BASIC SURGICAL SKILLS AND TECHNIQUES BASIC SURGICAL SKILLS AND TECHNIQUES THIRD EDITION Editors Sudhir Kumar Jain MS FRCS (Edinburgh) FACS FICS MBA (HCA) Professor Department of Surgery Maulana Azad Medical College New Delhi, India David L Stoker MD FRCS (Edinburgh) Consultant Surgeon North Middlesex University Hospital London, UK Professor St George's International Medical School London, UK Raman Tanwar MS MCh (Urology) FMAS Fellowship in Andrology and Men's Health Consultant Urologist and Andrologist Urocenter, Jyoti Hospital and Paras Hospital Gurugram,Haryana, India Jaypee Brothers Medical Publishers (P) Ltd. Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: [email protected] Overseas Oces J.P. 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Inquiries for bulk sales may be solicited at: [email protected] Basic Surgical Skills and Techniques First Edition: 2008 Second Edition: 2013 Third Edition: 2018 9789386322814 Printed at Dedicated to Our families, for their support in spite of their neglection by us during the process of this work Our parents, for their blessings Our teachers, for their wisdom Our students who inspire us Our patients, from whom we continue to learn daily Preface to the Third Edition The surgical science is rapidly advancing, and every year, new facets are being added in various aspects of surgery thus making it necessary to bring the third edition. Ever since the last edition many new frontiers in surgery have opened up. It has gone less invasive and more technology driven. Some new facets such as robotic surgery, single port surgery and surgery through natural orices have brought value addition as well as diversication. While it becomes dicult to stay abreast with all the new advances, we have tried our best to provide a fair insight into the advances which are well established, and less controversial like robotic surgery and lasers. The basic skills required to handle new technology and equipment have been incorporated, and a genuine effort has been made to keep it simple and illustrative. Almost every chapter has undergone changes with addition of new concepts and surgical pearls. We have ventured into the eld of endoscopy and robotic surgery through two dedicated chapters. Diagrams have been further simplied and made more descriptive. With the third edition, we hope to enrich the readers with knowledge regarding the recent advances at the same time covering the basics which could not make it in the last edition. We thank the readers for the feedback and support and look forward to constructive criticism. Sudhir Kumar Jain David L Stoker Raman Tanwar Preface to the First Edition Apprentices in surgery need a basic set of practical skills in order to care for their patients well. Although many of these skills are same as those used by their 20th century predecessors, today's trainees need to keep abreast of rapidly changing and advancing technologies that were not available even 10 years ago. At the same time, basic surgical training for medical students and junior doctors is being compressed into a shorter time frame, as other medical specialities evolve and need to be taught in growing curricula. There is increasing emphasis on communication skills, and self-directed learning in many undergraduate programs, and the student of surgery today has, therefore, to learn more in less available time. He/she will have less “hands on” experience in theater, ward or clinic, and inevitably the practical aspects of surgery tend to suffer. This book aims to facilitate the more rapid learning required in a modern surgical program, with concise chapters on the main techniques that need to be mastered in the early years of training. It is intended to be read mainly by senior medical students, and housemen or interns, but may also be a useful revision for those about to take their rst surgical postgraduate examinations. It is the book written by working general surgeons to enhance the practical training of their own teams. It is also an international collaboration between London and New Delhi, and will be of use to students studying the art and science of surgery everywhere. It is not an exhaustive reference book, but more of a brief guide, to be used as a learning tool mainly in operating theaters and emergency rooms. It contains simple lists and diagrams with no superuous text. There are clear explanations which should aid the student from scrubbing up to suturing up. This book is designed to enhance practical training, and the student is encouraged to spend as much time as possible putting the basic skills described to good use in a clinical environment. Surgery remains largely an apprenticeship specialty, where only lots of practice will make perfect. Sudhir Kumar Jain David L Stoker Our sincere thanks to Shri Jitendar P Vij (Group Chairman) and Mr Ankit Vij (Group President) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for the encouragement, support and inspiration. We are grateful to Ms Chetna Malhotra (Associate Director), for helping us by valuable suggestions during the process of this work. We express our special thanks to the whole production team of M/s Jaypee Brothers Medical Publishers (P) Ltd, especially Mrs Samina Khan, Mr Subrata Adhikary and Mr Manoj Pahuja for their hard work professionalism, and helped throughout the process of this publication. Basic Surgical Skills and Techniques Sudhir Kumar Jain, David L Stoker, Raman Tanwar CHAPTER 1: Scrubbing, Gowning And Gloving Techniques CHAPTER 2: Knot Tying Techniques CHAPTER 3: Wound Closure Techniques CHAPTER 4: Surgery Of Common Skin Lesions Under Local Anesthesia CHAPTER 5: Sutures In Surgery CHAPTER 6: Patient Positioning During Surgery CHAPTER 7: Anastomosis In Surgery CHAPTER 8: Art Of Instrument Handling CHAPTER 9: Drains In Surgery CHAPTER 10: Minimal Access Surgery CHAPTER 11: Hemostasis CHAPTER 12: Biopsy Techniques Chapter 1. Scrubbing, Gowning and Gloving Techniques Sudhir Kumar Jain, David L Stoker Table of Contents Surgical Hand Scrub ........................................................................................................................... 1 Preparation Before Scrubbing ....................................................................................................... 2 Environment and Equipment in Scrub Area ..................................................................................... 3 Solutions Used ........................................................................................................................... 3 Scrubbing Method ....................................................................................................................... 4 Scrub Up Technique ...................................................................................................................