BASIC SURGICAL TECHNIQUES G. W e ber M.D., Ph.D Professor of Surgery

1. BASIC SURGICAL TECHNIQUES G. Weber M.D., Ph.D Professor of Surgery Department of Surgical Research and Techniques Medical Faculty, Semmelweis University

2. BASIC SURGICAL TECHNIQUES Basic surgical skills are needed throughout the medical profession Our aim to teach and practice basic surgical maneuvers Topics: • special behavior in the operating theatre, • preparation the surgical team before operation, • surgical tools and instruments, • wound management. skills training and assessment

3. Skills training Skills training allows • to appreciate your own technical ability, • reveal whether youare interested in participating in technical procedures, and • therefore influence your choice of residency training.

4. Skills training and assessment Surgeon OR Researcher

5. Key competencies required for a physician Technical skills&Intellectual skills Coordinated team work

6. Intellectual skills(non-technical skills) manifested in aspects of performance, such as • leadership, • decision-making, • task management, • communication and team working, • situational awareness. Recognize: collapse, Decision: help (in time!)

7. DEPARTMENT OF SURGICAL RESEARCH AND TECHNIQUES Dpt. and secretary: NET XI. floor English course director: Györgyi Szabó e-mail: gyorgyisami@yahoo.com feedback: mutettan@gmail.com Homepage: http://semmelweis.hu/mutettan Informations and abstracts of the lectures here following the presentations.

8. Lectures: (Monday15.00-15.45)

9. Practical sessionsEvery group has 7 practicals – week ‘A’ and week ‘B’

10. Location of practical sessions The 1st to 4th and the 7th courses will be held in the Surgical Teaching Theatre. The theatre accessed from the Main Hall of the NET. Follow the signs down by the stairs.

11. Location of practical sessions The 5th and the 6th courses will be held in the laparoscopic training lab, in 1st Seminar room.

12. Expectations • Students are required to attend the lectures. • Attendance is obligatory on practical sessions. • To participate on the practice is your interest: practical items you can learn only here. Without required skill you will not be able to pass exam. • You are allowed to work only in the group where you have registered on the Neptun portal. • Because of limited capacity of operating theatre, absences can be replaced only after registration by joining another group.

13. Expectations • Practical sessions begin exactly on time. • Do not be late because you will not be able to accomplish your task. • Please note that during each course proper nail hygiene is necessary (fingertip-high nails). In addition, the use of nail-polish, artificial nails, any jewellery, including watches are prohibited. Who does not respect our requirements will not take part on the courses and considered absent without credit.

14. Expectations • Handle the surgical instruments properly. • If an instrument is damaged, cracked or broken during your practice you should sign a statement. • You do not need to pay for any damaged instruments except if your responsibility is clear.

15. Practical sessionsevery second week (3x45 perc = 2 h and 15 min.) 1. Getting acquainted with the operating theatre, ethics and behaviour, scrubbing-in, and preparation of the surgical field. Basic surgical instruments and their proper usage.2. Knotting and basic suturing techniques on the skill model (simple interrupted suture).3. Basic suturing techniques on the pig foot (interrupted sutures).4. Basic suturing techniques on the pig foot (continuous sutures).5. Presentation of the laparoscopic tower, the associated equipment and laparoscopic instruments.6. Practicing  hand movements using a  laparoscopic pelvitrainer. 7. Lessons in tissue dissection and suturing using anesthetised rats (removal of a „naevus” from the back and median laparotomy).

16. Practical session:scrubbing-in, gowning and gloving Goal: To train in the appropriate procedures and methods of gowning and gloving in preparation for participation in the operating room. Teacher will provide a brief introduction, demonstrate the appropriate technique, and provide feedback on each step.

