Practical

Surgical
Simulations
Supervised by Asst Prof Dr Hamzah bin Sukiman
Table of contents

01 02 03
CHEST TUBE TOILET & CENTRAL
SUTURE VENOUS LINE

04 05 06
HEMORRHOID SCRUBBING SURGICAL
BANDING AND GOWNING TUBES
01 CHEST TUBE
 INTRODUCTION

● A chest tube is a thin, plastic tube to inserts into the pleural

space (area between the chest wall and the lungs).
 INDICATIONS
1) Pneumothorax
2) Hemothorax
3) Pleural effusion
4) Empyema
EQUIPMENTS
1. Sterile gloves and gown
2. Skin antiseptic solution (such as iodine or 2% chlorhexidine in
70% alcohol)
3. Sterile drapes
4. Gauze swabs
5. Syringes and needles (ranging from 19-25 gauge for adults)
6. Local anesthetic (like lignocaine 1%)
7. Scalpel and blade
8. Suture kit (including stout and non-absorbable sutures like
1.0 - 2.0 silk or prolene)
9. Instrument for blunt dissection (if needed, like a curved
clamp)
10. Guide wire and dilators (for the Seldinger technique)
11. Chest tube
12. Connecting tube
13. Closed drainage system (including sterile water if using
underwater seal drainage)
14. Dressing equipment (may come in a kit form)
PROCEDURE STEPS
 COMPLICATIONS
● cardiac shock, if the tube punctures an area of the
heart
● excessive bleeding
● infection
● injuries to the heart, blood vessels, arteries, or lungs
● perforation (puncturing) of the diaphragm
● punctured lung
 TOILET &
02
SUTURE
 INTRODUCTION

Toilet - cleansing of a wound and

the skin around it

Suture - stitches on body tissues or

wounds

Toilet & Suture - Procedure in which

wound is cleaned and stitched
technically aseptically
 INDICATION

1. Lacerated wounds

2. Continuous bleeding

3. Repairing a torn or broken tendon

4. Surgical wounds
 STEPS
1. Wear a mask.
2. Wash hands aseptically.
3. Wear sterile gloves.
4. Clean the wound.
5. Apply local anaesthesia directly into the wound then the edge of the
wound.
6. Perform debridement if the edge of the wound is jagged or dirty.
7. Hold one third of the needle point using needle holder.
8. Hold the side of the wound edge using a toothed forcep.
9. Start suturing after wound is clean and ready to close.
10. Suture the wound edge (approximately 1 cm from each suture)
11. Tie the suture 2 times.
12. Cut the thread about 0.5 cm above the tie.
13. Clean the wound and place a bandage.
14. Removes gloves and mask.
15. Record in the treatment record book.
 COMPLICATIONS

1. Delayed wound healing

2. Infection

3. Inflammation

4. Bleeding
SUTURE MATERIALS
TYPES OF SUTURE
 CENTRAL
03
VENOUS LINE
 INTRODUCTION

A cannula placed in central vein. (Definition from LITFL)

A vascular catheter that is inserted into a large central vein usually under
ultrasound guidance.

Common sites of insertion into the superior vena cava from:

● Internal jugular vein

● Subclavian vein
● Femoral
● Peripheral vein in antecubital fossa (occasionally)
 INDICATIONS

1) Haemodynamic monitoring (Central Venous Pressure; CVP)

2) Anticipated long term IV therapy
3) Infusions of vesicants or irritant substances (vasoactive
agents or parenteral nutrition administration)
4) Therapies requiring high-volume extracorporeal circulation
5) Difficult peripheral IV access
EQUIPMENTS
Sterile equipment:

(a) Gloves, (b) Gown, (c) Full-body fenestrated

drape, (d) Gauze, (e) Disposable scalpel, (f)

Forceps, (g) Needle holder, (h) Suture material, (i)

Syringe for local anesthesia (right) and

Venipuncture (left), (j) 25-gauge needle for local

anesthesia, (k) Thin-wall needle for venipuncture,

(l) Guidewire, (m) Central venous catheter, (n)

Vessel dilator

Non-sterile equipment:

(o) Antiseptic, local anesthetic, and injectable

saline; (p) Surgical mask

 PATIENT’S PREPARATION
1) Obtain informed consent
2) Apply cardiac monitors to the patient
3) Place patient in Trendelenburg position
4) Skin preparation to create sterile field
5) Apply sterile full body drape
6) Ready ultrasound machine with sterile transducer cover

METHOD/ APPROACH
1) Aseptic technique
2) Head-down tilt
3) Seldinger technique
4) US guided (if possible)
 PROCEDURE STEPS

Patient in trendelenburg position with 15 ° head-down tilt and turned to the left

Note triangle between sternal and clavicular heads of SCM muscle

Identify carotid artery at level of thyroid cartilage using index and middle finger
left hand (Int Jugular vein lies lateral and parallel)

