).
Figure 9d
Figure 9b
16
Continue to hold the short end of the suture

in the left hand between thumb and index
finger looping the thread around the other
three fingers (Figure 9e).
Bring the strand through and then tighten by

drawing the right hand towards the operator
and the left hand away from the operator
(Figure 9h).
Figure 9e
Figure 9h
Bring the strand held in the right hand across

towards the operator to cross the left-handed
thread (Figure 9f).
On completion of the reef knot, the classical

pattern of the knot can be clearly seen
(Figure 9i and 9j).
Figure 9f
Use the distal phalanx of the left middle finger

to bring the left-handed strand under the righthanded strand (Figure 9g).
Figure 9i
Figure 9j
Figure 9g
For security another index finger throw is

usually applied.
open surgery
17
The instrument tie

Exercise
Loop the long end of the suture around the
instrument, the instrument being placed over
the thread (Figure 10a).
Now form a loop around the instrument, this

time the instrument being placed under the
thread (Figure 10d).
Figure 10d
Figure 10a
Grasp the short end again within the jaws of

the instrument (Figure 10e).
Grasp the short end of the suture within the

jaws of the instrument (Figure 10b).
Figure 10e
Figure 10b
Pull through to complete the classical reef

knot (Figure 10f).
Complete the first hitch (Figure 10c).
Figure 10f
Figure 10c
18
The surgeons knot

Exercise
A single throw is placed using a one-handed
or two-handed technique (Figure 11a).
A further throw is now fashioned in the same

manner as for a reef knot but not tightened
(Figure 11d).
Figure 11d
Figure 11a
A further throw in the same manner is placed

(Figure 11b).
A similar throw is again fashioned producing a

double throw as before (Figure 11e).
Figure 11e
Figure 11b
The double throw is tightened in a

conventional manner (Figure 11c).
The double throw is now tightened

(Figure 11f).
Figure 11f
Figure 11c
continued over....
open surgery
19
... continued
The result may not look very pretty but
it is very secure as long as the final
throw is tightened as horizontally as possible
(Figure 11g).
Figure 12b
This does not produce the classical picture

of a reef knot but it does slip and can be
used to ensure the right tension of the knot
(Figure 12c).
Figure 11g
The slip knot

Exercise
This should be used with care as it
is not secure. Two similar throws are
placed consecutively and then snugged down
(Figure 12a and 12b).
Figure 12c
A formal reef knot needs to be tied now in

order to give the knot security (Figure 12d).
Figure 12a
Figure 12d
20
Tying at depth
Exercise
The thread should be placed around the
object to be ligated with the right index finger
(Figure 13a) or using an instrument such as
a haemostat.
Snug the knot down using tension on the

long strand against the index finger of the
right hand, ensuring no tension exists on the
structure being ligated.
Fashion a further throw on the surface in the
manner of a reef knot (Figure 13d).
Figure 13d
Figure 13a
Fashion a classical throw for a reef knot on

the surface (Figure 13b).
Advance into the cavity and snug down with

the right index finger as before (Figure 13e)
Figure 13e
Figure 13b
Advance the knot down into the cavity using

the right index finger (Figure 13c).
Figure 13b
open surgery
21
Handling sutures
Basic principles
Attempt to remove all elements of tension
from any anastomosis.
Insert the needle at right angles to the
tissue and gently advance through the tissue
avoiding shearing forces.
As a rough rule of thumb, the distance from
the edge of the wound should correspond
to the thickness of the tissue and successive
sutures should be placed at twice this
distance apart, ie approximately double the
depth of the tissue sutured (Figure 14).
For long wounds being closed with

interrupted sutures, it is often advisable to
start in the middle and to keep on halving the
wound.
No suture should be tied under too much
tension or the subsequent oedema of the
wound may cause the sutures to cut out or
to develop ischaemia of the wound edge and
delayed healing.
In most cases it is advisable to only go
through one edge of the tissues at a time but,
if the edges lie in very close proximity and
accuracy can be ensured, it is permissible to
go through both edges at the same time.
For elliptical wounds following lesion excision,
the edges of the wound may be undermined
to help closure. However, the length of the
wound will need to be approximately three
times the width of the wound if closure is to
be safe and not under too much tension. Skin
hooks may be useful for display of the wound.
Forms of suturing
Figure 14
All sutures should be placed at right angles

to the line of the wound at the same distance
from the wound edge and the same distance
apart in order for tension to be equal down
the wound length. The only situation where
this should not apply is when suturing fascia
or aponeuroses when the sutures should be
placed at varying distances from the wound
edge in order to prevent the fibres parting
(Figures 15a and 15b).
You will be taught and asked to demonstrate the

following types of suturing:
interrupted sutures;
continuous sutures (including the art of
following);
mattress sutures;
subcuticular sutures; and
inverting and everting techniques.
Interrupted sutures (Figure 16)
Figure 15a
Figure 16
Exercise
Place carefully at right angles to the wound
edges.
Tie a careful reef knot and lay to one side of
the wound.
Figure 15b
22
Cut suture ends about 0.5cm long to allow

enough length for grasping when removing.
When removing sutures, cut flush with the
tissue surface so that the exposed length
of the suture, which is potentially infected,
does not have to pass through the tissues
(Figures 17a and 17b).
an assistant following by holding the suture

at the same tension as it is when handed to
them.
Take care not to purse string the wound by
too much tension.
Take care not to produce too much tension by
using too little suture length.
Secure the suture at the end of the
anastomosis by a further reef knot.
Mattress sutures
Exercise
Mattress sutures may be either vertical
(Figure 19a and 20a) or horizontal (Figure
19b and 20b).
Figure 17a
Figure 19a
Figure 19b
Figure 17b
Continuous sutures (Figure 18)
They may be useful for ensuring either

eversion (Figure 19) or inversion (Figure 20)
of a wound edge.
Figure 20a
Figure 18
Exercise
Place a single suture and ligate but only cut
the short end of the suture.
Continue to place sutures along the length
of the wound keeping tension by means of
Figure 20b
open surgery
23
Subcuticular sutures (Figure 21)
Handling tissues
Haemostasis
Two methods of securing haemostasis by
ligation will be demonstrated using vessels in
small bowel mesentery.
Figure 21
Exercise
This technique may be used with absorbable
or non-absorbable sutures.
For non-absorbable sutures the ends may be
secured by means of beads, etc.
For absorbable sutures the ends may secured
by means of buried knots.
Small bites are taken of the subcuticular
tissues on alternate sides of the wound and
these are then pulled carefully together.
Skin lesion biopsy
Exercise
Make an elliptical incision around the lesion.
Dissect the lesion out taking care not to
disrupt or burst it.
Remove the lesion (always send for
histological examination).
Undermine the skin edges if necessary.
Ensure that not too much tension exists for
closure.
Length of the wound should be approximately
three times the width of the wound.
If any tension exists, it is easier to start in the
corners and work towards the centre.
If no tension exists, the wound may be closed
by starting in the centre and then halving the
remaining wound.
Close the wound with interrupted sutures.
24
Exercise single vessel ligation

Carefully dissect out a single vessel in the
mesentery by dividing the peritoneum over it
and isolating a length of vessel on its own.
If possible do not go right through the
peritoneum on the other side of the
mesentery.
Pass ligature threads under the vessel by
means of haemostats and ligate at either end
of the isolated length of vessel.
Divide the vessel between the two ligatures
and cut the suture material of the knots.
Exercise pedicle ligation
Isolate a pedicle or leash of vessels and place
a haemostat at either end.
Divide the vessels between the haemostats.
Ligate the vessels in each haemostat with a
three-throw reef knot.
Dissection (if time and specimen allow)
Lymph node biopsy is commonly required for
histological examination.
Exercise
For this exercise the nodes in small bowel
mesentery are to be used.
Carefully divide the peritoneum over the node.
Dissect the node with care, avoiding any
crushing of the node or damage to the
underlying tissues. Minimal handling of the
node is desirable.
Each node will have feeding vessels which in
normal circumstances will need to be dealt
with by diathermy or ligation.
Handling bowel
Bowel anastomosis
The basic principles of bowel anastomosis
will be demonstrated using a small bowel
anastomosis.
The essentials for any anastomosis are:
no tension;
good blood supply (pulsating mesenteric
vessels);
accurate apposition; and
impeccable and accurate suture technique.
Although not the only safe suture method for
small bowel anastomosis, the technique to be
demonstrated on this course will be the single
layer extramucosal suture (Figure 22).
Figure 22
The basic exercise will be performed as an

end-to-end anastomosis on mobile small bowel
that can be turned to reveal the posterior wall.
Each participant will have an opportunity to
perform a complete anastomosis and also assist
their partner in their anastomosis.
Two sessions on bowel anastomosis are
included in the course and, for participants
who perform well, the techniques of end-to-side
anastomosis on non-mobile bowel will also be
demonstrated.
A continuous technique is also permissible,
taking care not to purse string the anastomosis.
End-to-end extramucosal anastomosis
Exercise
Assume resection of a lesion.
Line up the ends of the bowel. In operative
circumstances non-crushing bowel clamps
may be used to prevent spillage, etc.
Use 3/0 absorbable suture material with an
atraumatic round bodied needle.
Each suture should perforate the bowel from
the serosal surface, penetrating the muscle

layer and submucosa and emerging between
the mucosa and submucosa (Figure 22). It is
essential to include the submucosa as this is
the strongest layer of the bowel wall.
Insert stay sutures at the mesenteric and
antimesenteric borders; do not ligate them but
place in haemostats.
Starting from the mesenteric aspect, place
interrupted sutures along the anterior wall of
the bowel at approximately 0.5cm apart and
tie as they are placed. On completion, tie both
stay sutures, but do not cut and replace in
haemostats.
Pass antimesenteric stay suture under bowel
to emerge in mesenteric defect and, at
the same time, draw mesenteric stay suture
towards operator which will reverse the bowel
and the posterior wall will now lie anteriorly.
Suture the new front wall in a similar manner
using interrupted extramucosal sutures taking
care to ensure the angles are adequately
sutured.
On completion, return the stay sutures to their
original position, then cut them and inspect
the anastomosis.
In normal situations the mesenteric defect
must be closed, taking care not to damage
the mesenteric vessels.
In the exercise situation, cut out the
anastomosis and then open it up and inspect
from the inside as well as the outside.
Very little suture material should appear
within the lumen if the extramucosal suture
technique has been adequately inserted.
If a continuous technique is to be employed,
place a stay suture at the antimesenteric
border and do not tie but place in a
haemostat. In the same manner, place a stay
suture at the mesenteric border using a full
length of suture, ligate it and place the short
end in a haemostat. Take the other end and
use it to place a continuous suture across
the anterior wall of the anastomosis until the
antimesenteric stay is reached. Once again,
an extramucosal suture technique is used.
Care must be taken not to purse string the
anastomosis so the careful attention of an
assistant is essential. The antimesenteric stay
can now be tied but not cut. The bowel is
now reversed in the same way as before,
passing the needle and suture under the
partially fashioned anastomosis. On reversal
of the bowel, either continue on with the
same suture until the mesenteric stay is
open surgery
25
reached and tied to it, or use a double needle

suture at the outset for the mesenteric stay
suture, and the new front wall can then be
sutured from the mesenteric aspect towards
the antimesenteric aspect as before, using the
other needle.
End-to-side anastomosis on immobile bowel
Exercise
Use an end-to-side small bowel anastomosis
to demonstrate this technique.
In this technique the posterior wall is sutured
first using a vertical mattress suture technique
(Figure 23a). Each suture should perforate the
full thickness of the bowel wall from within
the lumen and then traverse the other portion
of bowel full thickness from outside to inside.
The suture should then return taking a small
segment of the mucosa on both sides. A reef
knot should then be tied on the lumen surface.
Figure 23b
Once again excise the anastomosis and open

it up for inspection. In this case all the
posterior sutures should be easily apparent
within the lumen but the anterior sutures
should be hardly visible.
The Aberdeen knot
Exercise
This knot is useful when, having finished a
continuous suture, you are left with a loop and
a free end (Figure 24a).
Figure 23a
The anastomosis should be started with

the corner stay sutures inserted in an
extramucosal fashion but it is best not to tie
them until later.
It is advisable to insert a stay suture in the
middle of both anterior walls as this will
facilitate the view of the posterior walls that
are about to be sutured. Alternatively, tissue
holders such as Babcocks can be used in the
same manner.
Insert all the posterior wall sutures as above,
tying as you go.
Now tie the stay sutures which are the first
sutures of the anterior layer and replace in the
haemostats. The mid-anterior wall stay sutures
can now be released. Then insert all the
anterior sutures in an extramucosal manner as
before (Figure 23b).
26
Figure 24a
Display the loop between the index finger and

thumb of your left hand making it as small as
possible by pulling on the other end of the
thread with your right hand (Figure 24b).
Figure 24b
Grasp the free end between the index finger

and thumb of the left hand through the loop
(Figure 24c) and by pulling it through and
releasing the right-hand thread, the old loop is
eliminated (Figure 24d).
The whole process is repeated about 67

times (Figure 24f).
Figure 24f
Figure 24c
Finally, pass the free end through the loop

(Figure 24g) and tighten down (Figure 24h).
The thread can now be cut.
Figure 24d
Once again the new loop is made as small as

possible by pulling on the right-hand thread,
and the whole process is repeated using a
type of see-saw movement (Figure 24e).
Figure 24g
Figure 24h
Figure 24e
open surgery
27
Abdominal incision and closure