17. Practical session:surgicalinstruments Goal: To introduce to the use and names of various surgical instruments.

18. 2. Practical sessionKnot tying/Basic Suturing on a skill model Goal: To introduce to the technique of knot tying and basic suturing. Task: to learn the appropriate use of suture equipments (needle holder, forceps, scissors), tie a two-handed knot, to perform an instrument tie and the proper technique of simple interrupted suture

19. 3. Practical sessionBasic suturing techniques on the pig foot simple interrupted suture interrupted sutures: Horizontal mattress and vertical mattress (Donati)

20. 4. Practical sessionBasic suturing techniques on the pig foot Simple continuous suturing intracutaneous suture

21. 5. Practical session Laparoscopic instrumentation By the end of the session the students will be able to demonstrate an understanding of laparoscopic instrumentation

22. 6. Practical sessionlaparoscopic basic skills A series of 6 plastic rings are picked up in turn by a grasping forceps from a pegboard on the surgeon's left, transferred in space to a grasper in the right hand, then placed around a post on the corresponding right-sided pegboard. After all rings are transferred from the left to right, the process is reversed, requiring transfer from the right to left hand.

23. Peg transfer • This task is designed to develop depth perception and • visual-spatial perception in a monocular viewing system and • coordinated use of both the dominant and nondominant hands.

24. 7. Practical sessionWound management on anaesthetized rats Tissue preparation and wound closure: removal of a „naevus” from the back and median laparotomy.

25. The exam The number of missed practices may not exceed more than 25%. (only one absence!) Missing two or more practices, the semester will not be credited. (only one replacement is possible!) Basis: lectures and practices The textbook and DVDcan be downloaded on the Neptun portal {Homepage » Information » Education » Documentations of faculties} Additional textbook (offered):R.M. Kirk: Basic Surgical Techniques ed. Elsevier

26. The exam The exam starts with a test of a minimum requirements. • Knowledge of relevant history of surgery • Details of asepsis and antisepsis • Understand the sterile field of the operating room • Theoretical and practical aspects of wound healing, knot tying, suturing materials, and suturing • Knowledge of general surgical and laparoscopic instruments You are allowed to continue exam achieving at least 80 %.

27. The exam Next step is the practical exam: Examinees rotate through six stations, where they perform elements of surgical tasks and are graded by expert examiners using global rating forms such as respect for tissues, economy of motion etc. and task-specific checklists. Workstation:1.) scrubing- in – gowning and gloving2.) knowledge of basic surgical instruments3.) manual knots4.) making stitches5.) knowledge of laparoscopic instruments6.) laparoscopic practice in pelvitrainer Last step is the theoretical part.

28. Practical exam- workstation I.Scrubbing and gowning – aseptic technique Task: to demonstrate the ability:• to perform perfect surgical scrub• assisted-gowning technique • gloving understand the sterile field of the operating room There is no part sterility!! Evaluation: perfect (20 point), any failure: (0 point)

29. Practical exam- workstation II.surgical instruments Task: to identify, appropriately handle and know the use of:• Basic cutting/dissecting instruments• Basic clamping/occluding instruments• Basic grasping/holding instruments• Basic retracting/exposing instruments• Needle holders instruments You should recognize and use5 surgical instruments asked randomly: 0-5 point

30. Practical exam- workstation III. manual knots Task: to demonstrate the ability to tie a two-handed knot (square and surgeons knot) You will be asked to tie four times two-handed knots. Based on quality and dinamic performance: 0-10 point

31. Practical exam- workstation IV.Basic Suturing Task: demonstrate the appropriate use of suture equipment (needle holder, forceps, scissors) demonstrate the ability to perform an instrument tie. demonstrate the proper technique for closing a wound simple interrupted simple continuous horizontal and vertical mattress intracutaneous suture You should demonstrate the proper technique of suturing Based on quality and dinamic performance: 0-10 point

32. Practical exam- workstation IV.Basic Suturing You should demonstrate the appropriate use of suture equipment (needle holder, forceps, scissors) Performance: 0 point !!

