Surgeons, what to buy for suture practice?

[Grurik]

Hey all,

I wonder what to buy for practicing sutures at home.

DeBakey forcep? Or just a normal forcep of any kind?
Needle driver?
Sutures? Are there sutures better than other for practice only? I guess the price is the only determinant haha..
This should be enough I guess..

Some specific questions:
- What would you recommend? I find needle drivers between like 10 cm to 30 cm. I know by experience I have had more trouble handling these long instruments, would you just take something in between and master it? Like 15-20 cm?

Is this "advanced suture technique":
- Palming the instruments?
- Learning to throw suture with your non-dominant hand? I have seen surgeons throwing sutures with their non-dominant hand, and other who choose to to "backhand" sew (don't know how to explain, haha..).

Then I have a question about general surgical technical skills:
I cannot see the difference about "put a suture there" on the skin, and doing vascular anastomosis. It seems to be to not be more technically challenging to close a skin than to make a vascular anastomosis. When I have been scrubbing in on technically difficult surgeries (Tx, whipples, CABG etc) I haven't been "Wow, how was he able to put a suture on that right place, that's insane..." .

What has made the surgeries I have been scrubbed in at difficult, that has made it to be a lot of discussion or calling an even more experienced colleague has been more. Whipple, the anatomy looked really weird, especially the vascular anatomy. Whipple, abnormal anatomy needed help how to get all thing together and a more senior colleague was only like "save some extra of the intestine, and it will make it easier finishing the last step later". Liver surgery, made the dissection into the liver hilum, found some suspect thing, had to call 2 radiologists to determine with US what it was - did not make it more technically challenging, just changed their dissection a bit.

I'm impressed of their work of course. It's not like I hear that the top surgeons at the academic centers are god technicians. And "Everyone can make hernia surgery, but if you want to do whipple procedure you will have to be a master". I was more impressed by their cerebral part.

My question is really, what is REALLY technically advanced surgery? (I have not been scrubbing in on microsurgeries).

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[alpinism]

Forceps, needle driver, and 4-0 or 5-0 is all you need.

For skin our surgeons usually use monocryl (absorbable) or nylon (non-absorbable) depending on the incision and if they can be removed later.

It really doesn't matter what specific types of instruments you use, in the end its all about practice.

 

[SouthernSurgeon]

Then I have a question about general surgical technical skills:
I cannot see the difference about "put a suture there" on the skin, and doing vascular anastomosis. It seems to be to not be more technically challenging to close a skin than to make a vascular anastomosis. When I have been scrubbing in on technically difficult surgeries (Tx, whipples, CABG etc) I haven't been "Wow, how was he able to put a suture on that right place, that's insane..." .

Well, the physical aspect of placing a stitch is not the most technically difficult portion of a case. I don't think any surgeon would say that it is.

For a vascular anastomosis - there are definitely technical aspects of suturing that are very important - more than just "putting a stitch in the right place" it is putting the stitch in the right place in the least traumatic fashion possible. If you put tension on the skin when you are suturing it's not a big deal. Do that during a vascular anastomosis and you can tear a delicate vessel, or create an intimal flap/dissection that will cause your anastomosis to thrombose. There's also the matter that often times you are doing the suturing in a 20 cm deep hole with 6-0 or so suture. Quite a bit harder to be precise than on the skin.

But the technically challenging part of a vascular anastomosis is actually the conceptual parts - picturing how the anastomosis will come together, making sure it will lay in an orientation that won't kink or have resistance to flow.

For a whipple, the technically challenging portions of the case are mostly in the dissection stage. The P-J anastomosis gets a lot of attention due to high leak rates and the complications that result from this, but that is more a factor of the tissue than it is the sutures themselves (i.e. don't f*** with the pancreas). Again, the difficulty in the anastomoses in a whipple (relative to closing skin) is just that you are often sewing at an awkward angle in a deep hole. And that it's a "one shot" suture - i.e. if you are repetitively putting holes in the pancreas because your sutures are in the wrong place or you pull back or something like that, I'm pretty sure your attending will have a stroke.

And "Everyone can make hernia surgery, but if you want to do whipple procedure you will have to be a master". I was more impressed by their cerebral part.

My question is really, what is REALLY technically advanced surgery? (I have not been scrubbing in on microsurgeries).

There has long been a cohort of general surgeons who treat the Whipple as the measure by which all surgeons are judged. If you were a department chair, odds were you were a whipple surgeon.

As I said above, the technically difficult portions of the case are the things you are ignoring to place emphasis on suturing. It's the portal dissection in a patient who has had preop neoadjuvant therapy. The other parts of the dissection where if you aren't in the right plane you will quickly get in trouble.

Yeah, in short, there are more technically challenging cases. But by focusing on suturing, you're missing the forest for the trees. The suturing is the easy part, oftentimes.