Exercise
You will be provided with a simulator
representing the abdominal wall. It will consist
of two layers of material simulating the skin
and linea alba of the abdominal wall. They will
be stretched over an inflated balloon which
is to represent loops of bowel within the
peritoneal cavity. The aim of the exercise is to
enter the peritoneal cavity without damaging
the inflated balloon, and then to close the
abdominal wall again without bursting the
balloon.
Make a midline incision in the simulated
abdominal wall skin (Figure 25a).
Incise the linea alba carefully ensuring

no damage to the underlying balloon
(Figure 25c).
Figure 25c
Enlarge the incision using scissors until the

incision is adequate for whatever procedure is
intended (Figure 25d).
Figure 25a
Expose the simulated linea alba and lift up

using haemostats (Figure 25b).
Figure 25d
Figure 25b
28
Proceed to close the incision by inserting

a non-absorbable suture at one end of the
incision, ligating the ends with the knot on the
inside. As most suture materials used for this
closure are monofilament, several throws are
required, laying each one formally as a reef
knot. Many surgeons will place at least one of
these throws as a surgeons knot. Currently
many surgeons are now using a blunt needle
(Figure 25e) for this procedure in order to
minimise the risk of needle stick injuries.
Figure 25e
Figure 25g
Ensure that there is enough suture length to

close the incision which should be four times
the length of the wound. If the suture length is
not adequate, a further suture can be inserted
starting at the other end of the incision.
Close the entire wound always ensuring that
no loop of bowel or tissue is caught up by the
suture material (Figure 25f).
A simplified model for this exercise can be

provided by modifying a lunch box as shown in
Figure 25h (courtesy of Professor E Guiney).
Figure 25f
Tie the suture material at the end of the

closure, either by several conventional throws
or by using an Aberdeen knot. If a loop suture
is used, one of the strands can be cut close to
the needle. The other end, still on the needle,
can then be passed again through the tissues.
Next the two ends can be ligated with several
throws of a reef knot and the knot buried.
The knot should be buried by cutting off the
short end or loop and then passing the needle
through the tissues. Pull the knot deep into
the closure and then cut the suture off flush
(Figure 25g). The complete closure should
then be inspected.
Figure 25h
open surgery
29
Handling vessels
Vascular anastomoses
Vessels need to be handled in a very different
manner from bowel. Extreme gentleness in
handling is required and whenever possible a
vessel should be manipulated by grasping the
peri-arterial or adventitial tissues only. When
direct manipulation is unavoidable, arterial wall
should never be grasped between forceps for
fear of injury to the intima or even a full thickness
tear. Two methods for atraumatic handling of
vessel walls may be used, either using the tips
of closed dissecting forceps to gently open the
arteriotomy (Figure 26a) or using the suture
material to be used for the anastomosis to
retract the arterial wall (Figure 26b).
Fine, accurate, watertight sutures need to be

inserted at even tension when suturing vessels.
Always insert the needle at right angles to the
wall and pass it through the wall with several
short pushes which allow the needle to travel
on the arc of its own circle, thus not splitting or
tearing the delicate wall.
The finer the vessel, the finer the sutures
required and the smaller the bites taken.
Therefore, aortic sutures need large bites
while femoral sutures require fine bites. Distal
anastomoses are often facilitated by operating
loupes glasses which magnify the image
between two and four times.
A smooth internal suture line is essential
or else platelet aggregates will collect and
compromise the anastomosis. The suture line
needs to be everted to result in good intimal
apposition, unlike a bowel anastomosis in which
the suture line tends to be inverted.
Technique of transverse arteriotomy
Figure 26a
Figure 26b
When suturing arterial wall it is advisable for

the needle to pass from inside to out (ie from
intima to adventitia) to fix any atherosclerotic
plaques and prevent the formation of intimal
flaps which may lead to dissection, embolisation
or thrombosis.
Non-absorbable, monofilament suture material
that moves smoothly through the vessel wall
is required. These suture materials require a
careful knot technique and several throws to
prevent the knot unravelling (most vascular
surgeons recommend six or seven throws). Do
not damage the suture material by gripping it
with dissecting forceps, the needle holder or a
haemostat as this can lead to fracture. For the
same reason, all knots need to be hand-tied.
30
Once an artery has been dissected free and

inflow and outflow controlled, arteriotomy is
performed to gain access to the lumen. For
simple procedures such as embolectomy, a
transverse arteriotomy is simplest and can
be closed primarily. When more complex
procedures are anticipated (eg endarterectomy
or a graft anastomosis) a longitudinal arteriotomy
provides the necessary flexibility.
In all but the largest calibre of vessels,
longitudinal incisions require closure with a
patch to prevent stenosis. Primary closure
of a transverse arteriotomy results in minimal
stenosis of the vessel lumen (Figure 27a)
whereas primary closure of a longitudinal
incision produces a long stenosis which
may reduce flow and promote thrombosis
(Figure 27b).
Figure 27a
Figure 27b
Exercise
Use a sharp, fine-pointed blade (eg a number
11 blade) and approach the vessel at right
angles to the site of the incision. In most
circumstances, commence your incision on
the uppermost surface of the vessel.
With the blade facing away from you,
use a short stabbing motion to pierce the
anterior wall. Beware of the point of the
scalpel entering the vessel too deeply and
penetrating the opposing wall. Once the
blade has entered the vessel lumen, lift it up
and away to make a small opening in the
wall without damaging the inside of the artery
(Figure 28a).
Primary closure of a transverse arteriotomy

For primary closure of an arteriotomy, use
two appropriately sized, double ended arterial
sutures. Two suture lengths are used to allow
suturing to begin in both corners of the arterial
incision in order to avoid placing the last stitch
at the corner of the arteriotomy, which can be
difficult.
By definition, not all of the sutures can pass
through both arterial walls from inside to out.
Plan the placement of your stitches whenever
possible so that intima to adventitia suturing
occurs on the downstream side of the incision
(as dissection is most likely on this side once
blood flow is restored).
Exercise
Commence at either end of your arteriotomy
and pass both needles from inside to out
(Figure 29). Tie the suture and secure in a
rubber shod haemostat.
Figure 28a
Complete the arteriotomy in a controlled

manner using appropriately angled Potts
artery scissors (Figure 28b). Lift the blade
within the lumen away from the posterior wall
to avoid damaging the inside of the vessel.
Aim to open the vessel around 1/3 to 1/2 of
its circumference, depending on how much
access is required.
Figure 29
Use your other suture in a similar manner

at the opposite extreme of the arteriotomy
and then continue suturing using fine, evenly
spaced stitches until you reach the apex of
the vessel.
continued over....
Figure 28b
Inspect the lumen of the artery using one or

more of the atraumatic techniques described
above.
open surgery
31
...continued
At this point, secure the apical thread in a
rubber shod haemostat and begin stitching
with your first placed suture (Figure 30).
When the sutures come close at the apex,
the last thread can be left loose to facilitate
suturing under direct vision as much as
possible.
outside through the apex of your arteriotomy

(Figure 31). Tie the suture and anchor one
end in a rubber shod haemostat.
Figure 31
Figure 30
Take the free end of the suture and work

down the far side of the arteriotomy. Insert
continuous stitches using fine bites while
holding the redundant portion of the patch
with your forceps (Figure 32). It is inadvisable
to suture both vein patch and arterial walls
with a single traverse of the needle unless
you are experienced. Suture the two walls
separately.
Tie the knot at the apex of the vessel after

flushing inflow and outflow vessels to get rid
of air and thrombus.
Vein patch graft
A vein patch is the safest way to close an
arteriotomy if there is the slightest suspicion that
direct closure will produce narrowing.
Exercise
Make an elliptical arteriotomy about 3cm long
in the vessel provided. Then cut one end of an
elliptical patch in the simulated vein patch or
prosthetic material provided. Leave the other
end of the patch long and unshaped at this
stage. The redundant portion can be used
to handle the patch without damaging intima
which will be in contact with flowing blood in
vivo.
Using a 5/0 prolene suture, insert an initial
stitch from outside to inside at the shaped
end of the patch and then pass it inside to
32
basic surgical skills open surgery
Figure 32
When you near the heel of the arteriotomy,

cut the patch to length transversely and then
shape into an ellipse. Continue around the
apex and place two or three sutures along the
proximal wall.
Now move back to your original suture and
continue along the proximal wall until you
meet the original suture. Flush inflow and
outflow vessel before tying the two sutures at
this point.
At the end of the procedure cut out the
anastomosis and observe from within the
lumen. There should be no roughness and no
irregularity or inversion of the suture line.
MODULE TWO: trauma and orthopaedics
The orthopaedic module is designed to help

you understand the principles of handling bone
and soft tissues, such as muscle, tendons and
contaminated tissues. The exercises have been
chosen to give you hands on experience of
handling these tissues. Participants will be
expected to discuss with the faculty, patient
care before, during and after the procedure
being simulated. After each exercise the clinical
relevance will be discussed and the results
compared.
The first exercise is to debride a simulated
contaminated wound. Attention should be paid
to the vital structures injured and the extent of
dead tissue removal. The importance of after care
should be emphasised.
The second exercise is a flexor tendon
repair in a pigs trotter. This simulates the
human arrangement of the finger flexors at
approximately twice the size. The exercise brings
home the importance of understanding the
anatomy of the tendon and the relevance of this
to the strength of the repair.
There will be a brief discussion of fracture
management. This leads onto a discussion of the
fixation of fractures. Application of a complete
cast and the safe removal of plasters will also be
taught. The session is completed with a discussion
of the pitfalls of plaster applications. Plaster
application is a skill that all doctors should
posses and most participants find this messy
exercise a pleasant end to the day.

The primary care of a contaminated wound is
pivotal in the subsequent healing. It is frequently
undertaken imperfectly. Secondary procedures,
once inflammation and scarring have
established, may result in chronic disability. Six
components to traumatic wound management
are to be considered:
wound toilet and irrigation;
inspection of the wound;
deep palpation of the wound;
excision of dead or contaminated tissue;
establishment of adequate drainage; and
dressing of the wound for later inspection.
Drainage and debridement
Exercise
You will be supplied with a leg of either
lamb or a large turkey in which a simulated
traumatic and contaminated wound is shown.
Clean the wound with water. Normal irrigant
and antiseptics are water bound rather than
spirit bound in dealing with open tissues.
Cleansing should be done by both irrigation
and using a swab. It is conventional to paint
the contaminated wound from the centre
working outwards.
Initial inspection permits removal of gross
contaminants and foreign material. The
wound will have simulated glass or pebbles
imbedded within it. It is essential that all
of these are removed. You will subsequently
be told by your tutor how may pieces of
simulated glass were in your wound.
Following the initial inspection, a methodical
detailed examination is required using forceps
and retraction. Work methodically, for example
clockwise, so that no component of the
wound is left unexamined. Look out for
and identify any structured anatomy including
nerves, vessels and tendons. You may be
asked to demonstrate these.
33
Palpation will reveal tracts which might

otherwise be overlooked. This should again
be undertaken methodically and is a further
opportunity to know every aspect of the
wound. Foreign material will be felt by
fingertip. Where a large overhang is present,
it is wise to extend the wound to permit
adequate toilet.
Excise all dead tissue, cutting back to healthy
muscle. There is an appropriate amount of
excision to be undertaken, but too little is
worse than too much. Open up all cavities.
This type of wound must not be under tension.
Any cavity or sump must be adequately
drained and when this cannot be provided
by a drain through the existing wound, it
may justify the use of a dependent drain. A
corrugated drain is provided to be inserted
into the most dependent cavity, applying the
principles of drain usage. Employing artery
forceps, identify the depth of a deep tract
in the wound and pass the forceps from the
base to the skin or surface and the snout of
the forceps are presented to the surface. A
corrugated drain which has been profiled by
scissors is drawn back into the wound to
rest through the line of penetration of the
forceps. The drain should be sutured by a
loose stitch into the skin and a safety pin
applied to prevent it dropping into the wound.
Wash the wound once finally with antiseptic,
and place a loose pack (swab) soaked in
antiseptic, such as acraflavine, into the wound
and its cavities. (For the exercise use water).
It is permissible to use one loose suture in
order to keep the pack in place but under no
circumstances should any attempt be made
to close this type of wound. It is vital to have
minimal tension and this will be checked by
your tutor. This type of wound will be reinspected at 4896 hours post surgery when
further excision and possibly skin grafting may
be appropriate.
tension of the sutures will leave voids and cause

failure of the repair. This will be tested by
distracting the repaired ends.
Tendon repair
Exercise
The pigs fore trotter includes a human-like
arrangement of the superficialis and
profundus tendons. Display a main profundus
tendon and cut it transversely with scissors.
Handle the tendon at all times with the tip
of a hypodermic needle and not with forceps,
which may cause crushing. If necessary, trim
the tendon ends until they are square and
neat (Figure 33). Preserve length as far as
possible.
Figure 33
Refer to the diagram for installing a Kessler

suture (Figure 34). The tendon is usually bean
shaped in cross-section. Using 4/0 Ethiflex,
install the sutures in the proximal tendon end
first starting at the cut end. The entry suture
should pass through the middle of one half
of the sectioned tendon and follow parallel
with the collagen fibres to 1.5cm, or twice the
diameter of the tendon, and then exit.
Handling tendons
Tendon surgery, particularly in the flexor tendon
sheath in the hand, demands high surgical
expertise and is beyond the remit of surgeons at
SHO level. Rehearsing the technique however
is of considerable value in developing surgical
competence. Crushing or other forms of surgical
trauma will provoke fibrous tissue reaction
and lead to tenodesis. Improper or inadequate
34
Figure 34
The transverse component of the suture now

passes a loop back just distal to the exit point
and through the central half of the tendon.
The reciprocal longitudinal suture pass is now
made, exiting accurately in the middle of
the second tendon half. Repeated misjudged
needle placement is poor technique. Do not
snug up the sutures at this stage, unless
adequate length of suture material is available
for the reciprocal insertion of the suture
design into the distal end of the tendon.
Repeat the procedure into the distal end,
having checked carefully the orientation of the
tendon so that it will match the proximal end
when the suture is tightened. Having placed
the sutures in a satisfactory position, reduce
the tendon accurately using the hypodermic
needles and transfix in the reduced position.
Methodically tighten the suture using the
same sequence as was employed in insertion
which will then leave the tail and needle end
of the suture to be tied and triple knotted so
that the knot is buried within the cut tendon
end (Figure 35).
Principles of fracture fixation

A fracture may be undisplaced, displaced into
a position which is acceptable for adequate
functional restoration or displaced into an
inadequate position. Displacement must take in
to account:
shortening;
angulation; and
rotation.
A simple transverse fracture in which a
periosteal or soft tissue hinge is present will
not reduce by simple traction if displaced
(Figure 37). It is necessary to exaggerate the
original deformity so that the tension is taken off
the periosteal hinge and the fracture slid into its
position. Three-point fixation is then adequate to
keep it reduced (Figure 38).
Figure 37
Figure 35
Remove the transfixing hypodermic needles

and apply tension to the tendon to ensure
that the suture is performing adequately.
If separation occurs the suture must be
repeated.
Insert the running stitch using 4/0 Nylon
(Figure 36). Insert the needle into the
paratenon approximately 2mm away from
the cut edge. Do not over-tighten. Each
bight of the running suture should be at a
separation of approximately 2mm. Rotate the
tendon using the hypodermic needles until the
complete running suture is in position. Tie off
to the original starting suture at the end using
a triple throw knot.
Figure 38
A spiral fracture is caused by rotation so

that traction alone may not achieve reduction
(Figure 39). Understanding the mechanism of
rotation and reversing is necessary.
Figure 39
Figure 36
35
Short oblique fractures are usually caused

by indirect force to the bone and are reduced
relatively easily by traction but cannot be
adequately stabilised with external splintage
(Figure 40).
layers must provide adequate strength without

being unnecessarily cumbersome. Incorrect
immersion in water will leave the plaster
unsatisfactory to work, with weak spots. The
reaction is rapid. A well-planned technique is
necessary to ensure the optimal position for
curing and crystal formation. The plaster may
be a simple slab, a full plaster, or full and split.
A complete plaster exposes the patient to the
potential hazard of venous tamponade leading to
Volkmanns ischaemia.
Back-slab
Figure 40
Comminuted fractures involve more than

two simple pieces and generally are unstable
(Figure 41).
Figure 41
These principles will be demonstrated by

your tutor using both x-rays and wooden
models comprising fracture types with a leather
simulated periosteal flap applied. Make sure that
you handle the models and become familiar with
the principles of reduction.
Plastering technique
Plaster bandage is widely used for the splintage
of fractures and immobilisation of joints and
limbs to protect them while healing is occurring.
The technique of plaster usage is applicable to
general surgery, plastic surgery and orthopaedic
surgery. Modern plaster bandage comprises
anhydrous calcium sulphate which, when mixed
with water, causes an exothermic rehydration to
the crystalline form known as gypsum. Planning
a plaster is dependent upon a particular
application. It may require immobilisation of the
joints above and below a mid-shaft fracture and
careful selection of a limb position. The bandage
36
This procedure will be demonstrated but not

