BASIC SURGICAL SKILL PART 2
DR. Reno Rudiman, dr., SpB-KBD
Irra Rubianti Widarda, dr., SpBP-RE(K)
Teguh Marfen Djajakusumah, dr., SpB(K)V
Putie Hapsari, dr., SpB(K)V
Rani Septrina, dr., SpBP-RE
Euis Maryani, dr. SpB, SpBTKV
I. General Objective
After completing skills practice, the student will be able to perform all the neccisity in
Basic Surgical Skills
II. Spesific Objects
At the end of skills practice, the student will be able to
1. Know the surgical instruments and its function
2. Handle each instrument properly
3. Perform local infiltration anesthesia
4. Perform interrupted and vertical matress suture
III. Sylabus Description
3.1. Sub Module Objective
After finishing skill practice, the student will be able to
1. Handle each instrument properly
2. Perform local infiltration anesthesia
3. Perform interrupted and vertical matress suture
3.2. Expected competencies
Student will be able to demonstrate the procedure for local infiltration anesthesia,
interrupted suture and vertical matress suture.
IV. Method
a. Presentation
b. Demonstration
c. Coaching
d. Self practice: role – play
3.3.Laboratory facilities
a. Skills laboratory : table, chairs, examination couch, surgical instruments (minor
set), sterile drape, lidocaine, 5 cc syringe, sterile gloves, povidone iodine, gauze,
suture needle, suture material.
b. Trainers
c. Manequin
d. Student learning guide
e. Trainer’s guide
f. References
3.4.Venue
Skills laboratory A3.1
3.5.Evaluation
a. Point Nodal Evaluation
b. OSCE
INSTRUMENT HANDLING
STEP / TASK
Preparation
1. Check all the instruments you have
2. Make sure you have the sterile instruments in a sterile container
3. Open the sterile surgical blade, gauze, syringe, suture material and sterile gloves. Place
them in the sterile area
4. Prepare the local anesthetic agent
5. Wash your hands thoroughly by using antiseptic liquid
6. Dry hands with sterile towel
7. Put on sterile surgical gloves
Handling instruments
1. Recognize the name of every instruments you have and its function
2. Take a scissors : recognize the type of the scissors. (tissue or suture)
Grip a scissors properly by inserting the distal phalang of thumb and distal phalange of
ring finger into the rings (or bows). Use the index finger to steady the scissors by
placing it over the scissor’s joint. Cut with the tips of the scissors
Steady the scissors over the fingers of the contralateral hand if needed
3. Take a haemostatic artery forceps: recognize the type of the artery forceps. Hold it in a
similar manner to scissors. Place on vessels using the tips of the jaws and secure
position using the ratchet lock. Learn to release it gently without tearing the tissue.
4. For the left hand, hold the forceps with the thumb and index finger. Grasp the distal
ring and the ring finger resting on the undersurface of the near ring and 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.
5. Take the needle holder : Grasp it in a similar manner to scissors. Try to be familiar
with its rachet lock
6. Read the package of suture material and the surgical needle. Open the package and
show the needle
7. Take the needle holder and grasp surgical needle in 1/3 proximal of its cirrcumference.
Pull the suture material from its package with your hand.
Needle and suture material have to be within your eye range.
8. Take the dissecting forceps : recognize the type of the dissecting forceps. Two main
types of forceps are available, toothed for tougher tissue such as fascia or skin, and
non-toothed (atraumatic) tor delicate tissues such as bowel and vessels.
Hold gently between thumb and fingers, the middle finger playing the pivotal role,
Handle it gently and not to crush the tissue
9. Take the scalpel (blade holder) : recognize the scalpel number with the appropriate
blade size
Note: scalpel no. 3 for odd-fronted-number blade (e.g 11,32) and scalpel no. 4 for
even-fronted-number blade (e.g 20, 22,23)
10. Take the blade from kidney dish. Grasp it with needle holder at the back of blade.
Take the blade holder. Slip the groove of blade holder in to the hole of the blade and
push it with your palm until you hear the sound “click”
Put them in the kidney dish. One kidney dish for one blade.
Learn to pass it within the kidney dish
11. Learn to use the scalpel no. 4 with palmar grip and scalpel no. 3 with pencil grip
12. Detaching the blade by flicking it from the groove. Push the blade a little and move
your needle holder to the back of the blade. Pull your scalpel
LOCAL ANAESTHESIA AND SUTURING
STEP / TASK
Client Assesment
1. Greet the patient and introduce yourself
2. Check the medical record : patient identification and the indication. Ask the patient
regarding allergic reaction
3. Asses the lesion / area for procedure
4.. Briefly explain the procedure and give detail answer when she/he ask certain question
with simply understood words
5. Have the patient remove the clothing necessary to provide adequate exposure of the field
of operation or have patients disrobe and put on a hospital gown
6. Ask the patient to scrub the operative area with generous amounts of soap and water or
preferably with a surgical soap
7. Let the patient lie on the table,get her/him settled in a comfortable position on the table
and try to put her/him at ease
Planning
1. Check all the instruments needed
2. Make sure you have the sterile instruments in a sterile container
3. Check the local anaesthetic : whether it is the appropriate anaesthetics and the expiring
date
4. Open the sterile surgical blade, gauze, syringe, suture material, drape and sterile
gloves. Place them in the sterile area
5. Do not touch the sterile instruments with unsterile hand and vice versa
6. Select specific type and size of suture material
7. Wash your hands thoroughly by using antiseptic hand soap and dry them with sterile
towel
8. Put on sterile gloves in closed technique
9. Ask an assistant/nurse to open the anesthetic ampoule and hold it while you take
sufficient amount of lidocaine with the syringe. Put the syringe back to the steril area.
Weaker the solution if needed
Implementation
1. Swab the injection site with povidone iodine or alcohol solution or similar antiseptic in
cirrcular manner before giving the injection
2. Cover the area with a sterile drape
3. Puncture needle 90 degree to the skin surface, draw it a little to make sure that it does
not puncture any vessels. Push the anesthetic agent to produce skin wheal. Then move
the needle approximately 45 degree and push the anesthetic agent as you move forward
slowly
Sudden injection in large volume will cause pain.
4. The infiltration area is such a way to circumscribe the lesion along what is to be the
proposed line of incision and dissection area
5. Wait an adequate time for anaesthesia to develop
Inspect ‘reactions’ and ‘allergic responses’ to local anaesthetics have been due to
inadvertent intravenous injection of the anaesthetics with or without added adrenalin
6. Make an incision by using a scalpel.
Insert the blade 900 from the skin and angulated to 450 as you move your incision.
Angulated it again 900 as you exit the skin
7. Take the needle holder and hold it properly
8. Insert the suture to needle holder
9. Start suturing : Interrupted sutures
10. Place carefully at 90 degree angles to the wound edges. First suture in in the half of the
wound
11. Tie a careful reef knot and lay to one side of the wound
12. Cut suture ends about 0.5 cm long to allow enough length for grasping when removing
13. Make another suture by using halving technique until the wound is perfectly
approximated
14. 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. Pull it
to the middle of the wound
15. Practice making vertical mattress sutures
Evaluation
1. Evaluate whether all the length of the wound already well-sutured
2. Evaluate any bleeding persists
3. Cover the wound with sterile dressing/bandage
Documentation
Document the following :
a. Date and time of the operation
b. Diagnosis and type of operation
c. Type and size of the suture
d. Difficulties encounters
e. Name of the operator and signature
