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References 47
in using disposable over non- disposable drapes in relation to the risk of SSIs (Kisher
etal.2018).
Where the surgical field is draped symmetrically in a ‘square drape’, the assistant
stands on the opposite side of the patient and mirrors the surgeon’s actions (Wha-
lan 2006). For non- symmetric draping, the surgeon will advise. Stand back when
opening drapes to avoid them touching the floor or other unsterile surfaces.
CONCLUSION
This chapter has discussed how vital a role the SFA has during the pre- operative phase
of the patient’s journey. It has highlighted their responsibilities in the safe preparation
of the patient in theatre to contribute to the efficiency of the surgical team.
REFERENCES
Association for Perioperative Practice (2021). Infection control, patient skin preparation.
https://www.afpp.org.uk/news/AfPP_Infection_Control- Patient_skin_
preparation (accessed 7January 2024).
Bilski J. (2023). Put a stop to pressure injuries from the start. https://www.aorn.
org/outpatient- surgery/article/put- a- stop- to- pressure- injuries-
from- the- start.
Centre for Perioperative Care (2024). The National Safety Standards for Invasive
Procedures (NatSSIPs). https://www.cpoc.org.uk/guidelines- resources-
guidelines/national- safety- standards- invasive- procedures- natssips
(accessed 21January 2024).
Dorfel, D., Maiwald, M., Daeschlein, G. et al. (2010). Comparison of the antimicrobial
efficacy of povidone- iodine- alcohol versus chlorhexidine- alcohol for surgical skin
preparation on the aerobic and anaerobic skin flora of the shoulder region. BMC
Antimicrobial Resistance and Infection Control 10: 10– 17.
Hasegawa, T., Tashiro, S., Mihara, T. et al. (2022). Efficacy of surgical skin preparation
with chlorhexidine in alcohol according to the concentration required to prevent surgi-
cal site infection: meta- analysis. British Medical Journal 6 (5): 1– 11.
Kisher, D.C., Wyatt, M.C., Beswick, A. et al. (2018). Does the type of surgical drape
(disposable versus non- disposable effect the risk of subsequent site infection)? Journal
of Orthopaedics 15: 566– 570.
McQuerry, M., Easter, E., and Cao, A.C. (2021). Disposable versus reusable medical gowns:
a performance comparison. American Journal of Infection Control 49: 563– 570.
National Health Service England (2024). Revised never events policy and framework.
https://www.england.nhs.uk/patient- safety/patient- safety- insight/
revised- never- events- policy- and- framework/ (accessed 15March 2024).
National Institute for Health and Care Excellence (2020). Surgical site infections preven-
tion and treatment. www.nice.org/guidance/ng215 (accessed 19January 2024).
48 Chapter 4 Pre- operative Preparation ofthe Patient
NHS England (2022). Delivering a ‘Net Zero’ National Health Service. London: NHS.
Perioperative Care Collaborative (2018). Position statement for the surgical first assis-
tant. file:///C:/Users/Dave/Downloads/sfa- position- statement- final- april- 2018.pdf
(accessed 12January 2024).
Royal College of Surgeons of England (2024). Surgical first assistant. https://www.
rcseng.ac.uk/careers- in- surgery/surgical- team- hub/surgical- team-
roles/surgical- first- assistant/ (accessed 5January 2024).
Shi, L., Cai, L., Wan, F. et al. (2022). Does povidone- iodine application in surgical pro-
cedures help in the prevention of surgical site infections? An updated meta- analysis.
Wideochirurgia I Inne Techniki Maloinwazyjne 17 (2): 261– 278.
Spruce, L. (2021). Preoperative patient skin antisepsis.
Sworn, K., Poku, E., Thokala, P. etal. (2023). Effectiveness of iodine- impregnated incise
drapes for preventing surgical site infection in patients with clean or clean contami-
nated wounds; A systematic literature review and cost- consequence analysis. Journal
of Perioperative Practice 33 (12): 368– 379.
Tanner, J. and Melen, K. (2021). Perioperative hair removal to reduce surgical site infec-
tion. www.cochranelibrary.com (accessed 28January 2024).
