Chapter 1. Surgical Technique

Asepsis, hemostasis, and gentleness to tissues are the bases of the surgeon's art. Nevertheless, recent decades have shown a shift in emphasis from the attainment of technical skill to the search for new procedures. Undoubtedly, this attitude resulted from the extraordinary increase in the application of surgical methods to new fields. Historically, such a point of view led to an unremitting search for new procedures when results were unsatisfactory, although faulty technique rather than the procedure itself was the cause of failure. Now that all regions of the body have been explored, it is appropriate to stress the important relationship between the art of surgery and success in surgical therapy. The growing recognition of this relationship should reemphasize the value of precise technique.

The technique described in this book emanates from the school of surgery inspired by William Stewart Halsted. This school, properly characterized as a “school for safety in surgery,” arose before surgeons in general recognized the great advantage of anesthesia. Before Halsted's teaching, speed in operating was not only justified as necessary for the patient's safety but also extolled as a mark of ability. Despite the fact that anesthesia afforded an opportunity for the development of a precise surgical technique that would ensure a minimum of injury to the patient, spectacular surgeons continued to emphasize speedy procedures that disregarded the patient's welfare. Halsted first demonstrated that, with careful hemostasis and gentleness to tissues, an operative procedure lasting as long as 4 or 5 hours left the patient in better condition than a similar procedure performed in 30 minutes with the loss of blood and injury to tissues attendant on speed. The protection of each tissue with the exquisite care typical of Halsted is a difficult lesson for the young surgeon to learn. The preoperative preparation of the skin, the draping of the patient, the selection of instruments, and even the choice of suture material are not so essential as the manner in which details are executed. Gentleness is essential in the performance of any surgical procedure.

Young surgeons have difficulty in acquiring this point of view because they are usually taught anatomy, histology, and pathology by teachers using dead, chemically fixed tissues. Hence, students regard tissues as inanimate material that may be handled without concern. They must learn that living cells may be injured by unnecessary handling or dehydration. A review of anatomy, pathology, and associated basic sciences is essential in the daily preparation of young surgeons before they assume the responsibility of performing a major surgical procedure on a living person. The young surgeon is often impressed by the speed of the operator who is interested more in accomplishing a day's work than in teaching the art of surgery. Under such conditions, there is little time for review of technique, discussion of wound healing, consideration of related basic scientific aspects of the surgical procedure, or the criticism of results. Wound complications become a distinct problem associated with the operative procedure. If the wound heals, that is enough. A little redness and swelling in and about wounds are taken as a natural course and not as a criticism of what took place in the operating room 3 to 5 days previously. Should a wound disrupt, it is a calamity; but how often is the suture material blamed, or the patient's condition, and how seldom does the surgeon inquire into just where the operative technique went wrong?

The following detailed consideration of a common surgical procedure, appendectomy, will serve to illustrate the care necessary to ensure successful results. Prior to the procedure, the verified site of the incision is marked with the surgeon's initials by the operating surgeon. Then the patient is transferred to the operating room and is anesthetized. The operating table must be placed where there is maximum illumination and adjusted to present the abdomen and right groin. The light must be focused with due regard for the position of the surgeon and assistants as well as for the type and depth of the wound. These details must be planned and directed before the skin is disinfected. A prophylactic antibiotic is administered within 1 hour of the skin incision and, in uncomplicated cases, is discontinued within 24 hours of the procedure.

The ever-present threat of sepsis requires constant vigilance on the part of the surgeon. Young surgeons must acquire an aseptic conscience and discipline themselves to carry out a meticulous hand-scrubbing technique. A knowledge of bacterial flora of the skin and of the proper method of preparing one's hands before entering the operating room, along with a sustained adherence to a methodical scrub routine, are as much a part of the art of surgery as the many other facets that ensure proper wound healing. A cut, burn, or folliculitis on the surgeon's hand is as hazardous as the infected scratch on the operative site.

The preoperative preparation of the skin is concerned chiefly with mechanical cleansing. It is important that the patient's skin be shaved immediately before operation; perferably in the operating suite after anesthetization. This eliminates discomfort to the patient, affords relaxation of the operative site, and is a bacteriologically sound technique. There should be as short a time lapse as possible between shaving and incision, thus preventing contamination of the site by a regrowth of organisms or the possibility of a nick or scratch presenting a source of infection. The skin is held taut to present an even, smooth surface as the hair is removed with power-driven disposable clippers. The use of sharp razors to remove hair is discouraged.

