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Basic Surgical Skills and
Techniques
Basic Surgical Skills and
Techniques

Editors
Sudhir Kumar Jain MS FRCS FACS FICS
Associate Professor
Department of Surgery
Maulana Azad Medical College and
Associated Lok Nayak Hospital
New Delhi, India

David L Stoker MD FRCS FRCSE

Consultant Surgeon
University College of London Hospitals and
North Middlesex University Hospital
London, UK

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

New Delhi • Ahmedabad • Bengaluru • Chennai • Hyderabad
Kochi • Kolkata • Lucknow • Mumbai • Nagpur
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
Corporate Office
4838/24 Ansari Road, Daryaganj, New Delhi - 110002, India, +91-11-43574357
Registered Office
B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi 110 002, India
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1745, Pheasant Run Drive, Maryland Heights (Missouri), MO 63043, USA, Ph: 001-636-6279734
e-mail: [email protected], [email protected]
Basic Surgical Skills and Techniques
© 2008, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by
any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and
the publisher.
This book has been published in good faith that the material provided by contributors is original. Every effort is made to
ensure accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error(s). In
case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition: 2008
ISBN 978-81-8448-408-3
Typeset at JPBMP typesetting unit
Printed at Ajanta
 Dedicated to

Our wives and children for their

support in spite of their neglection by us during the
process of this work
Our parents for their blessings
Our teacher for their wisdom
Our students who inspire us daily
our patients, from whom we continue to learn daily
 Contributors
Amit Gupta Shiv Chopra
Consultant Surgeon Consultant Surgeon
Vinayak Hospital, Noida Indraprastha Apollo Hospitals
UP, India New Delhi, India
Beryl Antoinette De Souza
Plastic Surgeon Sudhir Kumar Jain
Chelsea and Westminister Hospital Associate Professor
London, UK Department of Surgery
David L Stoker Maulana Azad Medical College and
Consultant Surgeon Associated Lok Nayak Hospital
University College of London Hospitals and New Delhi
North Middlesex University Hospital India
London, UK
Vanessa Brown
Gemma Conn
Specialist Registrar Specialist Registrar
North Middlesex Hospital North Middlesex Hospital
London, UK London, UK
 Preface
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 ten years ago.
At the same time, basic surgical training for medical students and for junior doctors is being
compressed into a shorter timeframe, as other medical specialties 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 or she will have less “hands on” experience in theater, ward or clinic and
inevitably the practical aspects of surgery tend to suffer.
This small 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 first 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 superfluous 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
 Acknowledgements
Our sincere thanks to Shri JP Vij, Chairman and Managing Director of M/s Jaypee Brothers Medical
Publishers for his encouragement, support and inspiration. We are grateful to Mr. Tarum Duneja
Director (Publishing) for helping us by valuable suggestions during the process of this work.
We express our gratitude to Mr Ravi, Medical Artist, Maulana Azad Medical College, New Delhi
for making illustrative and informative diagrams.
We express our special thanks to the whole production team of Jaypee Brothers Medical Publishers
for their hard work and professionalism, particularly Mr. Subrato for his help throughout the process
of this publication.
 Contents
1. Scrubbing, Gowning and Gloving Techniques .......................................................................... 1
Sudhir Jain, David L Stoker
2. Knot Tying Techniques ................................................................................................................... 11
Sudhir Jain, David L Stoker
3. Wound Closure Techniques ........................................................................................................... 30
Sudhir Jain, David L Stoker
4. Surgery of Common Skin Lesions under Local Anesthesia ...................................................... 36
Sudhir Jain, Beryl De Souza
5. Sutures in Surgery ............................................................................................................................ 40
Sudhir Jain, David L Stoker
6. Patient Positioning during Surgery ................................................................................................ 47
Sudhir Jain, David L Stoker
7. Anastomosis in Surgery ................................................................................................................... 52
Sudhir Jain, Amit Gupta
8. Instrument Handling ....................................................................................................................... 64
Sudhir Jain, David L Stoker
9. Drains in Surgery .............................................................................................................................. 73
Sudhir Jain, David L Stoker
10. Minimal Access Surgery .................................................................................................................. 77
Sudhir Jain, David L Stoker
11. Hemostasis ........................................................................................................................................ 86
Sudhir Jain, David L Stoker
12. Biopsy Techniques ........................................................................................................................... 90
Sudhir Jain, David L Stoker
13. Dissection Techniques .................................................................................................................... 94
Sudhir Jain, Shiv Chopra
14. Surgical Diathermy: Principles and Precautions ......................................................................... 97
Sudhir Jain, David L Stoker
15. Dressings and Wound Care .......................................................................................................... 102
Gemma Conn, Vanessa Brown