Veracammen, Y., Dauwe, D., Vliger, G. etal. (2021). Povidone iodine disinfection asso-
ciated with hypothyroidism and potentially contributing to prolonged kidney failure.
Critical Care 21: 1– 8.
Whalan, C. (2006). Assisting at Surgical Operations. Cambridge University Press
https://www.cambridge.org/core/books/assisting- at- surgical-
operations/FC4982C89E74DE47B757E139187A1CDD.
Wedmore, F. (2023). Reusable gowns and drapes in surgery could reduce carbon footprint
analysis shows. British Medical Journal 381: 853.
Wicker, P. and Dalby, S. (2017). Rapid Perioperative Care. Wiley.
World Health Organisation (2024). WHO surgical safety checklist. https://www.who.
int/teams/integrated- health- services/patient- safety/research/ safe-
surgery/tool- and- resources (accessed 17January 2024).
49
Surgical First Assistant: The Essentials of Practice, First Edition. Edited by Julie Quick and Mark Owen.
© 2025 John Wiley & Sons Ltd. Published 2025 by John Wiley & Sons Ltd.
CHAPTER 5
Assisting with Surgical
Incisions and Wound Closure
Carolina Britton
1,2
1
University College London Hospitals, London, UK
2
Association for Perioperative Practice, Harrogate, UK
SURGICAL INCISIONS
Before Knife- to- Skin
Thanks to standardisation of mechanisms for surgical safety, largely based on the
World Health Organization Surgical Safety Checklist (WHO2009), surgical teams
make a momentary pause (‘time- out’) prior to making the first incision. Regardless
of whether the operation site has been marked or not (see section ‘Skin mark-
ing’), this is the moment when everyone stops and confirms the name of the
patient, the consent, the surgery to be performed and the site of surgery, to avoid
operating on the wrong patient or the wrong site. Figure5.1 depicts the National
Safety Standards for Invasive Procedures (NatSSIPs) Eight, highlighting the
moments when ‘never events’ may occur against the checks designed to avoid
them (CPOC2023).
Operating on the wrong patient or on the wrong site is a ‘never event’, which con-
tinues to affect hundreds of patients every year (NHSE2018). In the 12months before
the 31 of March 2023, 169wrong site surgeries took place in England and around half
of them involved a wrong incision, with 24 incidents of wrong skin lesion being
removed (NHSE2023).
50 Chapter 5 Assisting with Surgical Incisions and Wound Closure
FIGURE5.1 ‘The NatSSIPs Eight’ Author: Nigel Roberts, Head Theatre Practitioner (Head of
Nursing) at Birmingham Women’s and Children’s NHS Foundation Trust, 2023. Supported by
Patient Safety Learning and DrAnnie Hunningher. Version 1– March 2023. Source: Centre for
Perioperative Care (CPOC) (2023).
Surgical Incisions 51
For the SFA, it can sometimes be appealing to use this pause to connect cables,
test equipment, reposition lights, etc., but it is crucial that the SFA does pause and
takes on their role within the team to verify and appropriately confirm the identity of
the patient and the surgical site.
Site andLength ofIncision
While the SFA will not make incisions, enacting this role demands knowledge about
the appropriate site, length and techniques. A surgical incision needs to offer the best
access for the required excision, repair, replacement or exploration that the patient is
to undergo. Secondly, it must ensure that post- operative function is preserved in the
case of surgery to limbs, but also with regards to respiratory function and pressure
areas to be avoided (Armitage and Lockwood2011).
There are several standard surgical incisions, such as a midline incision in abdom-
inal surgery or a sternotomy for open heart surgery, etc, but there are a few variables
that the surgeon weighs up when she or he makes an ‘incision decision’.
One of them is the possibility of having to extend the incision, depending on
intra- operative findings or complications. This is, for example, the case in minimal
access surgery, where opening a larger (often called ‘conventional’ or ‘open’) wound
should be possible by directly extending the original incision.
For the two examples given of midline incisions and sternotomies:
1. Transverse (as opposed to longitudinal) incisions of the abdomen do not offer
the possibility of extending along the target area (as they run across it, rather
than lengthwise), although they may lead to a speedier recovery for the patient
(Brown and Tiernan2005).