Obviously, it is a useless gesture to scrub the skin the night before operation and to send the patient to the operating room with the site of incision covered with a sterile towel. However, some surgeons prefer to carry out a preliminary preparation in elective operations on the joints, hands, feet, and abdominal wall. This involves scrubbing the skin with a cleansing agent several times a day for 2 or 3 days before surgery.

In the operating room, after the patient has been properly positioned, the lights adjusted, and the proper plane of anesthesia reached, the final preparation of the operative site is begun. The first assistant scrubs, puts on sterile gloves, and completes the mechanical cleansing of the operative site with sponges saturated in the desired solution. The contemplated site of incision is scrubbed first; the remainder of the field is cleansed with concentric strokes until all of the exposed area has been covered. The skin should appear flushed, indicating that the desquamating epithelium has been thoroughly removed and the germicides are effective. As with all tinctures and alcohols used in skin preparation, caution must be observed to prevent skin blisters caused by puddling of solutions at the patient's side or about skin creases. Similarly, electrocardiographic (ECG) and cautery pads should not be wetted. Some surgeons prefer to paint the skin with an iodine-containing solution or a similar preparation.

A transparent sterile plastic drape may be substituted for the skin towels in covering the skin, avoiding the necessity for towel clips at the corners of the field. This draping is especially useful to cover and wall off an ostomy. The plastic is made directly adherent to the skin by a bacteriostatic adhesive. After application of the drape, the incision is made directly through the material, and the plastic remains in place until the procedure is completed. When, for cosmetic reasons, the incision must accurately follow the lines of skin cleavage, the surgeon gently outlines the incision with a sterile inked pen before the adhesive plastic drape is applied. The addition of the plastic to the drape ensures a wide field that is, surgically, completely sterile, instead of surgically clean as the prepared skin is considered. At the same time, the plastic layer prevents contamination should the large drape sheet become soaked or torn.

Superficial malignancies, as in the case of cancer of the skin, lip, or neck, present a problem in that routine mechanical scrub is too traumatic. Malignant cells may be massaged free into the bloodstream in this way. Following a gentle shave, a germicidal solution should be applied carefully. Similarly, the burned patient must have special skin preparation. In addition to the extreme tissue sensitivity, many times gross soil, grease, and other contaminants are present. Copious flushing of the burned areas with isotonic solutions is important as mechanical cleansing is carried out with a nonirritating detergent.

Injuries such as the crushed hand or the open fracture require extreme care, and meticulous attention to skin preparation must be observed. The hasty, inadequate preparation of such emergency surgery can have disastrous consequences. A nylon bristle brush and a detergent are used to scrub the area thoroughly for several minutes. A wide area around the wound edges is then shaved. Copious irrigation is essential after the scrub and shave, followed by a single application of a germicide. An antibacterial sudsing cleanser may be useful for cleansing the contaminated greasy skin of the hands or about traumatic wounds.

When the skin has been prepped and the patient has been positioned and draped, then a TIME OUT is done. During this time, all physicians and staff must stop what they are doing and listen and verify the information presented, including the patient's name, scheduled procedure including the correct site, allergies, and whether preoperative antibiotics were administered and when as shown in Table 1 of Chapter 3.

Heavy suture materials, regardless of type, are not desirable. Fine silk, cotton, synthetics, or absorbable sutures should be used routinely. Every surgeon has his or her own preference for suture material, and new types are constantly being developed. Fine silk is most suitable for sutures and ligatures because it creates a minimum of tissue reaction and stays securely knotted. If a surgeon's knot is laid down and tightened, the ligature will not slip when the tension on the silk is released. A square knot then can be laid down to secure the ligature, which is cut close to the knot. The knots are set by applying tension on the ligature between a finger held beyond the knot in such a plane that the finger, the knot, and the hand are in a straight line. However, it takes long practice to set the first knot and run down the setting, or final knot, without holding the threads taut. This detail of technique is of great importance, for it is impossible to ligate under tension when handling delicate tissue or when working in the depths of a wound. When tying vessels caught in a hemostat, it is important that the side of the jaws of the hemostat away from the vessel be presented so that as little tissue as possible is included in the tie. Moreover, the hemostat should be released just as the first knot is tightened, the tie sliding down on tissue not already devitalized by the clamp. One-handed knots and rapidly thrown knots are unreliable. Each knot is of vital importance in the success of an operation that threatens the patient's life.

