Book/Reference for Sutures, Instruments, Etc. in 2020

[Lem0nz]

Hello,

I'm a surgical fellow and have reached a point in my training where my pride is worth nothing and I readily admit my weaknesses in hopes of being a better surgeon. Half-joke. Sort of. Maybe not joking.

But seriously, one thing I have somehow made it almost seven years of training and not figured out is a good understanding on surgical instruments, sutures, needle types, naming conventions, etc. Which instruments are safe for handling bowel? Which suture types are best for mucosa? For serosa? Why are people using vicryl and silk interchangably for a bowel anastomosis?

This isn't to say I don't have knowledge on these things - its just that most of my training is "this is how its always been done so this is how you do it". I would like a deeper understanding. From a long view, honestly, after 7 years many of these choices probably really doesn't make a difference. One vs. two layers vs. three, absorbable vs. permanent (as long as it isn't an intraluminal type suture) honestly probably doesn't make a difference, but I really want to know what these things were designed for originally and how they are *supposed* to be used, not how many surgeons just actually use them without knowing the underlying theory. Does it matter if I use a cutitng needle or a reverse cutting needle? Why? Do vascular anastomoses need to be done with prolene every time? I've seen someone do them with PDS - did it really matter?

In addition, I'd like like to have a better understanding of surgical instruments, names of them, etc. In particular, vascular clamps. There are like, 10,000,000 of them and I don't know the first thing about any of them other than trying to pick one that seems to fit the hole size that I'm jamming it into (and honestly, from what I can tell, 90% of surgeons with decades more experience than me are doing the exact same thing). I'd really like to understand though how and why these instruments were designed and if there is a difference. Maybe there just isn't and it really is just pick the instrument that fits the hole that you're trying to jam it into and the curve that will get you safely around the vessel without tearing a hole in it.

Also looking for a good guide on choosing surgical staplers and technique. I have a basic understanding of staple height and what color loads go to what tissue based on thickness but that is wildly simplistic. I'd rather be choosing staple height on the thickness of my tissue to be more adaptable to inflamed tissue, delicate tissue, etc. Further, I learned from one of my colorectal attendings that the EEA has that green zone on it and you aren't actually supposed to crank that stapler all the way closed - that anywhere in the green zone is fine and you should be using it based on how the tissue feels, not as hard as you can possibly tighten it until its all the way down, and that overtightening may actually increase your leak rate. This is the sort of information I want to understanding about staplers - the "next level" if you will.

Same question for choosing vessel sealing devices (which ligasure I should actually be using based on what I'm sealing, why).

Finally, looking for information on the da vinci robot - a guide concise guide on what is available, what instruments should be grasping what type of tissue safely, etc. How the the cautery numbers on the da vinci compare and relate to cautery off a conventional generator box for the bovie - how the vessel sealer compares to a ligasure. I want to understand all of this better instead of just picking "what works".

Appreciate any advice from senior surgeons, junior residents, or anyone in between that has had these questions come up and answered. I know some of this information is easily obtained from the reps and manufacturers but I've found that hard to translate into more practical applications because that information is really designed to sell us a product and tell you the EXACT scenario the instrument was designed for, when in reality surgeons may use it for 3,000 other applications that are "not what it was specifically designed for" but that it honestly may work wonderfully for.

Thanks!
-Idiot, Sorta Humble Fellow

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[Dr.LeoSpaceman]

Tools of the Trade, Rules of the Road by Ed Deitch. It's out of print, but it provides much of the info on the "basics" that most just assume we learn...even though it's never formally taught. I've honestly never found the same info in any other book. Some of it is dated, but most is timeless.

As it pertains to surgical energy, take a look at the ACS FUSE curriculum.

If you want technical information of staplers, I'd honestly reach out to the rep for Ethicon or Medtronic/Covidien. They'll either be able to get it to you, or find someone who can answer your questions. The interesting thing you'll find is that we often end up using the devices in a way that either isn't recommended (or we fail to take advantage of some of the benefits provided by certain devices).

And ultimately, regardless of what you find, you may not get answers that satisfy you. For better or worse, surgeons love dogma. It's not about the fact that--for example--I suspect PDS may in fact work on a vascular anastomosis. It's that when your anastomosis blows out, you know some old timer is going to tsk-tsk you for using PDS even if it had nothing to do with the suture you used.