Index .................................................................................................................................................. 107

 1 Scrubbing, Gowning and
Gloving Techniques

SURGICAL HAND SCRUB are brought to the skin surface by perspiration

A surgical hand scrub is performed prior to and oil secretions, and the bacterial count on the
skin again increases. Hand scrub therefore needs
donning a sterile gown and sterile gloves. Hand
to be repeated between procedures.
scrub does not render the skin sterile, but
surgically clean, by reducing the number of
Preparation before Scrubbing
organisms on the skin and hence reducing the
risk to the patient if a glove is perforated during Personal cleanliness is of paramount importance
surgery. for members of the surgical team. This includes
Surgical scrub can be defined as a systematic daily showers, frequent shampoos and attention
washing and scrubbing of the hands and forearms to hands and finger nails. Staff with rashes,
with an effective antibacterial cleaning solution infective lesions or open wounds of the skin on
to render the skin of hands and arms as free from hands, nails or arms should not scrub. Staff with
bacteria as possible. colds, sore throats or systemic infections should
The following two types of bacterial popu- not scrub.
lation are normally present on the skin. Scrubbed personnel should have short nails,
so that they are not visible over the tips of the
Transient Organisms fingers. Short nails are easy to clean and if kept
smooth will not puncture gloves. Finger nails
These organisms are introduced on to the skin
should be free from nail varnish, as chipped
surface by soil, dust and by various other
fingernail polish can harbor greater numbers of
substances. Surgical scrub will remove most of
bacteria. Artificial nails should never be worn as
these organisms.
fungal growth can occur when moisture becomes
Resident Organisms trapped between the artificial nail and natural
nail.
These are primarily gram-negative and gram- Watches, bracelets and rings should be
positive bacteria with a natural habitat under the removed and kept in a safe place. Bacteria and
finger nails and in the deeper layers of skin, e.g. in dead skin cells accumulate beneath jewellery.
hair follicles, sweat glands and in sebaceous Every surgical team member should wear a
glands. clean, short sleeved cotton scrub suit before
Scrubbing removes bacteria from the skin entering the semi-restricted/restricted areas of the
surface and from just beneath the surface. After surgical suite. Sleeves of the scrub shirt should be
gloving, resident bacteria from the deeper layers four inches above the elbow.
2 Basic Surgical Skills and Techniques

Street clothes or hospital uniforms are not A surgical mask should be worn by the
allowed in these areas. A scrub shirt may be tucked surgeon, and assistant to cover the nose and mouth
in to the trousers to avoid contamination by the completely. This protects the patient from exhaled
shirt tail flapping into the sterile field. Trouser oropharyngeal bacteria (Fig. 1.1). It may not be
legs should not touch the floor as this may necessary to wear a mask for all laparoscopic
transport bacteria from one place to another. surgical procedures.
Personnel should wear shoes especially
assigned for the surgical suite. Shoes should cover Environment and Equipment in Scrub Area
the toes completely. This is to prevent injury from The scrub area should be large enough to allow
sharp or heavy instruments falling from the the scrub personnel to gown and glove safely
operating table, and to prevent soiling of toes by without hindrance.
the patient’s blood or body fluids. Shoes should A wall clock should be strategically placed to
be cleaned at the end of the day. Street shoes are time the scrub, and there should be provision to
not allowed in restricted areas unless covered by control water temperature.
sterile shoe covers. Shoe covers should be used on Sink height should be sufficient to minimize
a single use basis and must be discarded on splashing, and taps should be elbow or knee
leaving the restricted area. operated.
Personnel should wear a disposable surgical
cap in such a manner so that hair is covered Solutions Used
completely to avoid contamination of the sterile
Hibiscrub—(Cholorhexidine 4%)
field by falling hair or dandruff (Fig. 1.1).
Betadine scrub—(Povidone iodine 7.5%)
Soap
These are in liquid form. The first two are
preferred because:
1. They are non-irritating to most people.
2. They leave a minimum number of micro-
organisms on the skin.
3. They have a prolonged antibacterial effect on
the skin when used regularly. They leave a
film on the skin which keeps the resident
bacteria to a minimum and do not interfere
with the skin’s natural resistance to transient
bacteria.
4. They lather easily in hot, cold or hard water.
5. The amount of detergent needed is small.