actually performed during the course. The
actual plastering exercise will be restricted to
performing a full forearm plaster.
When applying a back-slab there should be
minimal ulna deviation and, assuming the
treatment is for a Colles type extension injury,
approximately 10 degrees of palmar flexion is
appropriate.
A stockinette is prepared with a hole to permit
the thumb to pass through. It should extend
distally up to the metacarpophalangeal joints
and proximally up to the elbow.
The appropriate width of undercast padding
should be applied. This should be not more
than 10cm and run from the metacarpal
heads, covering 50% overlap. Avoid
bunching, particularly around the thumb,
which is more easily dealt with by making
a hole in the padding. Having completed
the application of padding, ensure that there
are no lumps and a consistent thickness is
obtained.
Six layers of plaster bandage of 15cm
or 20cm width should be used. The slab
should be of appropriate length and cut
to accommodate the thumb and retain
thumb movement (Figure 42). It should pass
obliquely across the metacarpal heads as in
the diagram (Figure 43) and proximally extend
to within 4.5cm of the antecubital fossa to
permit bending of the elbow.
Figure 42
Full plaster
Figure 43
Dip the plaster in cold or slightly warm water

retaining the two ends in your hand. Remove
it, squeeze it lightly and then place it on
the forearm to match the pre-prepared cuts
for thumb and metacarpal heads. Stretch it
longitudinally and pass the volar component
carefully and smoothly under the flexor tendon
region at the wrist. Now retain the plaster on
the forearm using a cotton or crepe bandage
pre-dipped in water, making sure that the
bandage is applied smoothly.
Mould the plaster as in the diagram using the
flat of the hands so that three-point fixation
is achieved (Figure 44). The shape of the
plaster around the wrist is crucial in retaining
position and should match the arrangements
of the bone which are oval and not round
(Figure 45). Make sure that no movement
occurs until adequate setting of the plaster
has been confirmed. The plaster will not be
fully dry from surplus water until 24 hours
after application, at which point it will have
achieved full strength.
Exercise
You will be required to apply a below elbow
cast on your partner and to split the cast.
Your partner will then have the opportunity to
reciprocate on you.
All the equipment must be gathered before
you start.
Apply the stockinette only if there is
no likelihood of swelling. The stockinette
can cause constriction and, when cut
through, may crease, thereby causing
pressure. Having decided to apply the
stockinette it needs to be measured distally
up to the metacarpophalangeal joints and
proximally up to the elbow allowing a bit extra.
Cut a hole for the thumb, roll and apply to
the limb.
It is important to position the limb before
you apply the padding. Maintain the position
throughout until the cast is completely set,
as movement equals ridges in the cast. The
position will vary according to the injury.
Open the bandages and keep them away
from the water until you are ready to use them.
In this case two 10cm POP bandages are
required, with a spare on the trolley.
Prominent bony areas, such as the ulnar
styloid, may require protecting with felt
(Figure 46). A single layer of 10cm undercast
padding should be applied smoothly, making
a hole for the thumb (Figure 47). As you break
the padding, hold the wrist firmly so that the
patient doesnt suffer discomfort or movement
at the fracture site.
Figure 44
Figure 46
continued over...
Figure 45
37
... continued
Figure 47
Soak the bandage in lukewarm water

(2025C) according to the manufacturers
instructions. Cold water retards and hot water
quickens the setting process. Both extremes
are uncomfortable for the patient. Hold the
bandage at 45 degrees loosely in the palm
of the hand with the first few centimetres
unwound to make it easier to find the
end. Count three full seconds, remove and
squeeze very gently to take out the excess
water.
Bandaging commences at the elbow end of
the cast rolling the bandage from within out
(Figure 48). Roll the bandage on evenly and
without tension, covering about one-third of
the previous turn and allowing tucks to form
to accommodate the contours of the limb.
The bandage should be brought up through
the grip, gathering it together very gently
(Figure 49). It should not be pulled down
through the grip as this pulls the metacarpal
heads together. Three times through the grip
in total should be adequate; two with one
bandage and one with the other. The second
bandage is applied quickly before the first
bandage has set. Constant smoothing and
moulding is necessary to make the cast whole
and not a succession of layers. Moulding must
be done with the palms of the hands. Do not
use the fingers as this can cause dents in the
cast. Make sure the cast is moulded well into
the palm. This can be done with the thenar
eminence. Maintain the position until the cast
is completely set, otherwise ridges will form.
38
Figure 48
Figure 49
The limb needs to be rested on a pillow,

because the cast could easily be dented and
this might cause a sore. Trim the edges of the
cast to allow full movements of the joints not
held. The completed cast should extend from
4cm below the antecubital fossa to the heads
of the metacarpals (Figure 50) and show the
palmar crease (Figure 51). If stockinette has
been used it can be turned back over the
edge and secured in place with strips of
plaster of Paris afterwards. Be careful when
you apply the strips of plaster that you dont
go over the stockinette edge and thereby
create a sharp ridge.
Instructions to patients in casts

Contact the doctor or hospital immediately if
you experience any of the following:
The toes or fingers become blue or swollen
or you are unable to move the limb.
The limb becomes painful.
You feel pins and needles or numbness.
Any blister-like pain or rubbing under the
cast.
Discharge or wetness under the cast.
If you drop any object down inside the cast.
Care
Figure 50
Exercise the joints not held in the cast as

much as possible.
Do not let the limb hang down unless it
is being used, elevate the limb especially
during the first few days.
Allow the cast to dry naturally and leave it
uncovered for 48 hours.
Do not sit close to a fire.
Do not let the cast become wet.
If the cast becomes cracked, soft or loose,
return to the hospital.
I confirm that I have received a copy of
Instructions to patients in casts.
Name:
(capital letters please)
DOB:
Signed:
Date:
Figure 51
It is very important to give full verbal and

written instructions to a patient on the care
of the plaster and the prevention of possible
complications. Make sure the patient really
understands when they should urgently return
to hospital. (See example sheet on the right).
39
Splitting a cast
Using plaster shears
To split a cast to relieve circulatory or nerve

impairment, a single lengthways/longitudinal
cut is required for a plaster of Paris cast. If
the cast is a resin-based product, it may need
to be bivalved (cut in two halves) to relieve
pressure. The padding, stockinette and any
dressings must be cut right through to the
skin.
Bearing in mind the underlying injury and, if
possible, avoiding bony prominences, mark
the cast (Figure 52). This task can be
performed with either plaster shears or,
providing the cast is dry, an electric oscillating
cast cutter.
The blade of the shears should pass between

the plaster and the padding. Keep the blade
parallel with the limb. If the blade is tilted
either way the point or the heel will dig in or
nip the patient (Figure 53).
Figure 52
Figure 53
The hand nearest to the cast holds the blade

parallel and remains still. To cut the cast push
the shears together with the other hand.
40
Using the electric cast cutter

The saw has an oscillating circular blade
which rubs its way through the hard plaster. It
is relatively safe to use if handled correctly. It
must be used on dry, padded casts with the
blade held at right angles to the cast and a
straight cut made without dragging the saw
along the cast.
Cut with the saw using an in and out motion
holding the blade at right angles to the cast.
Beware, the saw blade can cut the skin or get
hot enough to create a burn if:
You drag the blade along the cast, instead of
the in and out motion.
The cast is bloodstained when the padding
and gauze becomes hard and the saw cuts
straight through.
There is the presence of swelling or oedema
and the skin has become taut and therefore
easy to cut with the saw.
There is prolonged use.
The cast material is thick.
The cast is very large.
The blade is blunt or damaged.
The padding is thin and the patient may feel
the heat even in normal use.
The cast is unpadded, in which case special
care is needed.
The cast is a resin-based material, where
more energy is required to cut through the
material and therefore heat is generated and
may burn the patient.
If the patient moves or complains, always
believe the patient, stop, reassess and
continue carefully.
Use the cast spreaders to separate the cast
and the bandage scissors to cut the padding
and any dressing down to the skin.
A strip of padding can be placed in the split
and a crepe bandage applied around the cast.
Bivalving
To remove a cast fully, it should be bivalved,
that is cut in two halves. Mark the cutting lines
down the medial and lateral sides avoiding
bony prominences and proceed as before
using either the shears or the saw.
41
MODULE THREE: minimal access surgery
Minimal access surgery (MAS) is performed

through small incisions in order to minimise
the trauma of the surgical wound. This module
of the course is about laparoscopy and, in
particular, therapeutic laparoscopy - a form of
MAS particularly challenging to the theatre
team. The main purpose of this module is to help
course participants acquire the skills they need
to perform laparoscopy efficiently and, above all,
safely.
What happens in theatre is only a relatively
brief part of the patients overall care. For the
patient, MAS begins with preoperative assessment
and counselling and ends only when there has
been a full recovery and return to normal
activities. Before turning to skills and safety, we
begin with an overview of minimal access surgery
and some of the ergonomics relating to its use.
Operations carried out using the minimal access

approach should have the same quality of their
conventional open counterpart. It should be
emphasised that the difference between minimal
access surgery and open surgery is the extent
of the access as indicated by the name of
the technique. Minimal access surgery must not
compromise patient safety. There are several
factors which influence the use of minimal
access surgery:
Safety of the access to body cavity
With previous abdominal surgery, there is
a risk of bowel injury owing to adhesions.
The technique and the site of induction of
pneumoperitoneum need to be modified in
patients with previous surgery. Laparoscopy is
contraindicated in patients with a history of
previous extensive abdominal surgery.
Adequacy of exposure
Optimum assessment using the minimal access
approach requires adequate space to expose
and handle different organs. With gross obesity,
the laparoscopic approach is more difficult
and technically demanding. In the presence of
bowel obstruction or organomegaly, the intraabdominal space is reduced and, therefore,
experience and caution are required. In certain
cases, laparoscopy may not be practical.
Task difficulty
The mechanical and imaging constraints in
minimal access surgery make laparoscopic
task performance more difficult than its open
counterpart. The individual surgeon has to
balance his or her own laparoscopic experience
42
against the operative task. While a surgeon may

be competent in carrying out bowel anastomosis
using an open approach, he or she may not be
able to perform laparoscopic bowel suturing.
Patient safety
Some patients require effective and quick
intervention as in the cases of uncontrolled
shock or faecal peritonitis. These patients
are not suitable for lengthy laparoscopic
procedures. The surgeon must be prepared to
convert to an open approach should he or she
encounter technical complications or experience
a lack of progress with the procedure. This
should not be regarded as a sign of failure.
All patients undergoing laparoscopic surgery
should be warned of the risks of converting to
an open procedure. For example, the standard
conversion rate for elective cholecystectomy is
about 5% and all patients should be warned of
this possibility.
Constraints in minimal access

surgery
The minimal access approach creates a set
of mechanical and visual restrictions on the
execution of surgical tasks. Some of these are
considered below.
1. Mechanical restrictions
These are the restrictions encountered on
handling the tissues by endoscopic instruments
(Table 1).
Table 1. Constraints in minimal access surgery
Mechanical restrictions
Limited degrees of freedom of instrument
movement.
Diminished tactile feedback.
Small and long instruments.
Problems of organ retrieval.
Visual limitations
Two-dimensional imaging.
Reduced field of endoscopic vision.
De-coupling of motor and visual spaces
(monitor location).
Endoscope-instrument-tissue spatial relation
(port location).
Quality of video-endoscopic system
(resolution, illumination and chroma).
Standard endoscopic instruments have four

degrees of freedom of movement. A degree
of freedom is the potential for movement in
a single independent direction, or a rotation
around one axis. In contrast to the 4 of
freedom in minimal access surgery, there
are more than 36 of freedom of the bodyarm-fingertips movement in open surgery.
This limited number of degrees of freedom
makes handling of tissues in laparoscopic
procedures more difficult than during
conventional open surgery.
In minimal access surgery, direct tactile
feedback (hand to tissue) is lost and
the indirect tactile feedback (through the
instrument) is markedly diminished owing to
the length of endoscopic instruments and
the friction between the instruments and the
ports. This degrades the ability of the surgeon
to identify the nature of component tissues
and tissue planes. It can also lead to tissue
damage from excessive instrument grip, which
can be poorly appreciated by the surgeon.
The small size of endoscopic ports dictates
the size of endoscopic instruments. This
causes several difficulties in the design of
endoscopic instruments to perform the same
function as their open counterparts. Long
thin instruments have a poor mechanical
advantage. The length of endoscopic
instruments exaggerates hand tremors,
especially in a magnified endoscopic field.
minimal access surgery
43
Another intrinsic problem in minimal access

surgery is tissue retrieval after detachment
from adjacent tissues. This problem has two
aspects: (i) the tissue must be reduced to
the size of access wounds with preservation
of tissue architecture and (ii) the risk of
contamination including spillage of cancer
cells must be eliminated.
2. Visual limitations
The use of an image display system as the visual
interface between the surgeon and the operative
field has several visual limitations compared
to conventional open surgery (Table 1). The
limitations of current image display systems are
responsible for the degraded task performance
in minimal access surgery compared to direct
normal vision.
Standard monitors in current use in surgical
practice are two-dimensional imaging
systems. They present only two-dimensional
depth (pictorial) cues of the operative field
to the surgeon. For controlled endoscopic
manipulations, the surgeon has to reconstruct
a three-dimensional picture from a twodimensional image. This entails intense
perceptual and mental processing which has
to be sustained by the surgeon throughout
the operation.
Reduced field of endoscopic vision compared
to ordinary unrestricted sight results in a
decrease of the sensory input from the
periphery of the operative field. The field of
view describes the area inspected by the
endoscope. At a given distance from the
objective lens, the larger the field of
view, the greater the area that can be
observed. Restricted field of endoscopic
vision accounts for the incidental tissue injury
when instruments move outside the field of
view. All instruments should be moved within
the abdomen under direct vision to avoid
accidental injury.
The current layout of operating theatres with
crowding of free-standing equipment often
precludes optimal placement of the viewing
monitor in front of the surgeon who usually
operates from one or other side of the patient.
In consequence, the visual axis between the
surgeons eyes and the monitor is no longer
aligned with the hands and instruments.
44
Furthermore, the monitor is often far removed