2.
An anterior minimally invasive direct coronary artery bypass (MIDCAB) inci-
sion is made from the left border of the sternum over the fourth rib or the
fourth rib space, to provide direct access to the coronary arteries to be revascu-
larised, without the more painful splitting of the sternum; however, this inci-
sion does not allow for extension if cardiopulmonary bypass unexpectedly
needs to be established (requiring a full sternotomy) (Chikwe etal.2016).
Another variable in the planning and execution of surgical incision(s) is the skin’s
natural tension and wrinkle lines, which greatly determine the mechanical response
of the skin at the site of incision (Annaidg and Destrade2019). There are over 30 dif-
ferent guidelines for surgeons to decide the exact direction of elective incisions, and
research is ongoing on which are the most favourable locations to minimise the
aesthetic and functional loss due to scar contracture in different parts of the body (and
for people of different ages and ethnicity, for example), but many surgeons prefer
Langer’s lines (Savitha2017), as shown in Figure5.2. This may be because the use of
the terms ‘Langer’ and ‘skin lines’ has in fact become interchangeable, while the
slightly different wrinkle- line incisions (called ‘Kraissl lines’) are the most recom-
mended guidance in many areas (Maranda etal.2016). Typically, therefore, in every
52 Chapter 5 Assisting with Surgical Incisions and Wound Closure
speciality, there exist standard recommendations for the direction of incisions for
faster healing with smaller scars, and the most expansive literature on the subject is
perhaps found in the fields of elective facial cosmetic surgery and reconstructive head
and neck surgery (Hom2019).
Choice ofInstruments forSurgical Incision
The most common instrument for cutting in surgery is the scalpel (or ‘knife’), and the
most- used blades that can be attached to scalpels are the No. 10, No. 11, No. 15, No. 20
and No. 23 (Ballweg etal.2013). Whichever the size of the blade, the scalpel is consid-
ered the least traumatic and the most precise of all cutting instruments. An 11 blade
allows for sharp, stab- like incisions and is, for example, used to lance an abscess,
insert a chest drain or open a coronary artery for bypass grafting. A No. 10 blade
mounted on the appropriate size scalpel which is held like a violin bow, on the other
hand, is indicated for an incision (using the belly of the blade to modulate the depth
of the incision and the particular orientation with precision) in one smooth stroke
that cuts through the dermis (and other layers with subsequent use, i.e. subcutaneous
tissue and fascia) and prevents bevelling of the skin edges. For short and precise inci-
sions, the No. 15 blade is usually preferred; and for long incisions, such as midline
incision of the abdomen or a sternotomy, a No. 23 blade is the most adequate.
It is also possible to use cutting diathermy for the skin incision and, despite initial
concerns that it could delay healing, it is now considered to offer equal results in cos-
mesis, risk infection and healing (Armitage and Lockwood2011), and some have even
FIGURE5.2 Langer’s lines in female and in male bodies. Image attribution: Goran_tek- en, CC
BY- SA 4.0 <https://creativecommons.org/licenses/by- sa/4.0>, via Wikimedia Commons.
Surgical Incisions 53
found it to be associated with reduced incisional blood loss, incisional time and
post- operative pain (Ly etal.2012; Ayandipo etal.2015). A 2017 Cochrane review,
nevertheless, suggests that the jury is still out on the relative effectiveness of electrosur-
gery compared with scalpel for major abdominal incisions (Charoenkwan etal.2017).
Minimally Invasive Surgery
The use of ports to insert a camera and instruments for minimally invasive surgery
(such as laparoscopy, thoracoscopy and arthroscopy) means that, instead of a bigger
wound created for access, the patient will have one or several smaller incisions made.
Here, size matters once again, as the cosmetic appeal would be to make an incision
as small as possible, but this may lead to an increased risk of infection and tissue
necrosis if the port is then held too tightly; and resolving this later (due to diffi-
culties) often leads to overcompensation and the resulting incision being bigger than
the ideal (Parshad and Suhani2017). Many surgeons will refer to very specific lengths
for different types of trocars, such as an 8- mm incision for a 5- mm port, a 10- mm
incision for a 16- mm port and a 19- mm incision for a 12- mm port (McKay and
Blake2006). Others have described making an impression (or indentation) on the
skin with an empty trocar, and then making an incision along the maximum diam-
eter (Chang etal.2014; Parshad and Suhani2017).