Scrubbing Method
Scrub should be performed before the first case in
the morning and in between cases. Two methods
Fig. 1.1: Proper method of wearing of scrub technique are used, the time method and
cap and mask the brush stroke method. Rinsing time is not
 Scrubbing, Gowning and Gloving Techniques 3

included in the total scrub time if the time method Dispense around 5 ml of antibacterial soap
is used. In the brush-stroke method, a prescribed solution in to the palm. A nail brush should be
number of brush strokes are applied lengthwise used only on nails or in web spaces but not on
for each surface of fingers hands and arms. rest of the skin (Fig. 1.3).
Unsterile objects should not be touched once Scrubbing should start from fingers to one inch
the scrub process has begun. If this happens,
below the elbow, not from elbow to fingers
accidentally, the entire scrub process should be
repeated. (Fig. 1.4).

Scrub Up Technique
Scrubbing procedure must take a minimum of two
minutes if scrub solutions are used and five
minutes if soap is used.
Water temperature should be set at comfort
level.
Wet hands and forearms (Fig. 1.2).

Fig. 1.3: Scrub finger nails with nail brush

Figs 1.2A and B: Wet hands and forearms before Fig. 1.4: Scrub all sides of fingers
starting scrub
4 Basic Surgical Skills and Techniques

Following the final rinse, the hands and

forearms should be elevated away from the body
allowing water to drop from the elbows. Hands
and forearms should be dried using a folded
disposable hand towel separately for each side.
Drying should start from fingers towards elbows.
The towels should be discarded immediately after
drying the hands and forearm. Towel should
remain folded to double thickness while drying
(Figs 1.7 to 1.10).

Surgical Gown Technique

Gowns should be properly fitting, permitting
freedom of movement. Each sleeve should be
Fig. 1.5: Continuing scrub process on hands provided with a tight fitting cuff. Gowns should
ideally be water repellent.
Hands should be held higher than elbow, so When donning a gown one should touch only
that water flows downwards off the elbows the inside surface. If the outside of the gown is
(Fig. 1.5). touched, it is deemed contaminated and should
Water splashing on theater clothes should be be discarded. Gowns are folded with the inside
avoided as wet clothes may cause contamination facing the scrubbed person to facilitate sterile
of the sterile gown. Hands and forearms should gowning.
be washed and rinsed at least twice after scrub- Scrubbed personnel should keep their hands
bing (Fig. 1.6). and arms above their waist and away from the

Figs 1.6A and B: Rinsing forearms and hands

 Scrubbing, Gowning and Gloving Techniques 5

Fig. 1.7: Picking up folded hand towel Fig. 1.8: Drying hands using rotating movements

Fig. 1.9: Drying the forearms Fig. 1.10: Drying the elbows

body at an angle of 20 to 30° above the elbows. If Procedure for Gowning

scrubbed hands and arms fall below waist level Lift the inner side of the neck of the gown upwards
they are considered contaminated. and away from the table (Fig. 1.11).
After donning, the parts which are considered While holding at the neckline, the gown is
sterile are sleeves (except the axillary area) and allowed to unfold completely with inner side facing
the front from waist level to a few inches below the wearer (Fig. 1.12).
Slip both hands into the open armholes keeping
the neck opening. Gowns must be made of
the hands at shoulder level and away from the
material that minimizes the passage of micro-
body. Push both hands and forearm into the sleeves
organisms and body fluids, and should also be
of the gown but advance hands up to the proximal
tear and puncture resistant. They should be lint edge of the cuff. Do not allow hands to come out of
free to reduce particle dissemination into the the cuff (Figs 1.13 and 1.14). Ungloved hand should
wound or the environment. not touch the front of the gown.
6 Basic Surgical Skills and Techniques