from the surgeon and thus the spatial location
of the display system (sensory information) is
remote from the manipulation area at the hand
level of the operator (motor space). These
factors degrade task performance in minimal
access surgery.
The position of the instrument ports in relation
to each other and to the optical port is
an important determinant of the ease of
performance of an endoscopic procedure and
its execution time.
There are three major components that
determine the quality of the image: resolution,
luminance and chroma. Resolution determines
the clarity of the image; luminance measures
the amount of light available in the image
signal and the chroma represents the intensity
or saturation of the colour. In addition
to the quality of the monitor, the final
image produced by the endoscopic system
depends on the optical characteristics of the
endoscope and quality of the camera.
Ergonomics of the set-up in minimal
access surgery
For a particular operation, the surgeon has to
select the appropriate endoscope and place
the ports and the monitor in optimum locations.
The principles of the set-up of endoscopic
equipment are summarised in Table 2.
Table 2. Ergonomics of set-up
Endoscope selection
Optical axis-to-target angle of 90.
Visual field changes on rotation of obliqueviewing endoscope.
Port placement
Manipulation angle of 60.
Equal azimuth angle.
Narrow manipulation angle necessitates
narrow elevation angle.
Intra:extra corporeal shaft ratio below 1.0
degrades performance.
Endoscope and instrument aligned in the
same direction.
Monitor location
In front of the surgeon.
At the level of the workspace.
Endoscope selection
Direction of view of the endoscope describes
the angle between the centre of the visual
field (optical axis) and the physical axis of the
endoscope. Endoscopes can be of forward
viewing (0) or forward oblique direction of view
(30, 45). The angle between the optical axis
of the endoscope and the plane of the target
is referred to as the optical axis-to-target view
angle (Figure 54).
manipulation angle (1), Azimuth angle (2),

elevation angle (3)
optical axis
30 endoscope
1
2
physical axis
optical axis
horizontal plane
30
optical axis-to-target view angle
Figure 55. Angles govern port location
target surface
Figure 54
The best task performance during endoscopic

work is obtained when the optical axis-to-target
view angle approaches 90 and the decrease
in this viewing angle causes a significant
degradation of task performance. In practice,
however, only oblique viewing endoscopes or
ones with flexible tips can achieve an adequate
optical axis-to-target view angle approximating
to 90. For this reason, forward oblique
endoscopes are preferable, despite the easier
deployment of forward viewing types.
Port placement
For bimanual tasks, manipulation, azimuth and
elevation angles govern optimal port sites
(Figure 55). The manipulation angle is the angle
between the active and assisting instruments,
while the azimuth angle describes the angle
between either instrument and the optical axis
of the endoscope. The elevation angle of the
instrument is defined as the angle between
the instrument and the horizontal plane. These
angles determine optimal port location.
The maximal efficiency and quality

performance of intracorporeal knotting are
obtained with a manipulation angle ranging
between 45 and 75 with the ideal angle being
60. A better task efficiency is achieved with
an equal azimuth angle on either side of the
optical port. In practice, equal azimuth angles
may be difficult to achieve but wide azimuth
inequality should be avoided since this degrades
task efficiency. When a 30 manipulation angle
is imposed by the anatomy or build of the
patient, the elevation angle should also be
30 as this combination enables the shortest
execution time and allows an acceptable level of
performance. Likewise with a 60 manipulation
angle, the corresponding optimal elevation
angle, which yields the shortest execution time
and an optimal quality of performance, is 60.
Thus within the range of angles that ensure
adequate task efficiency, a good rule of thumb is
that the elevation angle should be equal to the
manipulation angle.
On planning port location, an adequate
intracorporeal instrument length should be
obtained. This depends on the size of the
patient and the site of the operation. The
intra:extra corporeal shaft ratio for optimal task
performance is 2:1.
45
The ports for instruments (active and

assisting) and the endoscope should be
inserted so that the instrument and endoscope
should be aligned in the same direction.
The surgeon must avoid operating against
the endoscope/camera as this produces a
mirror image and makes manipulations extremely
difficult.
Monitor location
The best task performance is obtained with the
monitor located in front of the operator at the
level of the manipulation workspace (hands),
permitting gaze-down viewing and alignment of
the visual and motor axis. Gaze-down viewing
by the endoscopic operator allows both sensory
signals and motor control to have a close spatial
location and thus brings the visual signals in
correspondence with instrument manipulations,
similar to the situation encountered during
conventional open surgery. In practice, the
location of the monitor is determined by the
site of the operation. For upper abdominal
procedures, such as cholecystectomy and
fundoplication, the monitor is placed near the
patients head. During appendicectomy, the
monitor is located over the right iliac fossa
and the surgeon stands on the left side near
the patients hypochondrium. Members of the
operative team should look at the monitor
placed in front and must avoid following the
procedure on the side monitor.
Principles of camera operation
The operation of the camera is crucial to surgical
manipulations. Operating the endoscope and
camera is a dynamic process throughout
the surgical procedure. The camera operator
actively takes part in the operation, and at times
it can be quite hard work!
Maintaining the task in the centre of the
endoscopic field
The centre of the endoscopic field has the
best illumination and least image distortion.
This provides the surgeon with the optimum
image quality. The best performance therefore,
is obtained with the task maintained in the
centre of the endoscopic field. In addition, if
the surgeon works at the periphery of the
field, instrument movement may accidentally
occur outside the displayed image, potentially
damaging adjacent structures.
46
Adjusting the size of the visual field and

image details
The distance between the endoscope and the
target determines the size of the visual field and
the resolution at the target area. The smaller
the endoscope-to-target distance, the smaller
the size of the visual field and the higher
the resolution at the target. Withdrawal of the
endoscope increases the area of the operative
field viewed by the surgeon. The surgeon needs
this view to insert endoscopic instruments or to
perform a task which requires a large area for
manipulation such as knot tying. On the other
hand, advancing the endoscope towards the
target increases the detail of the image viewed
by the surgeon at the expense of a smaller
operative field. The surgeon prefers this view to
perform detailed tasks, such as dissection and
picking up a thread.
The laparoscopic stack

As a member of the laparoscopic theatre team
you need to know what equipment is needed
and how to set it up and use it safely.
Important basic items of equipment for
laparoscopic surgery include:
rapid-flow insufflator;
light source;
video camera and camera cable;
laparoscopes;
monitors;
electrosurgical unit; and
suction/irrigation.
Rapid-flow insufflator
The insufflator supplies carbon dioxide (CO2)
to create and maintain the pneumoperitoneum.
It is recommended that the intra-abdominal
pressure should not rise above 1214mmHg,
to avoid compression of the IVC, with
resultant decreased cardiac return (see section
on pathophysiology of carbon dioxide
pneumoperitoneum on page 53).
Key features
Indicates the intra-abdominal gas pressure.
Stops the flow when a certain pre-set
pressure has been reached (usually
12mmHg).
Has an alarm to indicate excessive pressure.
Indicates the rate of flow of CO2 into the

abdomen.
Records the total volume of gas delivered.
Light source and cable
A powerful high-intensity light source is
necessary to give a clear view of the abdominal
cavity. A light source with 150300w xenon
or halogen lamp and automatic intensity control
will give continuous optimal illumination. The
appropriate liquid light or fibre optic light cable
is also essential.
Key features
Automatic light control adjusts light intensity
to give optimum illumination, reducing glare
from bright surfaces as the endoscope moves
within the peritoneal cavity.
In some systems light output and lamp life is
continually monitored and displayed to reduce
interruptions of the surgical procedure owing
to lamp failure.
All systems have an internal cooling system
that help to extend the life of the lamp.
The brightness of a high intensity light source
may cause retinal damage if shined directly
into the eye. This can happen if the shutter
is opened without the light cable in place
or if the light cable and laparoscope are not
carefully handled.
The instrument ends of some light cables
become very hot during use and can burn
the patient or staff if disconnected from the
laparoscope. The temperature at the end of
the laparoscope is 95C and at the end of the
light cable as high as 225C. The light should
be on its lowest setting or switched off unless
the laparoscope is in use.
Video camera and camera cable
The camera may be single chip or three-chip.
Single-chip cameras process the three primary
colours, red, blue and green, while three-chip
cameras have a chip for each of the three
primary colours and therefore give a better
definition, especially with red.
The camera head is an optical/electronic
interface which is attached to the laparoscope.
A standard eye-piece laparoscope requires a
coupler to connect to the camera head. A video
laparoscope has a camera attached directly to

the lens system.
Key features
Camera head is lightweight, comfortable to
hold and easy to move and manipulate.
White or colour balance adjustment allows
accurate colour reproduction. Some cameras
do this automatically.
Laparoscopes are available with a distal chip
camera and a light guide and video lead in
one cable.
Adjustments for variations in light intensity
maintain a constant light, usually by an
automatic iris.
An override or gain exists to improve
exposure if necessary.
Some camera heads have accessory buttons
to control light sensitivity as well as the printer
and the VCR function.
Camera etiquette
The camera operator is the eyes of the
team and should be ready to move where
requested by the operating surgeon.
It is the job of the camera operator to keep
the operative field in the centre of the monitor
screen.
Jerky movements hinder precise surgery.
The camera is marked to help orientation. The
marks differ between manufacturers.
Ensure that the camera is focused to give a
sharp picture at the start of the procedure by
focusing on an object outside the patient.
Instruments out of view are a potential danger
to the patient, especially if they are attached
to the diathermy machine.
The camera operator has an important role
during port insertion, guiding the surgeon
and minimising the risk of damage to intraabdominal organs
Laparoscopes
A standard laparoscope uses a rigid rod lens
system to transmit the image from within
the abdominal cavity. The operating field is
illuminated by light conducted through a fibreoptic illumination bundle, alongside the lens
system.
47
Key features
Laparoscopes are usually 10mm or 5mm in
diameter, with 0 or 30 field of view.
10mm 30 is most commonly used now.
Standard mount for attaching the camera.
Separate attachment for the light cable unless
it is a distal chip camera instrument.
Using the laparoscope
Make sure that the telescope is undamaged
before starting the operation. Defects at either
end can distort the image and broken fibres
reduce light transmission.
Warm the telescope to body temperature
before insertion to minimise fogging of the
distal lens. Anti-fog chemicals can also be
useful.
Thoroughly wipe the eyepiece dry to prevent
moisture in the space between it and the
camera.
The CO2 inflow is cold and preferably should
not go down the same port as the camera.
If a small film of blood adheres to the
objective lens, remove the laparoscope and
wipe the lens clean when the surgeon
requests it. Never clean the laparoscope with
anything abrasive. Surgical spirit, warm saline
and special solutions of anti-fog will break
down grease.
Suction/irrigation
Suction and irrigation is usually necessary. This
can be carried out by a suction unit and a
pressure bag for the irrigation fluid. Alternatively,
the surgeon may prefer to use a suction/
irrigation pump. Some surgeons add heparin
to the irrigation fluid to discourage blood
clotting (eg 1,000 units of heparin to 500ml of
Hartmanns solution).
Theatre set-up
The positioning of all equipment must be
carefully planned. Exact placement will vary
depending on the procedure to be performed,
the surgeons preference and the size of the
theatre. However, some generalisations can be
made.
The monitors should be positioned on
either side of the patient to provide a clear
unobstructed view for surgeon and assistant.
Ideally, the screen should be positioned directly
in the surgeons line of sight (Figure 56).
Monitors
A high-resolution colour television monitor is
necessary with at least an equal-line resolution
to that of the camera. The monitor should be
at least 13 in size, ideally 20, depending
on the distance from the screen the surgeon
is working. The ideal distance between the
surgeon and the monitor should be four to five
times the diagonal measurement of the screen.
A second monitor is preferable to give both
surgeon and assistants a clear and comfortable
view of the procedure.
Controls on the monitor allow adjustment of
the image if necessary. However, fiddling with
the controls should be discouraged.
Other accessories
A video cassette recorder and/or video printer
may also be required for teaching purposes and
documentation of procedures.
48
Figure 56
The insufflator should be within view of the

surgeon so that he or she can always monitor
the abdominal pressure.
Instrument trolleys, diathermy, suction/
irrigation, etc, should be positioned to allow the
surgeon mobility and to give theatre staff access
to equipment.
Leads and cables should be positioned so
that when connected, they do not become
tangled or restrict the surgeons movements.
Take care not to damage an expensive cable
with a carelessly applied sharp towel clip!
Picture interference will also be minimised
if the diathermy machine is positioned away
from the camera/monitors and if the diathermy

instrument is not close to the camera head when
in use. The diathermy and video leads should
also be kept apart.
Safety note: specialised storage trolleys with a
single power cable leave fewer trailing wires as
hazards for theatre staff.
The diathermy power cable should be connected
into a different socket and preferably a different
electrical circuit from the imaging equipment, to
reduce picture interference.
Do not fix more than one diathermy cable.
Remember that all attached electrodes become
active when the footswitch is pressed.
Positioning
Positioning of the patient is dependent on
the procedure and the access needed to
perform the operation. The patient may need
to be in a modified Lloyd-Davis position,
eg for laparoscopic Nissens fundoplication,
laparoscopic colectomy and laparoscopic
gynaecological procedures.
During laparoscopic cholecystectomy a
cholangiogram may be needed. Check to ensure
the patient is on an x-ray lucent table.
For some procedures, eg laparoscopic hernia
repair, the surgeon may not want the patients
arms on the chest (for venous access for the
anaesthetist) as this may restrict the camera
position.
Always make sure that the patient is properly
secured to the table. A steep tilt may be needed
in some advanced procedures.
Exercise
Familiarise yourself with the various
components of the system including: the
insufflator, the light source, the camera and
the cable, the laparoscope, the fibre-optic
cable, the monitor, the suction and irrigation
unit and the principle of white balance.
Safe induction and maintenance of

the pneumoperitoneum
Preliminaries
For surgery in the pelvis it is sensible to drain
the bladder with a urinary catheter. For upper
abdominal surgery a nasogastric tube may be
inserted to empty the stomach to make space
and prevent accidental visceral perforation. Both
can usually be removed at the end of the
procedure.
Positioning
The patient is placed supine or in a modified
lithotomy position. A diathermy pad is attached
to the thigh and the diathermy machine settings
checked. The patient is then draped widely to
expose the entire abdominal wall, which has
been prepared with antiseptic solution.
At this point the surgeon should check the
following:
Preoperative checks
Patient check
Patient position
Palpate for masses or organomegaly
Diathermy machine
Diathermy plate
Suction and irrigation
Insufflator
Telescope, camera and video
Insufflator tubing
Instruments
Penetrating the intact abdominal wall to
induce the pneumoperitoneum and insert the
first port is probably the most hazardous part of
a routine laparoscopic operation. If this is not
done with care and skill there is a danger of
injury to underlying viscera such as bowel and
bladder. Even deeper structures like the aorta,
iliac vessels and vena cava have been speared
by the inept and unwary. Once the first port is
in place and the pneumoperitoneum has been
induced, the surgeon can insert a laparoscope
and work with the abdominal contents safely in
view.
There are two main methods, the open and the
closed methods. Each has its fervent advocates
who say they only use one method. The open
method is safest and is increasingly being
accepted as best practice. Many surgeons
prefer to have both methods available for use
when appropriate.
49
Open method of inserting the first port