 

[Grurik]

Thanks a lot for answers!

southernIM, awesome answer! Been reading a lot of your posts around and it's always an enjoyable read.

It's not that I put all emphasize on the "suture movements", it was just that skill that seemed to take the most manual dexterity. It was more that I was impressed by the cerebral part, "shall we cut it?", "what can we do now on step 1 to make step 10 easier?". It was just no single step in the surgeries I felt I wouldn't have the dexterity to do after practicing it for a while (I might be very naive here, probably a lot of "hidden" manual dexterity is in this and that combined with having a great understanding of anatomy and variations make it seem easy), after all these guys I watched performs 1-3 whipples/week. On the other hand, you hear what technical gods these guys are. I'm impressed by the inguinal hernia surgeons, too, even though they by some seems to be seen as half-trained surgeons (ie not peforming the big whacks cases). It's just that the whipple surgeons has the experience of the surgery like "in step 6 you can mess things up really badly, I've learned that if you do X, than Y won't happen and you won't mess upp".

Could you please comment on the "palming instrument" and learning to sew with the non-dominant hand? Is that seen as advanced techniques, especially the sewing with non-dominant hand?

 

[giantswing]

Put two layers of gloves on. Slick your hands with water and oil, then practice tying and simples.

 

[Winged Scapula]

As a third year medical student, palming the instrument, sewing with your non-dominant hand and one handed ties are all advanced skills that you absolutely do not need to know or master. Also please do not purchase surgical instruments. Ask a scrub nurse or tech if you can borrow a driver, scissors and Adson, or get a suture removal kit and use the scissors as a driver.

 

[Kaustikos]

True story: I was tying with my non dominant hand when I first learned and it's still the one I'm most comfortable with. I didn't realize it until a resident asked if I was left handed... lol. It's so awkward using my right hand now. And it's my dominant hand.
It's all about using your hands correctly. Learning to use your wrist and not your entire arm. Being able to do forehand vs backhand. Knowing how to angle your needle.
My frustration is when someone asks me to suture left to right instead of the other way.
Also, micro needle drivers or whatever it is they use in vascular surgery. I HATE the ones that clamp. Hate hate hate them.

 

[Kaustikos]

As a third year medical student, palming the instrument, sewing with your non-dominant hand and one handed ties are all advanced skills that you absolutely do not need to know or master. Also please do not purchase surgical instruments. Ask a scrub nurse or tech if you can borrow a driver, scissors and Adson, or get a suture removal kit and use the scissors as a driver.

Agreed. I got a couple needle drivers now. And I usually have no problem getting suture/ties by asking scrub techs.
Also, no shame in asking for a tie to practice during cases.
Regarding how it doesn't look difficult... Well, wait until you do it. I got to do a cabg and the attending handed me the needle driver telling me to finish. I was nervous as ****. Realize that it's not that it appears easy...it's being able to do it consistently and without any error. Knowing how deep to drive.
Knowing how to angle.
And the obvious: every single step of the procedure memorized perfectly. Surgeons make a Whipple look easy but try and recall every step. Try being able to know what the next step is.

 

[Wordead]

True story: I was tying with my non dominant hand when I first learned and it's still the one I'm most comfortable with. I didn't realize it until a resident asked if I was left handed... lol. It's so awkward using my right hand now. And it's my dominant hand.
It's all about using your hands correctly. Learning to use your wrist and not your entire arm. Being able to do forehand vs backhand. Knowing how to angle your needle.
My frustration is when someone asks me to suture left to right instead of the other way.
Also, micro needle drivers or whatever it is they use in vascular surgery. I HATE the ones that clamp. Hate hate hate them.

The Castroviejos changed my life when I first used them. Don't know why they aren't utilized at more institutions. They feel so much more normal. Some institutions use them just for skin closures, which to me they are perfect for.

 

[mimelim]

I have a little drawer with practice stuff. Been collecting since MS3. Other than the castros and the fishing line which I bought, everything else I got from scrub techs or others in the hospital.

@southernIM hit all the major points. Only thing that I have to add is the fishing line or just a spool of thread is the best way to practice your knot typing. You will never run out and it cost like $2. That is the same spool that I had as an MS3. Learn your knots with a rope (see my bootstrap in the plastic bag) and then practice, practice, practice and lastly have someone check you doing stuff.

 

[Kaustikos]

The Castroviejos changed my life when I first used them. Don't know why they aren't utilized at more institutions. They feel so much more normal. Some institutions use them just for skin closures, which to me they are perfect for.

Yeah,
I like them and they are comfortable. I just need to become better experienced with clamping them. But knowing they have a non clamp version makes me want to just use those.
I'd also add that knowing the names of these instruments is helpful. Scrub techs prefer you calling them by their names instead of "pickups ". Because that's very vague... As I learned.
Also learning how to assist someone that's suturing via holding the line properly.