Fig. 1.11: Pick up the gown from inner side near neck Fig. 1.12: Unfold the gown

Fig. 1.13: Slide hands and arms in to the sleeves Fig. 1.14: Slide the arms into sleeves the full distance but
without protruding fingers from the cuffs

The gown is secured at the back by the 3. Gloved hands must be kept within full view at
circulating staff (Figs 1.15 to 1.16). all times.
Rules to observe while wearing sterile gowns
4. Do not tuck gloved hands under the arm pits,
and gloves.
1. Do not drop hands below the level of the as axillary region is considered contaminated.
umbilicus or below the sterile working area. 5. Never touch an un-sterile area with gloved
2. Never place hands behind the back. hands.
 Scrubbing, Gowning and Gloving Techniques 7

Figs 1.15A and B: Adjustment of the gown over the shoulder

Gloving
Closed gloving is the technique of choice because
gloves are handled through the fabric of the gown
sleeves, thereby preventing bare hands from
coming into contact with the outside of the glove.

Gloving Technique

1. Hands are advanced into the sleeves of the

gown till the cuff is reached.
2. The glove packet is opened in such a way that Fig. 1.16: Circulating staff secures the gown at the neck
the right glove faces the right hand.
3. Pick up the left glove by its folded cuff edge
with a sleeve covered right hand (Fig. 1.17).
4. Place the glove on the opposite gown sleeve,
palm down, with the glove fingers pointing
towards shoulder (Figs 1.18 to 1.20). The palm
of the hand inside the gown sleeve must be
facing upwards towards the palm of the glove.
Hold the bottom rolled edge of the glove with
thumb and index finger (Fig. 1.21).
5. Grasp the uppermost edge of the glove’s cuff
with the opposite hand and stretch the cuff of Fig. 1.17: Picking up a glove by its folded cuff edge with a
the glove over the hand. Put left hand covered sleeve-covered hand
with gown sleeve into glove’s cuff (Fig. 1.22).
Advance your finger out of the gown sleeve over the gown sleeve with right hand covered
inside the cuff of the glove and adjust them with gown sleeve (Fig. 1.23).
into the respective finger stalk. Adjust the glove 6. Don right glove in a similar manner.
8 Basic Surgical Skills and Techniques

Fig. 1.18: Place the glove on the opposite sleeve Fig. 1.19: Place the glove on the opposite sleeve
(Left glove on right sleeve)

Fig. 1.20: Glove should be placed in such a way that the Fig. 1.21: Hold the bottom rolled edge of the glove with
rolled edge of the gloved cuff is at the junction of gown thumb and index finger
cuff and sleeve

Fig. 1.22: Stretching the glove cuff over the hand Fig. 1.23: Pulling the glove on to the hand
 Scrubbing, Gowning and Gloving Techniques 9

Final Tie of the Gown (After Donning Gloves) If the gown is a paper disposable one, then a
If the gown is cotton, the waist tie can only be disposable tab attached to the waist tie can be
passed around behind the gowned person by a handed to a non-scrubbed member of staff to be
scrubbed and gowned member of staff, to main- passed around the waist. The disposable tab is
tain sterility. then discarded (Figs 1.24 to 1.28)

Fig. 1.24: Scrubbed person holds the paper tab holding Fig. 1.25: Paper tab holding belt passed to
belt and belt tie circulating staff

Fig. 1.26: Circulating staff holding paper comes to the Fig. 1.27: Scrubbed person hold the belt without touching
side of the scrubbed person the paper tab and pull on the belt
10 Basic Surgical Skills and Techniques

KEY POINTS
1. The purpose of scrubbing is to reduce number
of organisms on skin so that the risk to the
patient is less if gloves become perforated
during surgery.
2. One can scrub with antiseptic solution or
with soap.
3. Recommended scrubbing time is 2 minutes
with antiseptic solution and 5 minutes with
soap.
4. Scrubbing time does not include rinsing time.
5. While wearing a gown one should touch only
the inside of the gown.
6. A gown is contaminated if one touches out-
side of the gown.
7. Closed gloving technique is better than open
Fig. 1.28: Scrubbed person will take hold of the belt tie
and tie the belt to it gloving technique.
 2 Knot Tying Techniques