Some surgeons prefer electrocautery rather than ligatures to control smaller bleeders. This produces tissue necrosis, with the cutting electrocautery devitalizing a larger zone of tissue on either side of its incision than does a sharp scalpel.

As the wound is deepened, exposure is obtained by retraction. If the procedure is to be prolonged, the use of a self-retaining retractor is advantageous, since it ensures constant exposure without fatiguing the assistants. Moreover, unless the anesthesia is deep, the constant shifting of a retractor held by an assistant not only disturbs the surgeon but also stimulates the sensory nerves. Whenever a self-retaining retractor is adjusted, the amount of tissue compression must be judged carefully because excessive compression may cause necrosis. Difficulty in obtaining adequate exposure is not always a matter of retraction. Unsatisfactory anesthesia, faulty position of the patient, improper illumination, an inadequate and improperly placed incision, and failure to use instruments instead of hands are factors to be considered when visibility is poor.

Handling tissues with fingers cannot be as manageable, gentle, or safe as handling with properly designed, delicate instruments. Instruments can be sterilized, whereas rubber gloves offer the danger that a needle prick or break may pass unnoticed and contamination may occur. Moreover, the use of instruments keeps hands out of the wound, thus allowing a full view of the field and affording perspective, which is an aid to safety.

After gentle retraction of the skin and subcutaneous tissue to avoid stripping, the fascia is incised in line with its own fibers; jagged edges must be avoided to permit accurate reapproximation. The underlying muscle fibers may be separated longitudinally with the handle of the knife. Blood vessels are divided between hemostats and ligated. Because of the friability of muscle, immediate ligation is more desirable than electrocauterization. After hemostasis is achieved, the muscle is protected from trauma and contamination by moist gauze pads. Retractors may now be placed to bring the peritoneum into view.

With toothed forceps or hemostat, the operator seizes and lifts the peritoneum. The assistant grasps the peritoneum near the apex of the tent, while the surgeon releases hold on it. This maneuver is repeated until the surgeon is certain that only peritoneum free of intra-abdominal tissue is included in the bite of the forceps. A small incision is made between the forceps with a scalpel. This opening is enlarged with scissors by inserting the lower tip of the scissors beneath the peritoneum for 1 cm and by tenting the peritoneum over the blade before cutting it. If the omentum does not fall away from the peritoneum, the corner of a moist sponge may be placed over it as a guard for the scissors. The incision should be made only as long as that in the muscle since peritoneum stretches easily with retraction, and closure is greatly facilitated if the entire peritoneal opening is easily visualized. When the incision of the peritoneum is completed, retractors can then be placed to give the optimum view of the abdominal contents. The subcutaneous fat should be protected from possible contamination by sterile pads or a plastic wound protector. If the appendix or cecum is not apparent immediately, the wound may be shifted about with the retractors until these structures are located.

Although it is customary to wall off the intestines from the cecal region with several moist sponges, we are convinced that the less material introduced into the peritoneal cavity the better. Even moist gauze injures the delicate superficial cells, which thereafter present a point of possible adhesion to another area as well as less of a barrier to bacteria. The appendix is then delivered into the wound and its blood supply investigated, with the strategic attack in surgery always being directed toward control of the blood supply. The blood vessels lying in the mesentery are more elastic than their supporting tissue and tend to retract; therefore, in ligating such vessels, it is best to transfix the mesentery with a curved needle, avoiding injury to the vessels. The vessel may be safely divided between securely tied ligatures, and the danger of its slipping out of a hemostat while being ligated is eliminated. The appendix is removed by the technique depicted in Plates 54 and 55, and the cecum is replaced in the abdominal cavity. Closure begins with a search for sponges, needles, and instruments until a correct count is obtained. In reapproximating the peritoneum, a continuous absorbable suture is used.