Not all minimally invasive surgery is performed exclusively through one or sev-
eral trocars, and there are several types of smaller incisions which are used to mini-
mise scarring, pain and the risk of infection (as, for example, in minithoracotomies)
and so the important thing to remember is that the right incision requires careful
consideration by the main operator, who often performs the incision themselves, or
offers very close supervision to trainees taking on this step of the procedure.
Skin Marking
The surgeon
1
performing the operation should mark the patient’s skin (defining the
site of the operation and/or with an arrow pointing to it) in cases ‘involving laterality
or multiple structures or levels (e.g. a particular finger, toe, skin lesion, vertebra)’
(WHO2009, p.7). The ideal pen for site marking is appropriate to the colour of the
patient’s skin and the colour of the skin preparation to be used, besides that it should
be ineffaceable to this preparation (Bathla etal.2018).
The WHO also recommends that while site- marking for midline incisions or
single structures (e.g. spleen) will follow local protocols, consistent site marking in all
cases should be considered, as it ‘can provide a backup check confirming the correct
site and procedure’ (WHO2009, p.7).
1
The operating surgeon can appropriately delegate surgical site marking to surgical trainees or surgical
care practitioners, following the General Medical Council ‘Delegation and referral’ standards
(GMC n.d.).
54 Chapter 5 Assisting with Surgical Incisions and Wound Closure
A
B
C
D
E
F
G H
I
J
K
L
M
O
P
Q
R
S
T
U
V
W
X
Y
Z
FIGURE5.3 Overview of incisions of the neck, chest, and abdomen: (a) Carotid incision;
(b)Thyroidectomy incision; (c) Tracheotomy incision; (d) Subclavicular incision; (e) Sternotomy
incision; (f) Infraareolar incision (either side); (g) Inframmamary incision (either side);
(h)Clamshell incision; (i) Kocher or subcostal incision; (j) Mercedes Benz incision; (k)
Paramedian incision (either side); (l) Chevron incision; (m) Epigastrin or upper midline incision;
(o) McBurney’s or Gridiron incision (left side only– for appendicectomy); (p) Rockey- Davis or
Lanz incision (left side only– for appendicectomy); (q) Supraumbilical incision; (r) Infraumbilical
incision; (s) Pararectus incision; (t) Maylard incision; (u) Pfannenstiel or Kerr or pubic incision;
(v)Gibson incision (either side, but conventionally on the left); (w) Midline incision; (x) Inguinal
incision; (y) Femoral incision; (z) Turner- Warwick’s incision. Image attribution: Incisions of the
torso, CC0, via Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/
File:Incisions_of_the_torso.svg.
Common Types ofSurgical Incisions
The location, shape and size of elective surgical incisions follow tested and trialled
approaches to provide the best possible access and exposure and post- operative
recovery. They will depend almost entirely on the operation being performed (e.g. anterior
resection), and/or on the extent of the lesion that is being repaired (e.g. aortic aneurism).
A non- comprehensive list (as incisions for thoracic or thoracoabdominal surgery are
now shown, for example) of types of incisions of the torso is depicted in Figure5.3.
Wound Closure 55
Assisting withthe Surgical Incision
The role of the SFA with regards to the surgical incision is primarily one of vigilance
and advocacy to ensure safe surgery. Assisting with surgical incision, therefore, starts
with participating in the verification of the patient’s identity, planned operation and
location of surgical site incision. In addition, the SFA’s knowledge in the ‘incision
decision’ process is essential to providing expert assistance, namely in instructing
other members of the team and in challenging the operator when/if appropriate.
At the point of incision, the SFA’s assistance may be useful in providing traction,
by gently pulling on the opposite side to the surgeon’s, to facilitate the spread of the
tissue as it is cleaved (Ballweg etal.2013). This is accomplished by pressing down and
stretching the skin away from the projected line of incision, whether that is to be in a
straight line or an elliptical shape (in which case the assistant will press down and
diagonally away). Where incisions are small, the surgeon may prefer to exert traction
themselves, without assistance, using the index and thumb or a four- fingers tech-
nique for elliptical incisions (as originally described by Au1980), as this can allow for
more control and reduce the risk of sharps injuries.