(See Figure 57.) Open laparoscopy is favoured
for all cases by many surgeons who prefer not to
insert a sharp instrument where they cannot see.
Open access is recommended to all surgeons
where there are scars in the abdominal wall
close to the site of insertion of the laparoscope.
A 12cm intraumbilical incision is deepened
down to the linea alba which is incised between
stay sutures. The peritoneum is exposed and an
incision made into it under vision. A finger may
then be inserted to sweep away adhesions. A
blunt-tipped trocar is then inserted which will not
penetrate structures attached to nearby scars. A
supraumbilical incision may be preferable for the
obese patient.
Alternatively, the laparoscope and port can
be introduced together so that insertion can
be controlled endoscopically. A disposable port
and cutter instrument for insertion under visual
control is available.
Insufflation through the port begins once it is
safely in the peritoneal cavity. A purse string
suture around the port may help minimise gas
leakage.
The open insertion method is very safe but
there is a possibility of increased gas leakage
around instruments passed through the incision.
Proprietary trocars with occlusive balloons to
make a seal round the instrument may help.
Figure 57
Exercise
In the simulator provided, place a mark to
represent the umbilicus.
Make a 12cm umbilical incision and deepen
to a level representing the linea alba (this may
be marked with a red felt-tip pen for clarity).
Insert a stay suture to both edges.
Deepen the incision to reach peritoneum and
incise through into the peritoneal cavity. Insert
a finger to ensure that there are no adhesions.
Different types of port may be available for
you to examine and practise with. Insert
one such port with a blunt trocar into the
peritoneal cavity and use the stay sutures to
secure the cannula. A purse string suture may
be inserted instead of the stay sutures and
this may help prevent gas leakage.
There are a series of commercially available
cannulae that try to seal the wound and
prevent gas leakage.
50
Closed method of creating

pneumoperitoneum
This technique is not as safe as the open
method and therefore is not encouraged.
However, many laparoscopic surgeons still use
this technique and the safety issues regarding
its use are covered in this course.
Usually an intraumbilical incision is used
but for the very obese, for some advanced
upper abdominal procedures and where there
are pre-existing abdominal wall scars, other
access points may be used, such as the left
hypochondrium. For simplicity, only the umbilical
approach will be detailed here.
The Verres needle
The Verres needle is a hollow needle with a
spring loaded blunt central core. At the proximal
end is a Luer port closed by a tap.
The tap and spring mechanism of the Verres
needle should be checked and its patency
tested by attaching it to the insufflator and
running gas through at 1 litre per minute.
Inserting the Verres needle
Prior to making an incision a nasogastric tube
is usually placed to decompress the stomach
and a urinary catheter passed (or ensure that
the patient has voided urine immediately prior
to theatre), so that neither the stomach nor the
bladder can be damaged by the Verres needle.
Usually a vertical or transverse incision is
made deep inside the inferior aspect of the
umbilicus. It overlies the area where skin, deep
fascia and parietal peritoneum meet at the
thinnest point in the abdominal wall. In this
position, the needle has the least chance
of tenting the peritoneum to leaving its tip
in the space between the posterior rectus
sheath and the peritoneum. Gas accidentally
insufflated more superficially will cause surgical
emphysema of the anterior abdominal wall.
This is a common error for the novice, but
merely a nuisance, as opposed to the more
dangerous error of too forceful an insertion.
The patient is placed in a Trendelenberg
position of 2030. The anterior abdominal wall
is lifted up by the surgeon and assistant on
either side of the umbilicus to create negative
pressure within the abdominal cavity.
A Verres needle is then inserted, initially
perpendicular to the abdominal wall, and
advanced until it penetrates the linea alba and

peritoneum. When it does this, there is usually
a distinct give as the point enters the cavity.
It is now that damage to underlying structures
can occur. The needle is advanced under careful
control, held in the sensitive pinch grip between
forefinger and thumb, like a pen or a dart, to feel
the way through the layers.
The sacral promontory with its overlying great
vessels rises remarkably closely beneath the
umbilicus, especially in a thin patient. As soon
as the needle is through the abdominal wall, it is
then aimed towards the pelvic cavity. The central
spring-loaded core of the Verres needle should
advance when the sharp tip of the needle is
lying free within the peritoneal cavity (but do
not rely on it). The needle is inserted with the
tap open so that the negative intra-abdominal
pressure caused by lifting the abdominal wall
allows some air to enter so that the abdominal
contents fall away from the point of puncture.
Step by step
Check and test Verres needle.
Incise umbilicus.
Trendelenberg.
Lift abdominal wall.
Open tap of Verres needle.
Insert perpendicular to abdominal wall.
On entering abdominal cavity, aim needle
towards sacrum.
Checking the needle position
Once through the peritoneum the needle should
move freely from side to side. There are a
number of tests to confirm that the tip of the
needle is free in the peritoneal cavity.
The drop test
A drop of saline dropped into the open Luer
fitting of the Verres needle should fall from sight.
Saline injection
A small amount of normal saline is injected into
the needle. It should flow in without difficulty.
Drawing back should draw air or clear fluid
into the syringe and not bile, blood or bowel
contents.
51
Test insufflation
Slow insufflation at 1 litre per minute produces
little rise in the pressure reading if the needle is
in the right place.
Occasionally the Verres needle is blocked by
a plug of fat. This can sometimes be freed by
gently rotating and moving the tip from side to
side.
Insufflation
Insufflation can begin once it is certain that
the needle is correctly placed. The controls of
the insufflator are turned to automatic to deliver
a faster flow of gas. The pressure reading is
constantly monitored.
The abdominal wall should be percussed at
intervals to check for the characteristic uniform
tympanic sound as the abdominal cavity fills
with gas. If insufflation of the rectus sheath
occurs this can be detected by a rise in
inflation pressure, asymmetrical distension of the
abdominal wall and unevenness of the sound
when percussed.
Once liver dullness is lost, the head down
angle of the operating table is levelled. As long
as there is no appreciable rise in pressure
(certainly not above about 14cm of water),
insufflation continues until 3.5 to four litres of
gas have entered and there is visible distension
of the abdomen.
Step by step
Check freedom of movement.
Drop test.
Inject saline and aspirate.
Slow insufflation with minimal pressure rise.
Percuss abdomen during insufflation.
Exercise
Familiarise yourself with the Verres needle.
Make a small infra-umbilical incision.
Lift up the simulated abdominal wall (in the
simulator it is easier to use a towel clip).
Insert the Verres needle perpendicular to
the simulated abdominal wall. As the needle
encounters resistance, the blunt tip withdraws
and the needle cuts through the tissue.
Once the simulated abdominal wall has been
penetrated there is a distinct give and usually
a click can be heard. Angle the needle down
towards the pelvis and advance a little.
The needle can be rotated to show that it is
not caught in an adhesion or bowel loop.
52
Check that the needle is free in the peritoneal

cavity by aspirating gas/air back into the
syringe of saline and then by flushing through
and meeting no resistance. A further drop test
can be used, dropping saline onto the end
of the Verres needle and seeing it disappear
spontaneously into the peritoneal cavity on
elevation of the abdominal wall.
Connect the gas flow tubing.
Turn the gas pressure on the insufflator to
approximately 1214 mmHg.
Turn the gas flow on to one litre per minute
initially. Check the gas pressure reading it
should be low initially.
Once you are satisfied that free flow is
occurring, the flow rate can be increased to
three litres per minute.
If an obstruction to flow is encountered, the
commonest cause is from the Verres needle
lying against the omentum or small bowel.
Rotate the needle and if that fails, withdraw
the needle by a few millimetres. If there is still
a problem check that the gas flow tap on the
cannula has not been inadvertently turned off
or that the gas supply tubing has not been
kinked. If flow is still not free, the needle may
have been withdrawn into the abdominal wall
musculature and the procedure will have to
start again.
Insertion of the umbilical trocar and
laparoscope
If the abdominal cavity is well distended, the
peritoneal contents should fall away from the
abdominal wall. However, insertion of the first
port in the closed method remains one of the
most dangerous procedures in laparoscopy.
Pressure on the upper abdomen will move gas
into the space below the umbilicus. Lifting the
abdominal wall is not usually necessary at this
stage and may cause unpleasant bruising.
The port is inserted with great circumspection.
The body of the device is held in the palm while
an index finger extended along the insertion tube
will act as a guard to prevent more than a
centimetre or so of the sharp end entering the
peritoneal cavity.
Disposable trocars are equipped with
ingenious guarding devices which slide forward
to cover the point when it penetrates the
peritoneum. Unfortunately, time lapse
photography has confirmed that damage to
intra-abdominal structures can occur before the
shield has had time to advance and such

devices should not induce a false sense of
security.
Once in place the trocar is angled almost
horizontally and pushed towards the pelvic
cavity with due regard to the great vessels
coursing over the sacral promontory. This is
particularly crucial if the patient has a significant
lumbar lordosis. The laparoscope can then be
inserted.
Watch the video screen as the laparoscope
is inserted. Sometimes there is a film of
peritoneum or an omental adhesion which has
to be carefully negotiated by moving the end of
the instrument in order to enter the peritoneal
cavity.
All other ports are introduced under direct
vision.
Exercise
Familiarise yourself with the various types of
trocar and cannulae provided. Examine both
disposable and non-disposable ports with
their appropriate reducers.
The Verres needle should be removed once
the peritoneal cavity has been distended by
34 litres of gas and the pressure has risen
to 1214mmHg.
Insert the umbilical trocar into the simulator
perpendicular to the skin, lifting the abdominal
wall as before.
With reusable trocars the action of insertion
tends to be a screwing action, but for the
disposable trocars a straight pushing action
is needed. Once the simulated abdominal
wall has been penetrated, a characteristic
give is felt. Hold the trocar in such a way
as to prevent too deep penetration in an
uncontrolled manner by positioning a finger
along the shaft of the trocar.
Check position by venting gas from the
peritoneal cavity either through the Luer lock
or by pressing the gas valve.
Connect the gas flow tubing.
Insert the camera. Ensure there is no damage
immediately under the port. You may see the
saline used earlier in the exercise lying on the
floor of the simulator.
Inspect the inside of the simulated peritoneal
cavity.
Insert two working ports. The sites of these
ports will depend upon the procedure to be
undertaken. All secondary ports should be
inserted under direct vision. Pressure on the
abdominal wall indicates the site of insertion.

Make a small incision in the skin and then
insert the port under direct vision. A screw
grip may be used to secure the cannula.
Maintenance of the pneumoperitoneum
The insufflator should be set to a pre-set
pressure of 1214mmHg. The machine detects
a fall in pressure and responds by insufflating
more gas. If pressure exceeds a pre-set limit an
alarm sounds.
If the alarm sounds
Stop insufflating.
Recheck port positioning.
Check that gas tubing is not obstructed and
tap is open.
Let gas out to reduce intra-abdominal
pressure.
Check that anaesthesia has not lightened.
Physiology of carbon dioxide
pneumoperitoneum
The attraction of carbon dioxide as a gas
for insufflation is its solubility. This speeds
its elimination but increases its physiological
effects. When CO2 production exceeds its
elimination, acid base and respiratory
homeostasis is disturbed.
CO2 absorbed as the result of insufflation
is stored until eliminated by the lungs. The
total CO2 storage capacity of the human
body is approximately 120 litres. Bone is the
largest potential long-term reservoir. When CO2
retention occurs for less than an hour or so
skeletal muscle and visceral stores are more
important.
Pathophysiology of carbon dioxide
pneumoperitoneum
Effects of carbon dioxide
CO2 pneumoperitoneum can cause adverse
cardiovascular, respiratory and metabolic
changes. In all patients, there is a 2530%
drop in the cardiac return in the first 20 minutes
of a laparoscopic procedure, but most healthy
patients demonstrate no ill effects.
There is, however, a risk to patients
with reduced cardiopulmonary reserve. CO2
accumulation in these patients results in
decreased stroke volume and accelerated heart
rate which stresses the myocardium. Ventilation-
53
perfusion shunts occur so that increases

in arterial PaCO2 may not be matched by
changes in the CO2 measured in the expired
gases. Patients with significant respiratory or
cardiovascular disease must therefore have their
arterial gases monitored.
Volume effects
Insufflation of gas into the peritoneum has a
number of effects related to the volume of gas
used. Partial obstruction of the inferior vena
cava and splinting of the diaphragm become
important when the procedure lasts longer than
20 to 30 minutes. Venous pooling in the legs
may predispose to deep venous thrombosis.
Diaphragmatic splinting may compromise
ventilation, especially when there is pre-existing
lung disease.
Cardiac dysrhythmias may occur during
insufflation. Sinus bradycardia is most common
and can be corrected by temporarily releasing
the pneumoperitoneum and administering
intravenous atropine. Other dysrhythmias are
usually secondary to reduced venous return
and cardiac output with underperfusion of the
myocardium.
The anaesthetist must have adequate
intravenous access throughout a laparoscopic
procedure and effective monitoring, including
central venous pressure measurement if
necessary, is mandatory.
Gas insufflated at room temperature does
not cause significant hypothermia. However,
gas leakage allows water vapour to escape
and there may be heat loss as latent
heat of vaporisation. (It is as if a wind
were blowing over the exposed abdominal
contents.) If the procedure is prolonged, the
core temperature should be monitored and
hypothermia corrected.
Difficulties with access
Long needles and trocars are available for use in
the very obese but they should never be used by
mistake in patients of normal stature because of
the increased risk to deep structures.
Inserting the Verres needle in thin people
may also be problematic. Not only are the
great vessels close to the surface, but tactile
recognition of the layers of the abdominal wall
may be impaired.
54
Inspecting the peritoneal cavity

The first port must be large enough to allow the
laparoscope to pass and a 10mm port is usually
selected.
The first and vital step is to identify any
structure that could be harmed during the
procedure. No two abdominal cavities are
identical and significant variants are quite
common.
Insertion of additional ports
The number and sites of additional
instrumentation ports depend upon the
operation to be performed. Their size depends
on the instruments to be passed through
them. The port trocars are inserted through
skin incisions which may be prepared with an
injection of bupivacaine.
The course of the epigastric vessels should
be avoided. When the ports are in place they
are secured by a threaded securing collar or
by a suture. When instruments are removed the
ports are closed by a gas-tight trumpet or flap
valve. The entry of the point is viewed with the
laparoscope so that damage to intra-abdominal
structures cannot occur.
Management of profuse bleeding during port
insertion
If a large vessel in the abdominal wall
(for example an inferior epigastric vessel)
is punctured by a trocar, the bleeding can
sometimes be very dramatic. Do not panic.
Wait a while because the bleeding sometimes
stops spontaneously. If it does not, DO NOT
REMOVE THE TROCAR because it marks the
track of insertion along which the bleeding
vessel is located. A strong suture on a straight
needle should be passed directly alongside the
trocar and retrieved in the abdomen with a
needle holder. It is then passed out through
the abdominal wall on the other side of the
trocar. The procedure is repeated forming a
Z-stitch embracing the track of the trocar.
The trocar is removed and the knot tied to
achieve haemostasis. Unfortunately, an untidy
scar results.
Alternatively, a Foley catheter can sometimes
be inserted through the port and the inflated
balloon used to tamponade the bleeding. If in
doubt, convert to an open procedure.
Removal of ports
All ports should be removed under direct
laparoscopic vision to be sure that there is no
bleeding from port holes. The last port should be
removed slowly with the laparoscope inside the
port to be sure that there is no bleeding.
Closure of port holes
The 10mm port holes must be closed with care
to avoid later hernias. Most surgeons advocate
formal closure of deep layers with interrupted
synthetic absorbable or non-absorbable suture
(usually using a J-needle) with separate skin
closure. Take care not to pick up small bowel in
the closing stitch. The 5mm port holes do not
require closure of the abdominal wall and simply
need skin closure.
Minimal access surgery