Knots are used in surgery for approximation of 7. Tension should be maintained on the knot after
tissues or for ligation of blood vessels. More than the first loop has been tied to avoid loosening
1400 knots have been described in Encyclopedias of the throw.
of knots, but only a few are used in surgery. The 8. Extra ties do not add to the strength of a
type of surgical knot used depends upon the properly tied and squared knot but only add
material used, location, depth of the incision and to the bulk.
the amount of stress placed upon the wound.
Multifilament sutures are easier to tie than Methods of Knot Tying
monofilament sutures, because they have a high 1. Hand tied knot
coefficient of friction and the knots remain in 2. Instrument tied knot
position as they are laid down, in comparison to 3. Endoscopic knot tying
the monofilament variety which have a low
A hand tied knot can be:
coefficient of friction, resulting in the knot having
1. Granny knot
a tendency to loosen. Monofilament sutures have 2. Square knot or reef knot
memory, and they tend to return to their resting
3. Surgeon’s knot
shape. While tying knots, surgeons must work
4. Reverse surgeon’s knot
slowly and meticulously, as undue speed in knot 5. Double-double knot
tying may result in a poor tie, and slippage.
A hand tied knot can be either by one hand or
by two hands.
Safe Principals of Knot Tying
1. The completed knot must be firm to avoid The Importance of Knot Tying
slipping. The knot is the weakest link in a tied surgical
2. Knot must be as small as possible and ends suture. The consequences of suboptimal and faulty
should be cut short. knot construction may be disastrous. For example,
3. Whilst tying a knot, friction between strands massive hemorrhage may result from a poorly tied
must be avoided as this can weaken the suture. knot on a large artery. Knot disruption may also
4. Avoid excessive tension to the suture while lead to wound dehiscence or incisonal hernia.
applying knot. It is important to understand the mechanical
5. Final tension on the final throw should be as performance of a united and knotted suture, and
nearly horizontal as possible. an important consideration in a suture’s mecha-
6. Care should be taken to avoid damage to the nical performance includes knot breakage and
suture material when handling it. knot slippage.
12 Basic Surgical Skills and Techniques

Components of a Knotted Suture Loop then the index finger throw is used. If the short
end is towards the operator, the middle finger
A tied suture has three components:
1. The loop created by a knot maintains approxi- throw is used. If the short end is towards the right
hand side of operator, then one can use either
mation of the divided wound edge.
index finger throw by left hand or middle finger
2. A knot is composed of a number of throws
snagged against each other. A throw is a throw by right hand. If the short end is towards
the left side of operator, then one can use middle
wrapping or weaving of two strands.
finger by left hand or index finger throw by right.
3. Ears act as insurance that the loop will not
Crossing of hands at the end of each throw is
become untied because of knot slippage.
important. It means the short end is away from
Each throw within a knot can be either a single the operator, it should come towards the operator
or double throw. A single throw is formed by at the end of throw. Crossing of hands is also
wrapping the two strands around each other so known as squaring of the knot and is important,
that the rotation of the wrap is 360°. so that the knot does not become an unsafe slip
In a double throw, the free end of the strand is knot.
passed twice instead of once around the other 1. Hold the short end of suture between the
strand. The rotation of this double wrap throw is thumb and ring finger of the left hand with the
720°. loop over the extended index finger. Hold the
remainder of the suture material with the right
Square knot: When the right ear and the loop of the
hand. Abduct the left index finger, so that short
two throws exit on the same side of the knot or end of suture forms a loop (Fig. 2.1).
parallel to each other. 2. Bring the suture held in right hand near loop
Granny knot: When the right ear and loop exit or of short end held in left hand, by moving right
cross different sides of the knot. hand away from you (Fig. 2.2).
3. Bring the index finger of left hand in front of
Surgeon’s knot: It comprise of initial double throw thread held between left thumb and ring finger
followed by a single throw. (Fig. 2.3).
4. Pronate the left hand so that the left index
Reverse surgeon’s knot: It comprise of initial double
finger brings the thread held between left
throw followed by a single throw and then
thumb and ring finger inside the loop.
followed by a double-wrap throw.
5. Pull the thread out of loop by grasping it
Double-double knot: It consists of two double between left index and middle finger and
throws. complete the throw by bringing left hand
towards you and right hand away from you
One handed square knot technique: It can be tied using (Fig. 2.4).
either hand. 6. Continue to hold the short end of the suture in
This type of knot is employed if using a suture left hand between thumb and index finger. Flex
with a needle attached to it. After passing the and abduct left index finger so that it lies at
needle through tissue, the thread is pulled until right angle to remaining left hand fingers
the end of the suture attached to the needle is long. (Fig. 2.5).
One handed tying of a knot uses two types of 7. Bring the thread held in the right hand across
throws, i.e. index finger throw and middle finger the left middle finger towards the operator to
throw. If the short end is away from the operator cross the left handed thread (Fig. 2.6).
 Knot Tying Techniques 13