Infiltrate local anaesthesia into skin at proposed puncture site

Advance needle through skin lateral and parallel to carotid pulsation, at 60° to skin (until free aspiration blood
seen)

Remove needle and repeat manoeuvre with seldinger needle

Flexible J end of guidewire passed through needle into vein, remove needle, leave guidewire

Dilator passed through wire into vein and withdrawn. Advance catheter over wire then remove wire. Leaving
catheter in situ

Blood aspirated from catheter (all ports) confirming position in major vein
Flush with saline and suture to skin to fix it in position and apply sterile dressing.
Perform chest xray to confirm position and exclude presence pneumothorax
 COMPLICATIONS

Immediate Early Late

● Pneumothorax ● Hemopericardium and ● Catheter related blood

● Accidental arterial puncture tamponade stream infection (CRBSI)
● Haemothorax ● Blockage catheter ● Thrombosis
● Arrhythmia ● Catheter knots ● Vessel stenosis
● Thoracic duct injury ● Cyclothorax
● Air embolism
 HEMORRHOID
04
BANDING
 INTRODUCTION
A cone of mucosa just above the haemorrhoidal neck is drawn into a banding instrument, often by
suction, and tight elastic bands released around the base of the cone, constricting the hemorrhoidal
vessels

Indications Contraindications

● First degree haemorrhoids which do not ● Patients with coagulopathies

regress with conservative treatment ● Patients on anticoagulation or antiplatelet
● Second degree haemorrhoids medications
● Patients with cirrhosis and portal hypertension

Because of the risk of significant delayed hemorrhage

● Acutely thrombosed hemorrhoids

● Chronic anal fissure (Surgery is a more
appropriate treatment)
 INSTRUMENTS AND PATIENT’S PREPARATION

Instrument Patient’s preparation

● Proctoscope ● No pre-procedure enema, antibiotic or

anaesthesia required
According to RBL systems used: ● Place the patient in jack-knife or left lateral
● Ligator decubitus or lithotomy position
➔ Grasper or forceps
➔ Endoscopic suction ligator
➔ Wall suction ligator
● Rubber bands
 PROCEDURE STEPS

● Patient is properly placed

● Introduce proctoscope into the rectum. Then, the dentate line is located and the hemorrhoids are
identified
● The largest hemorrhoidal column should be treated first
● If utilizing a forceps ligator, an assistant must stabilize the scope while the clinician performs the
ligation
● The internal hemorrhoid is gently grasped about 1 to 2 cm proximal to the dentate line using
forceps (ask the patient regarding any pain or sensation)
● Once it is determined that the appropriate tissue has been grasped, any excess tissue is drawn
towards the tip or drum of the handheld ligator gun apparatus, and the trigger is activated to
release the rubber band

*Misapplication of the band below the dentate line can lead to severe pain, necessitating the
immediate removal of the band by cutting it if severe pain occurs during placement.
 COMPLICATIONS

● Most common complications:

➔ Mild bleeding, pain and delayed bleeding

● Minor complication:
➔ Slippage of bands
➔ Priapism
➔ Difficulty in urination
➔ Anal fissure
➔ Chronic longitudinal ulcers

● Major complications ( less common)

➔ Massive bleeding, thrombosed hemorrhoids, severe pain, urinary retention requiring
catheterization, pelvic sepsis, fistula, and death
 SCRUBBING
05 AND
GOWNING
 INTRODUCTION

Scrubbing, gowning and gloving are vital steps before surgery.

It is an important procedure required to reduce the risk of contamination by

microorganisms during operative procedures

Involves decontaminating of the hands, donning a sterile surgical gown and pair of
sterile gloves
 PREPARATIONS

● Dressed appropriately to enter operating theatre

● You must open your gown and gloves before you scrub to not contaminate your
hands
● Fingernails must be short and no abrasions on skin
● Remove watch, ring and all jewellery
● Wear face mask
● Fold up sleeves of OT attire to >5 cm above the elbow
 STEPS

SCRUBBING
1. Wet hands until 5 cm above the elbow
2. Dispense a small amount of anti-microbial cleansing agent on palm of hand
3. Perform initial hand washing using friction and hand rubbing to 5 cm above the
elbow
4. Rinse hands thoroughly under running water with hands upright
5. Pick a sterile brush
6. Dispense a small amount of anti-microbial cleansing agent on the brush
7. Brush fingernails of both hands then drop the brush
8. Rinse fingernails of both hands
9. Dispense a small amount of anti-microbial cleansing agent on the palm
10. Perform hand rub: rub the palms and back of both hands with fingers interlaced.
Up to 5 cm above the elbow of both forearms
11. Rinse both hands
12. Apply antimicrobial agent on the palm. Perform final hand rub on the palm until 5
cm below wrist of both forearms
13. Rinse both hands thoroughly
 STEPS

GOWNING
1. Open the second layer of gown packs
2. Dap hands with sterile hand towel
3. Grasp collar of sterile gown, hold the gown up and allow bottom of the gown to
unfold downwards
4. Don the gown correctly

GLOVING
1. Keep hands well within the sleeves
2. Pick the right side glove using left hand
3. Place glove on the palm of right/left hand
4. Fingers of the glove pointing towards wearers
5. Right/left thumb of the glove parallel to right/left thumb of hand
6. Stretch and unfold the cuff to cover the right/left ahead within the sleeve
7. Pull the gloves to cover the sleeve
8. Repeat for the other hand
9. Tie sterile gown
 SURGICAL
06
TUBES
 FUNCTION?