This traction can be provided throughout (layer by layer) and at specific points of
the operation (e.g., when opening a coronary artery or incising the spleen) and so
forceful traction can be extremely damaging, causing nerve injury, uncontrolled
haemorrhage or tearing of organs (Ballweg etal.2013).
Gentle tissue retraction and assisting with haemostasis usually immediately
follow the skin incision, as superficial planes are incised and dissected. The SFA can
apply skin and superficial retraction, but nerve and deep tissue retraction require
direct oversight by the operating surgeon (PCC2018). As for haemostasis, the SFA can
assist by dabbing minor bleeds with a swab improving visibility, and with indirect
application of surgical diathermy, as directed by the surgeon (RCSn.d.). SFAs with an
extended scope of practice, who have undergone approved surgical skills training, can
apply direct diathermy for superficial haemostasis (PCC2018), but beyond that, all
direct haemostatic activity with diathermy, haemostats, ligaclips or suturing is reserved
to the surgeon, supervised surgical trainee or surgical care practitioner (RCSn.d.).
WOUND CLOSURE
It is worth starting by remembering the role of the SFA, as highlighted by the Royal
College of Surgeons, in that ‘SFAs are not allowed to undertake tasks considered to be
surgical interventions [but] are allowed to undertake skin suturing to close simple
wounds provided they have received appropriate training and assessment (e.g.
through the Intercollegiate Basic Surgical Skills course or through demonstrating
competence at the same level)’ (RCSn.d.).
Knowledge of types of wounds, types of wound healing, techniques for wound
closure and of how to assist with wound closure, as follows, will therefore be relevant
56 Chapter 5 Assisting with Surgical Incisions and Wound Closure
to all SFAs. The final sub- sections in this chapter (closing a surgical wound and placing
wound drains) will guide the activities of the SFA with an extended scope of practice.
Types ofSurgical Wounds
The most widely used system to classify types of surgical wounds is that originally
devised by the Centers for Disease Control (CDC) (Herman and Bordoni2023) and
adopted in NICE guidelines (NICE2019), into:
• Class 1 (clean): not infected or inflamed and which does not involve the
respiratory, gastro- intestinal, genital or urinary tracts; it should be closed with
sutures or adhesive closure materials (i.e. by primary intention) and drained
with closed drainage if necessary; examples include a mastectomy wound or an
arthroplasty wound.
• Class 2 (clean- contaminated): not inflamed but with low level of contamina-
tion because it involves entry into the respiratory, gastro- intestinal, genital or
urinary tracts under controlled circumstances; examples of class 2wounds are
hysterectomy or laryngectomy wounds.
• Class 3 (contaminated): surgical wounds of this class are a result of a breach
in surgical aseptic technique (e.g. for open cardiac massage) or of leakage
from the gastrointestinal tract (e.g. bile or from infarcted/necrotic bowels); it
also includes incisions resulting from acute or non- purulent inflammation;
examples are non- sterile debris in the field, cholecystectomy with bile spill-
age and/or acute inflammation and appendicectomy after a ruptured appendix.
• Class 4 (dirty or infected): these are surgical wounds infected as a result of the
presence of organisms in the perioperative field at the time of surgery as is the
case with perforated viscera; examples include surgical management of abscess
and repair of perforated bowel.
SFAs, however, may encounter different wounds, caused by trauma or pressure
injuries, for example. A short and useful image guide, called the Scottish Wound
Assessment and Action Guide (HIS2021), can be found online, illustrating different
types of wounds alongside a brief description and treatment options.
Wound Healing
Wounds heal through a complex interaction between inflammatory mediators and cells,
in an organised sequence of overlapping phases involving haemostasis, inflammation,
proliferation and maturation towards formation of scar tissue (Ballweg et al. 2013;
Grubbs and Manna 2023). Figure 5.4 illustrates these overlapping phases of wound
healing, where limits to typical durations vary within faded intervals, depending on the
severity of the wound.