Fig. 2.1 Fig. 2.2

Fig. 2.3 Fig. 2.4

Fig. 2.5 Fig. 2.6

14 Basic Surgical Skills and Techniques

Fig. 2.7 Fig. 2.8

Fig. 2.9

Figs 2.1 to 2.9: Various steps of single handed reef knot

8. Use middle finger of left hand to bring short Double Handed Reef Knot
end under the right handed strand of suture.
A double handed reef knot is used if there is a free
(Figs 2.7 to 2.11).
suture without needle attached to it. So instead of
9. Grasp the short end between left middle and
ring finger and bring short end away from you the short end and long end, there will be two equal
and tightened the knot. ends. One end away from operator and one end
towards operator.
Single Handed Surgeon’s Knot 1. End away from operator is placed over
In this knot there is double throw in the first half extended index finger of left hand and held
knot. To create this knot the short end is drawn in palm of left hand, keeping left thumb free.
twice through the loop made over index before Other end is held in right hand (Fig. 2.11).
pulling the short end towards operator. Knot is 2. End held in right hand is brought between
completed by making a middle finger throw. left thumb and index finger (Fig. 2.12).
 Knot Tying Techniques 15

Fig. 2.10A: Cross-section of completed reef knot Fig. 2.10B: Completed reef knot final appearance

3. Left hand is turned inwards by pronation

and thumb is brought under the end over left
index finger to form the first loop (Fig. 2.13).
4. End held in right hand is crossed over the
loop on left thumb and held between thumb
and index finger of left hand (Fig. 2.14).
5. Right hand releases the end held by it. Left
hand still holding the other end between
index finger and thumb is supinated and
brings the other end through the loop formed
over left index finger (Fig. 2.15). Fig. 2.11
6. Other end released by left hand and grasped
by right hand.
7. First half knot completed by applying
horizontal tension and crossing hands
(Fig. 2.16).
8. Left hand supinated and loop formed over
left thumb (Fig. 2.17).
9. End held in right hand is brought in between
left thumb and index finger and is crossed
over the loop formed on thumb by end held
in left hand.
10. Left hand supinated (Fig. 2.18). Fig. 2.12
16 Basic Surgical Skills and Techniques

Fig. 2.13 Fig. 2.14

Fig. 2.15 Fig. 2.16

Fig. 2.17 Fig. 2.18

 Knot Tying Techniques 17

Fig. 2.19 Fig. 2.20

Fig. 2.21 Fig. 2.22

Figs 2.11 to 2.22: Various steps of two hand tied reef knot

11. End held in the right hand is now held 15. Final tension on the final throw should be as
between left thumb and index fingers nearly horizontal as possible.
(Fig. 2.19).
12. Left hand is pronated and rotated inwards Surgeon’s Knot by Two Hands
thus carrying the other end through the loop (Figs 2.23 to 2.33)
formed over left thumb (Fig. 2.20).
13. Right sided end is regrasped between right This differs from two handed square knot in the
thumb and index finger. first half. Other end held in right hand is passed
14. Second half knot completed by applying hori- through the loop formed over left index finger
zontal tension across two ends (Figs 2.20 to twice, before pulling the two ends in opposite
2.22). direction in horizontal plane.
18 Basic Surgical Skills and Techniques

Fig. 2.23A Fig. 2.23B

Fig. 2.24A Fig. 2.24B

Fig. 2.25A Fig. 2.25B

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