DRAIN

ACTIVE PASSIVE
NASOGASTRIC
Tubes that are inserted through the nares to pass through the posterior oropharynx, down the esophagus, and
into the stomach. (Salem-sump vs Dobhoff tube vs SBFT)

Indication:
● Decompression of the stomach in the setting of intestinal obstruction or ileus
● Administer nutrition or medication to patients who are unable to tolerate oral intake

Length: Adult vs Children

Relative Contraindications
Contraindication:
● Anticoagulation
Absolute Contraindications
● Previous Gastric Bypass Surgery
● Significant Facial Trauma (basilar skull fractures)
● Hiatal Hernia Repair
● Esophageal Trauma
● Abnormal GI Anatomy
● Esophageal Obstruction (Presence of neoplasm or foreign object)

Complication: ● Esophageal
● Nasal Trauma Perforation
● Misplacement ● Metabolic Alkalosis
● Sinusitis
 Pigtail Catheter/Tube
Is a flexible tube typically made of medical-grade plastic or silicone used for drainage purposes in various
clinical settings.

Indications Contraindications
● Pleural Effusion ● Coagulopathy or Bleeding Disorders
● Pneumothorax ● Infection at the Insertion Site
● Ascites ● Class III Obesity
● Abscess Drainage (Liver abscess) ● Peritoneal Adhesions
● Lack of Imaging Guidance
Advantages ● Patient Allergy to Catheter Material
● Less Traumatic
● Effective Drainage

Complications
● Infection
● Blockage
● Dislodgement
 T-Tube
Is latex, silicone, or red rubber shaped, similar to the English letter T which placed in the common bile duct following
procedures involving the duct.

Provide external drainage of bile via a controlled route the original pathology is resolving.

Indication:
● Choledochotomy
● Duodenal fistulas
● Pancreaticoduodenectomy
● Hepaticojejunostomy in liver transplantation
● Intractable stones before the ERCP

T tube placement may also be used for CBD drainage when ERCP and PTC fail to clear the CBD intraluminal
non-malignant obstruction. This is a rare indication, but it can relieve the obstruction and prevent further
complications.

Complication:
● Leak around the tube: This can occur due to improper sealing or placement.
● Tight closure of the choledochotomy → Strictures
●
Penrose Drain
Passive Drainage
Draining surgical wounds and sites with shallow abscesses.

Jackson-Pratt (JP) Drain

Active Drainage
Postoperative drainage of fluid and blood

Hemovac Drain Active Drainage

Postoperative drainage (where significant fluid
accumulation is expected)

Cholecystostomy Tube
The cholecystostomy tube is used for percutaneous
drainage of the gallbladder.

Nephrostomy Tube
For direct drainage of the renal pelvis.
Continuous Bladder Drainage
A procedure for inserting a catheter into the bladder for therapeutic or diagnostic purposes.
Indication:
Therapeutic: Diagnostic:
● Management of urinary retention (acute or chronic)
● Perioperative urine management in surgeries ● Measurement of aerodynamics
● Management of neurogenic bladder dysfunction ● Collection of urine for urinalysis
● Urinary incontinence management ● Radiographic studies (e.g., cystogram)
● Hygiene and social reasons in certain patients
● Close urinary output measurement in acutely ill patients
● Delivery of chemotherapy drugs
● Bladder irrigation

Complications Contraindications
● Infections (CAUTI , Bladder) ● Blood at the meatus indicating potential
● Pain due to traction on the drainage bag injury
● Paraphimosis ● Gross hematuria
● Urethral injury ● Evidence of urethral infection
● Catheter obstruction from sediment buildup ● Urethral pain or discomfort
● Urine leakage from bladder spasms ● Low bladder volume/compliance
● Patient refusal
Significant Concerns
 Methods of Continuous Bladder Drainage
Indwelling Foley Catheter Suprapubic Catheter

A Foley catheter is a thin, flexible tube A suprapubic catheter is inserted through a

inserted into the bladder through the small incision made in the lower abdomen
urethra. It has an inflatable balloon at the directly into the bladder.
tip that is filled with sterile water to keep
the catheter in place inside the bladder.
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