33. Practical exam- workstation V.knowledge of laparoscopic instruments Task: to identify, appropriately handle and know the use of laparoscopic instrumentation You should recognize and use 5 laparoscopic instruments asked randomly: 0-5 point

34. Practical exam- workstation VI.laparoscopic practice in pelvitrainer Task: Peg transfer with mid air transfer Time 0:00-2:30 min 10 point 2:31-2:45 9 2:46-3:00 8 3:01-3:15 7 3:16-3:30 6 3:31-3:45 5 3:46-4:00 4 4:01-4:15 3 4:16-4:30 2 4:31-4:45 1 4:46 - 0 Exercise is scored for efficiency (time) and precision (penalty).

35. Final result Workstations 60 point Theoretical part(oral) 40 point 100 point The final grade is determined by the practical and the theoretical performance 0-59 points: failed (1)60-69 points: passed (2)70-79 points: average (3)80-89 points: good (4)90-100 points: excellent (5)

36. DEPARTMENT OF SURGICAL RESEARCH AND TECHNIQUES After the successful final exam students are allowed to participate in the research program of the department (Students’ Scientific Association (TDK) and demonstrator students are also welcome! Please, contact course director or your teacher!

37. Operating theater in which students and other spectators could watch surgeons to perform surgery. Today the term is used as operating room, the room that provides a sterile environment within a hospital where surgical operations are carried out.

38. Operating theater Gaetano Petrioli (Róma, 1750) Würzburg 1804

39. Operating theater - XXI. SRI International, Menlo Park, CA January, 2007

40. Operating theater - XXI. SRI International, Menlo Park, CA January, 2007

41. Operating theater - XXI.

42. Patient care – Future SRI International, Menlo Park, CA January, 2007

43. Operating team consists of the chief surgeon, who directs the surgery; one or more assistant surgeons, who help the chief surgeon; the anesthesiologist, who controls the supply of anesthetic and monitors the person closely; the scrub nurse, who passes instruments to the surgeon; and thecirculating nurse, who provides extra equipment to the operating team.

44. Anesthesia The monitoring equipment and anesthesia used during surgery are usually kept at the head of the bed. The anesthesiologist stands here to monitor the patient's condition during surgery. Depending on the nature of the surgery, various forms of anesthesia or sedation are administered.

45. Operating room typically contains a monitor that displays vital signs, an instrument table, and an operating lamp. Anesthetic gases are piped into the anesthetic machine. A catheter attached to a suction machine removes excess blood and other fluids, which can prevent surgeons from seeing the tissues clearly. Intravenous fluids, started before the person enters the operating room, are continued.

46. Operating room All personnel wear protective clothing called scrubs. They also wear shoe covers, masks, caps, eye shields, and other coverings to prevent the spread of germs. The surgical site is cleansed and surrounded by a sterile drape.

47. Location of the Operating Theatre Suites • Separated from the main flow of hospital traffic • Should be easily accessible from surgical wards and emergency rooms. • Floor should be covered with antistatic material, • The walls should be painted with impervious, antistatic paint. (reduces the dust levels and allows frequent cleaning) • The surfaces must withstand frequent cleaning and decontamination with disinfectant.

48. Layout of the Operating Theatre sterile supplies store scrub-up area Recovery area Anesthetic room clean corridor

49. Temperature and Humidity • The temperature and the humidity (not less than 55%) play a important role in maintaining staff and patient comfort. • They must be carefully regulated and monitored.(In low humidity there is a danger of the production of electrostatic sparks.) • Ideally, the operating room should be 1ºC cooler than the outer area. (This aids in the outward movement of air: the warmer air in the outer area rises and the cooler air from within the operating theatre moves to replace it.)

50. Laminar flow & ultraclean air Laminar airflow is designed to move particle free air over the aseptic operating field in one direction. It can be designed to flow vertically or horizontally and is usually combined with high efficiency particulate air (HEPA) filters. HEPA filters remove particles > 0.3 micron in diameter with an efficiency of 99.97%.