instrumentation
The expanding range of laparoscopic
procedures creates a demand for novel
instruments. However, a number of basic
instruments are common to all therapeutic
laparoscopic procedures.
Basic instruments
A basic instrument set might consist of:
1 x 10mm 0 laparoscope.
2 x Verres needles (120mm and 150mm).
2 x 10mm trocar and cannula with trumpet valve
and gas inlet.
2 x 5mm trocar and cannula with trumpet valve
and gas inlet.
1 x 5mm insulated grasping forceps.
1 x 5mm insulated grasping forceps with
ratchet.
1 x 5mm insulated dissecting forceps.
1 x 5mm insulated scissors.
1 x 5mm reducing sleeve.
1 x 10mm clip applicator.
1 x 5mm right angled diathermy hook.
1 x 5mm suction/irrigator.
1 x 10mm retrieval forceps.
1 x light cable.
1 x diathermy lead.
1 x gas lead.
1 x cholangiography catheter.
Note: Try to ensure that all diathermy
instruments are compatible with a single
diathermy electrode fitting. Have bipolar forceps

available.
Verres needle
Used for closed method of creating
pneumoperitoneum.
Has a spring-loaded obturator that advances
over the sharp tip as soon as the needle
enters the abdominal cavity.
Luer fitting to attach gas input from the
insufflator.
Tap to control gas flow.
Trocar and cannula
Used to establish a port of entry into the
abdominal cavity.
Spring-loaded valve to allow instruments to
pass while preventing the escape of gas.
Most common sizes are 5mm and 10mm in
diameter.
Cannulas with or without gas inlet.
Reusable 10mm and 5mm trocar and cannula.
Disposable cannulas for single use may be
more expensive but have the advantages of:
always being sharp;
a protective safety shield; and
are radiolucent.
Grasping forceps
Used for grabbing and retracting tissues
within the abdominal cavity.
May have a ratchet to keep the jaws closed.
Traumatic or atraumatic jaws.
Type used will depend on the surgery being
performed.
Dissecting forceps
For spreading, separating and dividing.
Atraumatic.
Straight or curved.
Scissors
For cutting tissue or sutures.
May be hooked, straight, curved or micro.
Grasping/dissecting forceps and scissors may
or may not be insulated and/or rotating.
Insulated instruments have the advantage that
they do not reflect light.
55
Instruments for preparation, incision and

closure
Sponge holders.
Blade handle and blade.
Fine toothed dissecting forceps.
Mayo and suture scissors.
Artery forceps.
Needleholder.
Baby Langenbeck retractors.
These instruments are also needed for the
open method of inducing pneumoperitoneum.
Always have available, if not ready, the
instruments necessary if the case proceeds to
open surgery.
Additional instruments available for
particular procedures or surgeon
preference:
10mm 30 laparoscope for hernias and
advanced procedures.
5mm 0 laparoscope for use with a 5mm port.
2 x 5mm needleholders.
1 x 10mm retractor.
5mm and 10mm Babcocks (Beware! Some of
these are very traumatic.)
5mm and 10mm bowel clamps.
Biopsy forceps.
Bipolar forceps.
Endoscopic stapling instruments.
Endoscopic retrieval bags.
Endoloops.
Dejardin stone grasping forceps.
The number of instruments and sets you will
have depends on the level of service, the type
of procedures being performed and financial
constraints.
It is important for theatre staff to have a good
knowledge of the instruments available within
their unit. They are then able to offer assistance
or guidance, especially if the unexpected occurs
or the surgeon is inexperienced. For example,
if the cystic duct is too wide to clip safely, an
endoscopic stapling gun or endoloop might be a
suitable alternative, thus avoiding conversion to
an open procedure.
Selecting and purchasing instruments for
minimal access surgery is complex as more
than one department/specialty is involved. There
are a number of manufacturers supplying
instruments, each of which may have different
preparation, sterilisation, assembly and
disassembly, cleaning, and maintenance
requirements. It is therefore obviously easier
for theatre staff and a better use of resources
if some standardisation can be agreed and
maintained.
56
Selection of instruments will also depend on

unit policy with regard to disposable equipment
and the surgeons preference.
Disposable instruments
Advantages
Sterile, sharp, functional, insulated and ready
to use, with safety features such as the shield
on the trocar and cannula and caps to cover
the working end of the instrument for safe
disposal in a sharps bin.
If discarded correctly, the instrument is safer
for theatre staff as there is no risk of injury
during cleaning and maintenance.
Keeps pace with improvements in instrument
design.
No time spent on cleaning and maintenance.
Disadvantages
Cost.
Require storage space.
More waste for incineration pollution and
environmental issues.
It is tempting to reuse a disposable
instrument but it is impossible to guarantee
adequate cleaning and instrument function
after re-sterilisation. Reuse must be avoided.
Manufacturers will not accept product liability if
a disposable product is reused.
Reusable instruments
Advantages
Cost containment larger initial outlay but
seen as more cost-effective in the long run,
simply because they can be used again and
again.
Less storage space required.
Less clinical waste.
Disadvantages
Hidden costs of cleaning, sterilisation,
maintenance, repair and the training to do
this.
Less safe for patients and staff:
More risk of injury to staff when
disassembling and cleaning.
May be difficult to check that all surfaces are
clean and sterile.
Possibility of incorrect re-assembly causing
instrument malfunction.
Possibility of unnoticed damage to
insulation.
Less able to take advantage of developments

in instrumentation because of a reluctance to
lay out more expenditure.
The actual cost of disposable instruments,
with their saving in time and safety benefits to
patients and staff, should be compared with the
actual costs of maintaining reusable instruments
in optimum working condition.
Exercise
Familiarise yourself with and practise the
correct handling of each of the instruments
displayed.
Grasping and manipulation skills

Exercise 1 grasping and manipulation
Insert a 5mm grasper into the right-hand port
constantly watching as it is inserted. Pick up
an object such as a cotton pledget from a
galley pot and place it on the floor of the
simulator. Release it and pick it up again
and return it to the galley pot. Withdraw the
instrument.
Repeat the exercise using the left hand and a
grasper in the left-hand port.
Now use both hands to pick up a pledget
from the galley pot with the right-hand
grasper, transfer it to the left-hand grasper
and then place it on the floor. Pick it up again
with the left-hand grasper, transfer it to the
right-hand grasper and replace it in the galley
pot.
Repeat the exercise starting with the left-hand
grasper.
Withdraw both instruments watching and
following each move with the camera.
There are many such exercises that you
may be required to perform, such as passing
matchsticks through loops or sweets one on top
of another.
Exercise 2 manipulation and cutting
Draw a disc on a glove and pin the glove
out on a cork board. Insert the board into the
simulator.
If you are a right-handed surgeon, insert a
grasper via the left-hand port and scissors
via the right-hand port. Use the left hand to
expose the target and then cut out the disc,
taking care not to cut through both layers of
the glove. Only cut when you have a good
view.
Try and position the curve of the scissors so

that the incision is not too ragged.
Withdraw the excised disc through the lefthand port.

Clipping and loop ligation
Therapeutic laparoscopy constantly requires
pedicles, such as the cystic duct, to be
ligated and divided. Clips are used for
this, followed by a division using scissors.
Occasionally for larger pedicles, such as the
appendix stump, a surgical loop (endoloop)
is used. Familiarise yourself with these
instruments.
Exercise
Isolate a limb from a foam tree within the
simulator by dissection using a grasper in
the left-hand port and scissors in the righthand port. Insert a clip applicator and place
three clips on the foam limb, ensuring no
other tissue gets caught in the clips. Before
firing each time, rotate the clip applicator to
demonstrate that the jaw of the clip extends
beyond the structure to be divided. Cut
between the clips.
Practise using an endoloop outside the
simulator initially. Insert the endoloop in an
introducer and then pass the loop over the
finger of an assistant. Break off the end
of the endoloop and tighten the knot. If
endoloops are in short supply, ensure that you
understand the principles behind its use and
then omit the exercise outside the simulator.
Now practise applying the endoloop within
the simulator.
Blow up a rubber glove and secure it by tying
the base. Then use an endoloop to ligate the
base of one of the inflated fingers, which is
used to simulate a distended appendix.
Insert an endoloop into a 3mm introducer and
pass into the simulator via the right-hand port.
Extend the loop out of the introducer.
Pass the grasper through the loop, pick up
the inflated finger and draw it through the
loop.
continued over....
57
... continued
Break off the end of the endoloop and then
tighten the knot around the base of the finger.
Cut the suture material. Now grasp the finger
with grabbers and then cut the finger off using
scissors inserted via the left-hand port.
If the endoloop has been positioned and
tightened properly, the rest of the glove will
not deflate.
Bipolar diathermy
In bipolar diathermy, the heating occurs in tissue
held between two small active electrodes.
Diathermy
Dangers of diathermy (electrosurgery)
Surgeons have employed electrical current to
cut and coagulate tissue for over 70 years
although few have had any formal training in
its use. Many of the accidents that occurred
in therapeutic laparoscopy arose when surgical
diathermy was used. This has drawn attention
to the need for better understanding of this
useful, but potentially hazardous, surgical tool.
Most accidents are caused by unintended burns
which are avoidable if diathermy is used with
care.
How surgical diathermy works
When an electrical current passes through a
conductor some of its energy appears as heat.
For any given conductor, the heat generated
depends upon its resistance and the density of
current flow. This is the principle of the light
bulb and the electric fire. When a lot of current
passes through, a lot of heat is produced. The
same applies to human tissue. When a large
amount of electrical current passes through a
piece of tissue, the temperature rise can be
enough to give a useful surgical effect.
Figure 58
What is the difference between

monopolar and bipolar diathermy?
(Figure 58)
Monopolar diathermy
In monopolar diathermy, the surgeon uses an
active electrode with a small surface area tip
to concentrate a powerful current producing
heat at the operative site (the power density
is high). The large return electrode plate which
completes the circuit spreads the current over a
wide area so that it is less concentrated and it
produces little heat (the power density is low).
58
Why is the patient not electrocuted?

An alternating current of low frequency
stimulates nerves and muscles and it is this
stimulation which kills someone connected to
the mains current. This effect, which is named
after Michael Faraday (Faradism), does not
occur when the frequency is very high. A
low frequency current as small as 1mA
can stimulate the heart fatally, but the
radiofrequency (RF) currents as high as 2A
used in surgical diathermy pass through the
body without dangerous neuromuscular effects.
These currents have a frequency which is up to
a million times that of the mains current which
alternates at 50Hz (50 oscillations/sec).
High frequency alternating currents have
some surprising properties which have safety
implications in laparoscopic diathermy.
Bipolar diathermy has been generously supported by Eschmann equipment
How does cutting current differ from

coagulating current?
Surgical diathermy is used for cutting and
coagulation.
Cutting occurs when sufficient heat is applied
to tissue to cause cell water to explode into
steam. As we have seen, to get a high
temperature we need to pack a high current into
the tissue.
For coagulation, a less violent heating effect
leads to cell death by dehydration and protein
denaturation. The dead tissue is shrunken and
dried distortion of walls of blood vessels,
coagulation of plasma proteins and stimulation
of the clotting mechanism all act to check
bleeding. Ideally, intracellular temperatures do
not reach boiling point so there should be no
unwanted cutting.
You will find that monopolar diathermy is most
effective when you hold the active electrode a
small distance from the tissue. The electrical
discharge arcs across the tiny air gap creating
a series of sparks which produce the high
temperatures needed for cutting.
The CUT current is a continuous wave form.
If you set the machine to CUT and gradually
reduce the power setting, you will come to a
level when the effective voltage is no longer
enough to drive sparks across the gap and no
current will flow. If you now touch the electrode
onto the tissue, current will flow again because
it does not have to jump across a gap. There
will be no sparks and the current will flow away
into the adjacent tissue. The heating effect is
relatively gentle with loss of intracellular water
and coagulation with tissue necrosis in depth.
This effect is called desiccation and gives
reasonable coagulation. Desiccation is more
commonly achieved by using COAG current in
contact mode.
Contact diathermy
In contact diathermy, the main impedance
(resistance) to current flow is at the interface
between the electrode and tissue, where it is
influenced by the type of tissue and its state
of hydration. The impedance of fat is high
compared to muscle and contact diathermy
works badly on adipose tissue. As diathermy
proceeds, the tissue in contact with the
electrode dries and impedance rises. Eventually,
the current flow is insufficient to produce further
heating and the surgical effect ceases. This
limits the depth of penetration of diathermy
applied to one spot. The effect of contact

diathermy also depends upon the size and
shape of the active electrode. A ball electrode
with a large surface area held in contact with
tissue will tend to apply current at a relatively
low density, coagulating to a depth of tissue
which is proportional to the square of the
diameter of the ball. Contact cutting by point
diathermy is mainly by physical disruption of
tissue softened by coagulation and is usually
less effective than non-contact cutting.
Fulguration
If you set the diathermy machine to COAG or
press the COAG pedal you can fulgurate tissue.
In fulguration, you use a higher effective voltage
to make longer, fatter sparks jump an air gap
the word means to flash like lightening. The
COAG current has an interrupted (modulated)
wave form with the current chopped into bursts.
Because the current is turned off most
of the time, COAG current can have large
peak voltages and currents and yet apply less
electrical energy over a given time than a
CUT current of equivalent amplitude. A less
explosive, more sustained heating effect leads
to coagulation and haemostasis. The high peak
voltage can drive current through the high
resistance (impedance) of desiccated tissue.
Thus fulguration can continue until carbonisation
or charring occur.
Summary
The CUT current is typically a continuous
wave, producing sparks whose heat explodes
intracellular water to steam. The COAG current
is a sine wave current supplied in bursts
to fulgurate tissue. This allows the sustained
heating in depth needed for coagulation. Peak
voltage and mean power output can be varied
by adjusting the duration of bursts of current
and their intensity to give a combination of
cutting and coagulation. This is known as
blended current.
Be wary. Surgical diathermy generators differ
widely and there is often little relationship
between the output settings of one machine and
another. In particular, there may be a significant
difference between the power displayed and
the power in watts which is actually delivered
to the patient. The setting recommended by
the manufacturer for a particular application is
frequently on a scale which is meaningless to
the surgeon.
59
What is capacitative coupling?