With the peritoneum closed, the muscles fall together naturally unless they were widely separated. The fascia overlying the muscles is carefully reapproximated with interrupted sutures and the muscles will naturally realign their positions. Alternatively, some surgeons prefer to approximate the peritoneum, muscle, and fascia in a one-layer closure with interrupted sutures.

Coaptation of the subcutaneous tissues is essential for a satisfactory cosmetic result. Well-approximated subcutaneous tissues permit the early removal of skin sutures and thus prevent the formation of a wide scar. Subcutaneous sutures are placed with a curved needle, large bites being taken through Scarpa's fascia so that the wound is mounded upward and the skin edges are almost reapproximated. The sutures must be located so that both longitudinal and cross-sectional reapproximation is accurate. Overlapping or gaping of the skin at the ends of the wound may be avoided readily by care in suturing the subcutaneous layer.

The skin edges are brought together by interrupted sutures, subcuticular sutures, or metal skin staples. If the subcutaneous tissues have been sutured properly, the skin sutures or staples may be removed on the fifth postoperative day or so. Thereafter, additional support for minimizing skin separation may be provided by multiple adhesive paper strips. The result is a fine white line as the ultimate scar with less of a “railroad track” appearance, which may occur when skin sutures or staples remain for a prolonged time. To minimize this unsightly scar and lessen apprehension over suture removal, many surgeons approximate the incision with a few subcutaneous absorbable sutures that are reinforced with strips of adhesive paper tape.

Finally, there must be proper dressing and support for the wound. If the wound is closed per primam and the procedure itself has been “clean,” the wound should be sealed off for at least 48 hours so it will not be contaminated from without. This may be done with a dry sponge dressing.

The time and method of removing skin sutures are important.

Lack of tension on skin sutures and their early removal, by the third to fifth day, eliminate unsightly cross-hatching. In other parts of the body, such as the face and neck, the sutures may be removed in 48 hours if the approximation has been satisfactory. When retention sutures are used, the length of time the sutures remain depends entirely on the cause for their use; when the patients are elderly or cachectic or suffer from chronic cough or the effects of radiation therapy, such sutures may be necessary for as long as 10 to 12 days. A variety of protective devices (bumpers) may be used over which these tension sutures can be tied so as to prevent the sutures from cutting into the skin.

The method of removing sutures is important and is designed to avoid contaminating a clean wound with skin bacteria. After cleansing with alcohol, the surgeon grasps the loose end of the suture, lifts the knot away from the skin by pulling out a little of the suture from beneath the epidermis, cuts the suture at a point that was beneath the skin, and pulls the suture free. Thus, no part of a suture that was on the outside of the skin will be drawn into the subcutaneous tissues to cause an infection in the wound. The importance of using aseptic technique in removing sutures and subsequent dressing under proper conditions cannot be overemphasized. Adhesive paper strips, colloids, or glue, when properly applied, can make skin sutures unnecessary in many areas.

The example of the characteristics of a technique that permits the tissues to heal with the greatest rapidity and strength and that conserves all the normal cells demonstrates that the surgeon's craftsmanship is of major importance to the patient's safety. It emphasizes the fact that technical surgery is an art, which is properly expressed only when the surgeon is aware of its inherent dangers. The same principles underlie the simplest as well as the most serious and extensive operative procedure. The young surgeon who learns the basic precepts of asepsis, hemostasis, adequate exposure, and gentleness to tissues has mastered his or her most difficult lessons. Moreover, once surgeons have acquired this attitude, their progress will continue, for they will be led to a histologic study of wounds, where the real lessons of wound healing are strikingly visualized. They will also be led to a constant search for better instruments until they emerge finally as artists, not artisans.

The surgeon unaccustomed to this form of surgery will be annoyed by the constant emphasis on gentleness and the time-consuming technique of innumerable interrupted sutures. However, if the surgeon is entirely honest and if he or she wishes to close all clean wounds per primam, thus contributing to the patient's comfort and safety, all the principles that have been outlined must be employed. Fine suture material must be utilized—so fine that it breaks when such strain is put on it as will cut through living tissue. Each vessel must be tied securely so that the critically important vessel will always be controlled. Strict asepsis must be practiced. All this is largely a matter of conscience. To those who risk the lives of others daily, it is a chief concern.