One of the peculiar properties of alternating
currents is that they can apparently pass
through insulating material. This effect occurs
in an electrical device called a capacitor in
which an insulator is sandwiched between two
electrode plates. When the alternating current is
switched on, it seems to flow from one electrode
plate to another.
In laparoscopic surgery, it is potentially
possible to construct a capacitor without
knowing it. The insulated electrode passes
through a metal tube, say a laparoscopic
port the core of the electrode acts as
one plate, the metal tube as the other with
an insulator between which results in a
capacitor (Figure 59). In these circumstances,
even though the instrument is well insulated,
a part of the current can flow to the patient.
This capacitative coupling is an interesting
and remarkable result of the high frequency
alternating current which induces an alternating
magnetic field, which itself induces electrical
currents in nearby conducting objects. This
is how diathermy flowing through an active
electrode (hook, graspers) can induce a current
in its metal cannula despite insulation. This is
termed electro-magnetic induction.
Figure 59
The current flow is relatively small, but if there

is a small point of contact then dangerous
overheating can be produced which could
damage adjacent tissues (Figure 59). The
current flows from the metal sheath directly to
the bowel. It is greater in open circuit activation
and in 5mm cannulae compared to 10mm
cannulae. There remains some doubt about
the frequency with which injury has occurred
as a result of capacitative coupling during
laparoscopic surgery. Most accidents probably
happen through causes which are easier to
understand such as inept handling or poor
maintenance of diathermy equipment.
60
General hazards of diathermy

Electrocution
Diathermy machines are manufactured to
national and international safety standards which
minimise the risk of any part of the machine
becoming live with mains current. As with any
electrical device, servicing must be regular and
expert.
Fire and explosion
Alcohol-based skin preparations can catch fire
if they are allowed to pool on or under the
patient. This is less likely in endoscopic work
but you must still take care that all excess spirit
is removed before using diathermy. Better still,
avoid inflammable chemicals if you can. Do not
use diathermy with explosive gases, including
those which may occur naturally in the colon.
Neuromuscular stimulation
Although the high frequency current used
for surgical diathermy does not cause
neuromuscular stimulation, the sparks which it
induces may invoke secondary currents which
can do so. The sparks make random electrical
noise in the midst of which are alternating
frequencies able to induce a Faradic effect.
Such currents can be electronically suppressed
by capacitors in the circuit. However, they may
be sufficient to cause trouble in the special
conditions of diathermy in the region of nerves
or large masses of skeletal muscle which can be
induced to contract strongly and unexpectedly.
The problem is especially seen in urological
surgery where diathermy near the ureteric orifice
can induce an obturator kick by stimulation of
the obturator nerve and the psoas muscle. The
problem is seen with both CUT and COAG
current and can usually be abolished by full
chemical neuromuscular blockade.
Pacemakers and diathermy
Diathermy currents can interfere with the
working of pacemakers with possible danger to
the patient. Modern pacemakers are designed
to be inhibited by high frequency interference
so that the patient may receive no pacing
stimulation at all while the diathermy is in use.
Some demand pacemakers revert to a fixed rate
of pacing and the anaesthetist must have a
magnet available so that they can be reset if
necessary.
A number of additional precautions are wise

in these patients. First, if monopolar diathermy is
to be used, the patient plate should be sited so
that the current path does not pass through the
heart or the pacemaker. Secondly, the heartbeat
should be monitored throughout the operation.
Lastly, a defibrillator should be on hand in
case a dangerous dysrhythmia develops through
malfunction of the pacemaker.
Burns
Burns are the most common type of diathermy
accident in endoscopic and open surgery. They
occur when current flows in some way other
than that intended by the surgeon. Burns are
much more common in monopolar rather than
bipolar diathermy.
When monopolar diathermy works properly,
heating occurs only at the tip of the active
electrode. The current passes through the
patients body and escapes safely via the return
electrode. Unfortunately this long current path
offers opportunities for alternative unwanted
passage of current to earth.
Return electrode plate
Most devices monitor the attachment of the
patient plate and sound an alarm when contact
is inadequate. A simple method is to attach
the plate by two wires through which a
small current flows. If a wire breaks, the
current is interrupted and the diathermy can
be automatically inactivated. This checks the
integrity of the connection of the plate to the
diathermy machine. It does not guarantee that
the plate itself is properly attached to the
patient. Another safety device uses a small
direct current which in passing through the
active electrode, the patient and the patient
electrode, monitors the integrity of the whole
diathermy circuit. Other machines have even
more sophisticated safety measures. Remember
that the safety of the return electrode depends
upon its proper attachment. Both the surgeon
and the theatre nurse have a duty to see that it
is checked.
If the patient electrode is incorrectly attached,
there is a particular danger that the circuit might
be completed by a small earthed contact point
such as a drip stand, a metal component of
the operating table, electrodes used for patient
monitoring or even the surgeon! If the current
density at this point is sufficient, the patient
(and/or the surgeon) will be burned.
All patient monitoring equipment should be

isolated from earth wherever this is possible.
Electro-cardiograph electrodes should be wellgelled and of a large enough area to disperse
the current. Needle electrodes should not be
used. As a general rule, the return pad should be
sited as near to the operation area as possible
so that the main current path will be distant from
other potential routes that the current might take
to ground.
Safety rule: always check that the return pad
is properly connected, that safety monitors are
active and that there are no small earthed
contacts attached to the patient.
Laparoscopic diathermy
Inadvertent burns to the patient are a special
hazard of laparoscopic surgery. There are
several mechanisms:
Burning the wrong structure.
Inappropriate or inadvertent activation of
electrodes out of view.
Faulty insulation.
Instrument to instrument coupling (direct
coupling).
Retained heat.
Capacitative coupling.
Burning the wrong structure
Probably the most common cause is
misidentification of the structure to which the
diathermy is applied.
Inappropriate or inadvertent activation of
electrodes
Pressure on the footswitch leads to activation of
all the active electrodes which are connected.
In open surgery, any devices which are not in
use must not be in contact with the patient and
an unused electrode should be safely stored
in an insulated quiver where it will be safe
if the footswitch is inadvertently activated. In
laparoscopic surgery, devices connected to the
diathermy generator often remain within the
operating field while not in immediate use. If they
are in contact with tissue when the footswitch
is activated, a burn will occur. There is particular
danger if the electrode is out of view at the time.
Devices attached to the diathermy machine
must not touch tissue while not in use.
61
It is safest to remove or disconnect devices

attached to the diathermy machine when not
in use.
Do not attach more than one active electrode.
Faulty insulation
It is possible for burns to occur when
conducting parts of instruments other than the
operating electrode come into contact with
the patient. In practice, this arises when there
is a defect or crack in the insulation of a
laparoscopic diathermy instrument which allows
current to travel to tissue as well as by the
intended path from the electrode.
Abrasives used to clean laparoscopic
instruments may wear away the thin insulation
near the tip increasing the length of the exposed
active electrode.
Raising the temperature of the bowel to 60C
for even a short time leads to denaturation of
intracellular enzymes and tissue death in situ.
Subsequent autodigestion of the necrotic tissue
leads to late perforation.
Instruments are more likely to become
damaged with age but you must not assume
that single-use instruments are immune from this
problem. The higher the effective voltage of the
current being used, the more likely it is to leak.
Leakage is also more likely if the diathermy is
activated when the electrode tip is distant from
target tissue (open circuit activation).
Do not use diathermy instruments which are
damaged or badly maintained.
Avoid open circuit activation.
Flow of current from one instrument to
another
Contact or close approximation of the active
electrode and another conducting instrument
can establish an unwanted and unnoticed
current path. This is known as direct coupling of
the current. In an open operation such contacts
are easily noticed and appropriate action taken.
In laparoscopy, arcing between instruments may
occur outside (behind) the field of view and
you may not notice anything other than that
the diathermy does not work as expected at
the site where you think you are applying it.
Turning up the power in these circumstances
can have disastrous consequences. Remember
that COAG and BLEND currents have a larger
effective voltage and can jump bigger gaps.
Open circuit activation is particularly dangerous.
62
Instrument to instrument coupling is more

likely with open circuit activation.
Do not activate the diathermy unless the
whole of the active electrode is in view.
Do not activate the diathermy if there is a
chance that two instruments are in electrical
contact or close enough for arcing to occur.
Retained heat
When you have been using the diathermy for
some time the tip of the active electrode
becomes hot and remains so for some time. The
electrode may be hot enough to damage tissue
although no current is flowing.
Do not allow a hot active electrode to touch
tissue.
Unintentionally high current density in
pedicles
The heating effect of diathermy depends upon
the current density and the resistance of the
tissue. The sight of penile necrosis on a
small boy is so disturbing that most surgeons
are aware of the danger of using monopolar
diathermy to perform a circumcision. The current
path through the base of the infant penis is small
in cross-section, the current density is high and
the heating effect disastrous. The same effect
can also occur when applying diathermy to a
pedicled structure such as the appendix or a
gall bladder freed from the liver and attached
to the common bile duct by the cystic duct.
The heating effect may be sufficient to cause
destruction of tissue and the effects may be just
as awful as penile necrosis.
Safety rule: monopolar diathermy should not be
used on organs attached by small pedicles to
important structures.
Capacitative coupling
Finally, there is the more difficult concept of
capacitative coupling. This is probably very rare
and only occurs in special circumstances.
There are two ways to avoid capacitative
coupling.
When using a diathermy instrument through a
trocar, either:
use a non-conducting troca; or
if you use a metal trocar, it should make a
good electrical contact with the abdominal
wall.
Also, avoid open circuit activation and avoid

using high voltage diathermy currents in noncontact mode (eg fulguration).
Bipolar diathermy
Bipolar diathermy is intrinsically safer than
monopolar diathermy because current passes
between two small electrodes on the same
hand-piece. Secondary currents induced by the
main radiofrequency may leak to ground but they
are too small to cause trouble. Bipolar diathermy
devices are being developed for laparoscopic
surgery but their use is not yet widespread
because they tend to be less effective at cutting.
Exercise diathermy cutting and
dissection
Mark a star on the skin of a piece of chicken.
You may wish to check the instruments and
practise initially outside the simulator.
Place the marked piece of chicken in the
simulator and then insert a grasper via the lefthand port and a diathermy hook via the righthand port. Cut the star of skin out using the
diathermy hook being careful not to damage
the underlying tissues. Use the left hand to
produce traction and elevation of the skin flap
and to ensure that each cut is safe.
Take care to avoid contact between the metal
of the grasper and the diathermy hook.
During dissection it is important that the foot
controlling the foot pedal is moved away from
the pedal when not in use to avoid inadvertent
activation.
Remove the skin disc via the left-hand port.
63
ASSESSMENT
We will be continuously assessing your

performance throughout each module of the
course, in order to give you a profile of
your strengths and weaknesses. You will be
individually assessed, and will receive advice on
the areas in which you need further practice.
On the following page you will find a sample
assessment sheet that covers all the three
modules of the course, ie open surgery, trauma
and orthopaedics and minimal access surgery.
This assessment seeks to concentrate on the
generic skills listed under each course module
and a grading will be given at the end of each
half day session for each of the generic skills.
These gradings are:
3 no errors observed
2 occasional errors, but corrected by participant
1 frequent errors or occasional errors
uncorrected by participant
0 persistently unsatisfactory performance
A grading will be given at the end of each half
day, and this will demonstrate how a participant
has improved over the period of the course and
over each module (where it consists of more
than one half day).
The overall grade for each module will be
recorded at the end of each module in the last
column (ie the column with a heavy box around
it. Any 0 grading or four or more grade 1s out
of the six skills assessed, would result in a not
satisfactory performance for that module.
It is expected that the great majority
of participants will receive results in the
satisfactory category. Trainees with such
results will receive a certificate of completion
after the end of the course. Only participants
whose performance is deemed to be not
satisfactory in either the open surgery module,
or any two modules of the course as a whole,
will need to repeat the three-day programme
and we do not anticipate that many trainees will
fall into this category.
64
One of the most important aspects of

the assessment is the feedback between
instructors and participants. This has proved
most valuable in previous courses and
participants have greatly appreciated the
constructive criticism that helps them improve
their technique. The comments will be both
verbal and recorded in the feedback section of
the assessment form.
In summary, we hope you will look upon this
activity as another way in which to build upon
the skills you already possess, and not as an
ordeal to be endured! In our turn, we will use the
assessment process to measure how effectively
we have been teaching you, and to reflect on
how we can continue to improve the course.
pm
am
Pneumoperitoneum induction
Abdominal incision
and closure
Haemostasis
assessment
The Royal College of Surgeons of England 1998
Participant name:
Handling bowel
Dissection
Plastering techniques
Handling sutures

(clipping and loop ligation)
Diathermy
Grasping and manipulation
Handling tendons
Knots
Course
Dates:
Instructors
Signature:
Overall grading for

course:
Overall grading:
comments
Satisfactory/not
satisfactory*
Satisfactory/not
satisfactory*
am
Module 3: minimal access surgery

Generic skills
Port placement
Port insertion
Instrument selection/handling
Camera management
Surgical procedures technique
Safety
pm
Practical session
Handling vessels
Satisfactory/not
satisfactory*
feedback
Centre:
Overall grading:
Generic skills
Knotting technique
Tissue handling
Safety
Plaster technique
Module 2: trauma and orthopaedics
Instructors
Signature:
* Delete as appropriate
comments
Satisfactory/not
satisfactory*
am
Assessment
Practical session
Theatre etiquette
Instructors
Signature:
Overall grading:
Generic skills
Knotting technique
Tissue handling
Safety
Assisting
Module 1: open surgery
Basic surgical skills assessment and feedback form
pm
NB: temporary assessment form will be replaced with new design
65
APPENDIX A: needles
Selection of appropriate needles

Surgical eyeless needles are manufactured in
a wide range of types, shapes, lengths and
thicknesses. The choice of needle to be used
depends on several factors such as:
the requirements of the specific procedure;
the nature of the tissue being sutured;
the accessibility of the operative area;
the gauge of suture material being used; and
surgeon preference.
Regardless of use, however, all surgical
needles have three basic components: the point,
the body and the swage (Figure 60).
Figure 61
Figure 60
The point depends on the needle type (see

next section). The body of the needle usually
has a flattened section where the needle can be
grasped by the needle holder. In addition, some
needles have longitudinal ribs on the surface
which reduce rotational movement and ensure
that the needle is held securely in the jaws of
the needle holder. If the needle does not have
a flattened section, then it should be grasped
at a point approximately one third of the needle
length from the butt (Figure 61).
66
The majority of surgical needles nowadays

are eyeless, that is they are already swaged to
the suture material. This has many advantages,
including reduced handling and preparation and
less trauma to the tissue. (An eyes needle
has to carry a double strand which creates a
larger hole and causes greater disruption to the
tissue). A swaged (eyeless) needle has either a
drilled hole or a channel at the end of the needle
for insertion of the suture material. The drilled
hole or the channel is closed round the needle in
the swaging process.
Types of surgical needles

Needles are normally classified according to
needle type. The main categories are described
in this section.
Round-bodied needles
Round-bodied needles are designed to separate
tissue fibres rather than cut them, and are used
either for soft tissue or in situations where easy
splitting of tissue fibres is possible. After the
passage of the needle the tissue closes tightly
round the suture material, thereby forming a
leak-proof suture line, which is particularly vital in
intestinal and cardiovascular surgery.
Needle type
Description
Typical application
Intestinal
The hole made by this needle is

no larger than the diameter of the
needle. The hole is then filled by the
material, which reduces the risk of
leakage.
Gastrointestinal tract; biliary tract;

dura; peritoneum; urogenital tract;
vessels; nerve.
Heavy
In some situations where

particularly strong needles are
required a heavy wire diameter
needle would be appropriate.
Muscle; subcutaneous fat; fascia;

pedicles.
Blunt taperpoint
Where needlestick injury is a

major concern, particularly in the
presence of blood borne viruses,
the blunt taperpoint needle virtually
eliminates accidental glove
puncture.
Uterus; pedicles; muscle; fascia.
Blunt point
This needle has been designed for

suturing extremely friable vascular
tissue.
Liver; spleen; kidney; uterine cervix

for incompetent cervix.
appendix a: needles
67
Cutting needles
Cutting needles are required where tough or
dense tissue needs to be sutured.
Needle type
Description
Typical application
Tapercut
This needle combines the initial

penetration of a cutting needle with
the minimised trauma of a roundbodied needle. The cutting tip is
limited to the point of the needle,
which then tapers out to merge
smoothly into a round cross-section.
Fascia; ligament; uterus;

scar tissue.
Cutting
This needle has a triangular crosssection with the apex on the

inside of the needle curvature.
The effective cutting edges are
restricted to the front section of the
needle.
Skin; ligament; nasal cavity;

tendon; oral.
Reverse cutting
The body of this needle is triangular

in cross-section with the apex on
the inside of the needle curvature.
Skin; fascia; ligament; nasal

cavity; tendon; oral.
In addition, there are surgical needles

for specialist areas, such as microsurgery,
ophthalmics and endoscopic surgery.
68
Needle shape
The choice of needle shape is frequently
governed by the accessibility of the tissue to
be sutured and normally the more confined the
operative site, the greater the curvature required.
The following table shows the basic shapes and
typical applications.
Shape
Typical application
Straight
Skin; subcuticular; purse string.
1/4 circle
Eye; microsurgical.
3/8 circle
Eye; fascia; muscle; vascular; plastic; skin;

subcuticular.
1/2 circle
Gastrointestinal tract; pelvis; respiratory tract;

peritoneum; muscle; urogenital tract.
5/8 circle
Urogenital tract; pelvis; oral cavity.
J-shape
Laparotomy closure; vagina; rectum (per anus).
Compound curve
Oral; eye, anterior segment.
Needles has been generously supported by Ethicon Ltd

a
company
appendix a: needles
69
APPENDIX B: suture materials
Characteristics of suture
The ideal suture would consist of material
which permits its use in any operation, the only
variable being the size as determined by the
tensile strength. It should handle comfortably
and naturally to the surgeon. The tissue reaction
stimulated should be minimal and should not
create a situation favourable to bacterial growth.
The breaking strength should be high in small
calibre. A knot should hold securely without
fraying or cutting. The material must be sterile.
It should not shrink in tissues. It should be
non-electrolytic, non-capillary, non-allergenic and
non-carcinogenic. Finally, after most operations
the suture material should be absorbed with
minimal tissue reaction after it has served its
purpose.1
No single type of suture material has all
these properties and therefore, no one suture
material is suitable for all purposes. Besides,
the requirement for wound support varies in
different tissues from a few days for muscle,
subcutaneous tissue and skin to weeks or
months for fascia and tendon, to long-term
stability for vascular prosthesis. However, the
surgeon must be assured that the selected
suture has the following properties:
predictable performance;
pliable for ease of handling and security of
knots;
minimal tissue reaction;
high uniform tensile strength, permitting use
of finer sizes;
sterile, ready for use; and
consistently uniform diameter per size.
Types of suture materials

Suture materials are either absorbable or nonabsorbable. Absorbable sutures offer temporary
wound support over a period of time and
thereafter are gradually absorbed either through
a process of enzymatic reaction (catgut) or
70
hydrolysis (synthetic materials). It is important

to recognise that losing tensile strength and
losing mass absorption are two separate events,
because a suture may support the wound for
only a very short time, and yet be present as
a foreign body for a long period after. The
ideal suture would be one which disappeared
immediately after its work was complete, but
such a suture does not yet exist.
Non-absorbable sutures do not absorb, but
some, especially those of biological origin,
lose strength without any change in the
mass of the suture material. Others gradually
fragment over time. Yet other non-absorbables,
especially those of synthetic origin, never lose
tensile strength or change in mass following
implantation.
Sutures can be subdivided into monofilament
or multifilament. A monofilament suture is
made of a single strand. It resists harbouring
micro-organisms and ties down smoothly. A
multifilament suture consists of several filaments
twisted or braided together. This gives good
handling and tying qualities.
A further classification is based on the origin
of the raw material; it can either be from
a biological source of from man-made fibres.
Sutures have been produced from a biological
or natural source for many thousands of years.
They tend to create greater tissue reaction than
man-made sutures; the result can be localised
irritation or even rejection. Another disadvantage
is that factors present in the individual patient,
such as infection and general health can affect
the rate at which enzymes attack and break
down absorbable natural sutures. Man-made or
synthetic sutures, on the other hand, are very
predictable and elicit minimal tissue reaction.
1
Postlethwait RW: Wound Healing in Surgery, Somerville,

NJ: ETHICON Inc, 1971, pp8-9.
appendix b: suture materials
71
Polydioxanone
Glycolide
(rapid absorption)
Absorbable monofil
Absorbable
braided, coated
Man-made polymer
56 days
180 days
Being absorbable, should not

be used where prolonged
approximation of tissues under
stress is required.
Ligate or suture tissues where

absorbable is desirable except
where approximation under
stress is required.
stress is required.
6090 days
Polymer of glycolic acid.
30 days
For closure of skin and mucosa,

eg minor surgery, paediatric
surgery, perineal repair, oral
mucosa, scalp wounds,
wounds under plaster.
Should not be used in tissues
that heal slowly and require
support beyond seven days.
42 days
1014 days
Copolymer of lactide and

glycolide coated with
polyglactin 370 and
calcium stearate.
Absorbable
braided, coated
Glycolide and
lactide
Ligate or suture tissues where

absorbable is desirable except
where approximation under
stress is required;
ophthalmology.
stress is required.
5670 days
28 days
Copolymer of lactide and

glycolide coated with
polyglactin 370 and
calcium stearate.
Absorbable
braided,coated
Glycolide and
lactide

stress is required.
By 90 days
At least 28 days
Purified animal intestines

(sheep or beef).
Absorbable monofil
Chromic catgut
Abdominal and thoracic

closure; subcutaneous tissue;
colon and rectal surgery.
ophthalmology.
Ligation;
ophthalmology.
Ligation; subcutaneous and

other fast healing tissues;
Should not be used in tissues

that heal slowly and require
support.
By 90 days
Frequent uses
At least 21 days
Purified animal
intestines (sheep or
beef).
monofil
Absorbable
Plain catgut
Contra-indications
Mass absorption rate
Tensile strength
retention
Raw material
Type
Suture
72
Suture materials has been generously supported by Ethicon Ltd
company
None
Non-absorbable;
Polymer of propylene.
Non-absorbable
monofil
Polypropylene
remains encapsulated
in body tissues.
None
Degrades at a rate of
about 15-20% per year.
Loses 1520%
per year
Polyamide polymer.
Non-absorbable
monofil
Monofilament
polyamide
Indefinite
None
Degrades at a rate of
about 15-20% per year.
Loses 1520%
per year
None
Non-absorbable;
remains encapsulated
in body tissues.
Indefinite
Man-made.
Non-absorbable
braided
Polyester
Polyamide polymer.
Most body tissues for ligation

and suturing; general surgery;
Should not be used for

placement of vascular
prostheses or artificial heart
valves.
Usually cannot be
found after about two
years.
Loses most or all

in about one year
Natural protein fibre of

raw silk spun by silk
worm.
Non-absorbable
braided
Silk
Braided polyamide Non-absorbable

braided
Subcuticular skin suturing,

ligation, gastrointestinal,
muscle.
Should not be used in neural

tissue, cardiovascular,
microsurgery, ophthalmology
(except strabismus) or where
extended support is required.
90120
21 days
Copolymer of glycolide
and caprolactone.
Absorbable monofil
Poliglecaprone
General; plastic;
cardiovascular; skin closure,
ophthalmology.
Skin closure; retention; plastic

surgery, ophthalmology.
Most body tissues for ligating

and suturing; general closure;
neurosurgery.
Cardio-vascular; general
surgery; retention.
ophthalmology.
Frequent uses
Contra-indications
Mass absorption rate
Tensile strength
retention
Raw material
Type
Suture
APPENDIX C: gloves and surgical handwashing
The choice of surgical scrub and glove is

critically important to a surgeon, and this point is
often not fully realised or appreciated.
Surgical handwashing
Surgical handwashing using approved scrub
solutions is a technique which involves an initial
washing of the hands and forearms to remove
transient micro-organisms and reduce the count
of resident flora, and then a second wash to
further reduce the level of resident colonising
flora.
Traditionally a sterile brush has been used for
the first application of the day, but continual
use is inadvisable as damage to the skin
may well occur. New alcohol-based formulations
have been demonstrated to be suitable for
use for surgical hand scrub and for brushless
application.
Alcohol antiseptics are as effective and have
as wide a spectrum of antimicrobial activity as
the more conventional methods using antisptic
detergent solutions and are no more damaging
to the skin. Therefore, scrub solutions should be
chosen which:
Have substantial initial reduction of transient
and resident flora.
Are effective against a wide spectrum of
micro-organisms.
Have a persistent effect and will continue
to work after application (in case of glove
puncture).
Are not damaging to the skin.
Glove choice
Given the length and complexity of many
operations it is obvious that gloves must fit well
and securely and offer optimum sensitivity and
durability without hand fatigue. They should not
lose their shape or integrity during use.
Less well understood is the need for

the glove to be of high quality, low in
extractable latex proteins and powder-free. It
is well-documented that adhesions and other
post-operative complications including delayed
wound healing can be attributed to glove
powder which transfers latex proteins from the
surface of the glove.
The surface of the glove must also be low in
residual accelerators used in the manufacturing
process, as these can cause localised skin
conditions which can occur up to 48 hours
after contact. With increased latex glove usage,
the incidence of latex allergy in the United
States has now risen to between 28% and 67%
in some high-risk healthcare workers, and is
estimated at 6% in the general population.
Latex allergy can often take time to develop,
with exposure taking place over months or even
years before any reaction occurs. Although it
is recognised that latex is still the best barrier,
latex-free alternatives should be considered
when sensitisation to the proteins in natural
rubber latex has occurred. Gloves should also
be pyrogen-free, since pyrogens can induce
pyrexia and misdiagnosis in some patients. This
fact is also well documented.
Powder-free, latex-free synthetic gloves should
also be available for:
Wearers who are known to be type 1 latex
allergic (and therefore prone to anaphylactic
shock).
Those patients who may be at higher risk of
latex allergy, such as spina bifida patients,
people with previous atopy, dermatitis, asthma
or food allergies, or those who have
undergone multiple surgical procedures.
These gloves should be of the same high
quality as latex gloves to allow comfort and
sensitivity, and must be part of a total protocol
within a surgical unit, to eliminate risk to
sensitised individuals.
appendix c: gloves and surgical handwashing
73
Glove puncture is commonplace during

surgery and occurs in over 50% of cases
in some operative procedures. Studies show
that between 50% and 88% of perforations
pass undetected. Therefore for some high risk
procedures, eg some orthopaedic, cardiac or
gastrointestinal procedures, it may be necessary
to double glove using a green under glove
to ensure added protection. The use of two
surgical gloves has been shown to maintain
the barrier between the wearer and patient
in four out of five cases in which the outer
glove has been breached. The system will allow
early identification of up to 97% of all glove
punctures. The inner glove is a half size larger
than the outer to optimise sensitivity, dexterity
and comfort. If the outer glove is punctured, fluid
penetrates between the two gloves and a dark
green patch alerts the wearer that a puncture
has occurred and the outer glove can then be
replaced.
In summary, therefore a surgeon should
choose a glove which:
is suitable for the surgical procedure;
fits well and does not lose its shape or
integrity;
offers optimum sensitivity and durability;
is powder-free;
contains low levels of latex allergens and
residual accelerators and is pyrogen free; and
is powder free and synthetic for those with an
allergy to natural rubber latex.
The scrub solutions and gloves you are
offered for your Basic Surgical Skills course
meet all these stringent criteria.
Powder-free, latex-free gloves should also be
available for suitable emergency cases.
Gloves and surgical handwashing has been generously supported by Regent Medical
74
Acknowledgements
Membership of the basic surgical skills working party for the first edition:
Bill Thomas (chairman)
Chris Fowler
Professor Jack Hardcastle
Jerry Kirk
Professor John Monson
Rodney Peyton
John Shepperd
Denis Wilkins
Andrea Kelly (educational adviser)
Margaret Jacques and Jai Ramcharan (technical advisers)
Saskia Smethurst (secretary to the working party)
Membership of the intercollegiate review group for the third edition:

Bill Thomas (chairman) (The Royal College of Surgeons of England)
David Smith; David Large (The Royal College of Surgeons of Edinburgh)
Professor Edward Guiney; Professor Oscar Traynor; (The Royal College of Surgeons in Ireland)
Graham Sunderland, Kay Whittle (The Royal College of Physicians and Surgeons of Glasgow)
Judy Murfitt, Peter Oudejans, Steve Enticknap (The Royal College of Surgeons of England)
Please note
While every effort has been made to ensure the accuracy of the information contained in this publication, no
guarantee can be given that in its compilation all errors and omissions have been excluded. Readers wishing
to use this information are recommended therefore to verify the facts for themselves, when appropriate.
Photography and design by the photography studio and publications department, The Royal College of Surgeons of England
Illustrations by Patrick Elliott, Medical Artist, Royal Hallamshire Hospital, Sheffield and Naomi Gonzalez
Appendix A illustrations, Ethicon Limited
Printed by Dexter, Dartford, Kent

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This handbook was written and revised by Mr Bill Thomas, Blond surgical skills tutor and chairman of

introduction to the course

trauma and orthopaedics

Module three: minimal access surgery

INTRODUCTION TO THE COURSE

This handbook has been designed and written

Each course will be offered under the

introduction to the course

Module one: open surgery

Module two: trauma and orthopaedics

Module three: minimal access surgery

Day 1 module one: open surgery

Registration (faculty meeting)

Introduction and statement of course objectives

Theatre safety (principles of safe surgery)

Discussion and feedback

Day 2 (am) module one: open surgery (continued)

The Aberdeen knot

Handling vessels (continued)

Day 2 (pm) module two: trauma and orthopaedics

Handling traumatised tissues

Principles of fracture fixation

Discussion and feedback

basic surgical skills

Day 3 module three: minimal access surgery

Introduction to minimal access surgery

The laparoscopic stack

Safe induction and maintenance of the

Minimal access surgery instrumentation

Grasping and manipulation skills

Advanced dexterity skills

Summary and feedback

Preparation for the course

Theatre safety (principles of safe

basic surgical skills

Other important principles

assistants or scrub nurses. This is particularly

Basic principles has been generously supported by Keeler Ltd

they provide magnification when needed and

MODULE ONE: open surgery

This module of the course is designed to teach

basic surgical skills

For finer work the scalpel may be held like a

Use the index finger to steady the scissors by

Always pass the scalpel in a kidney dish.

Cut with the tips of the scissors for accuracy

Two main types of forceps are available,

Haemostats (artery forceps)

Select the needle holder carefully. For

basic surgical skills

The one-handed reef knot technique

Use the distal phalanx of the left index finger

Pull the thread through and complete the

Bring the remainder of the suture material in

basic surgical skills

Continue to hold the short end of the suture

Bring the strand through and then tighten by

Bring the strand held in the right hand across

On completion of the reef knot, the classical

Use the distal phalanx of the left middle finger

For security another index finger throw is

The instrument tie

Now form a loop around the instrument, this

Grasp the short end again within the jaws of