 

[TraumaLlamaMD]

I’d like to second the above recommendation for Tools of the Trade - great book that covers a lot of the topics you mentioned, OP, with the exception of robotic surgery. I have asked my robotic reps questions in the past like “what instrument have you seen other surgeons using for this task?” which has gotten me a bit of anecdotal, “off label” advice.

 

[mestielest]

Good topic, thanks heartily I suppose most of us experienced similar situations. Firstly, there is a "in charge problem" in surgery. When you are the chef, you get out of the rules. Of course you should not, but in practice it is very common. So there are some surgeons around use X or Y during some part of the procedure and never questioned why. They just learned that way and used. Some of them never renew their knowledge. I know some folks who are practicing the same thing they have learned from their seniors in 80s. For instance using a heavy prolene to anchor the mesh to the pubis during a Lichtenstein. So, not everything we see from our seniors (or even from experts of the field) are correct.

There is also no "single answer" in some situations. Some practices are kinds of dogma as @Dr.LeoSpaceman mentioned just above. Someone said that "it should be like this" and we all followed him. There can be some alternatives etc. There is a bunch of different practices around involving the practice but never reported in the literature. After starting to practice you just use one of them. One can use Vicryl or silk or small clips to ligate varicocele; you can do a end-to-end or end-to-side for bowel; you can use a fine vicryl or a fine pds or a fine monocryl for ureteral repair; a middle size pds or vicryl or monocryl for renal repair, you can close the median cystotomy by a continous 2/0 vicryl taking the whole layers or a three layer closure with 4/0 vicryl for the mucosa 3/0 vicryl for the detrusor and 2/0 vicryl for a Lambert etc etc. They will all provide similar results.

Another point that the practice is not linear. Some mistakes may go uneventful while some solid procedures may go disasterous. soi that's life. For example, in a radical nephrectomy I spotted that I have fired a intestinal load to the renal hilum. It was a pure mistake. But nothing happened. Thus, we cannot propose using a intestinal load to control vessels, however, I can say that one time I did it unintentionally and it worked. Someone who were watching me may thought I use intestinal load during nephrectomy, but in reality it was just a mistake. On the other hand, unfortunately, there are some surgeons around who does not even know the difference. They just use it. It is another kind of problem. There are some dump people on the street, and in the operating theatre. There are some surgical nurses who thinks that Rapid Vicryl and Vicryl are the same; while both are Vicryls (I know it makes sense ) There are some surgeons who cannot understand the basics of the anatomical dissection. I saw a fellow in a tertiary center who were trying to pass a mid-penil stab-wound by a flexibl cystoscopy. The wound was 5-6 cm below the frenulum and had very well wound sides. It was just like a scalpel cut. So only thing he should have done was clearing the wound, putting a catheter and making a primary repair using a fine absorbable suture. Even if he decided to leave to a secondary healing (which was ridicilous), he could put a catheter under direct vision. I asked him what he was trying to do. He said that he would pass the are with a cystoscope and put a catheter and leave it to a late repair??? I asked him why and he said that because erectile function is better in late repairs. So, he was not able to differentiate a bulbous rupture due to a whole-body trauma vs a single stab wound to the penile urethra. And yes, he was a politically-supported one. These kind of people exist. Try to learn from their mistakes, not from their practice.

And some important part is the healing process. Some people got wounds and heal spontanously while some healthy-looking people are dying just during their routine. It also applies to the surgery. I had patients who had an uneventful course after a ureteral perforation without and drainage; I had a patient who passed away because of urosepsis even after a timely (at least we thought it was) nephrectomy and ICU care. So a good anastomosis may work or not; a bad anastomosis will probably not work - but sometimes it can work. So seeing a practice and its result may not answer all questions; some questions also may have multiple correct answers.

At the last, I could overcome some questions in my mind using textbook references (for instance Hinman's or Sabiston's). However, after started to practice I saw that we do not use that thorough information. We all have our practice and somewhat learning during our lifetime. So, read that textbooks and don't mind that much. Try to make thing good, and follow the patients. It will find its way.

Take care.

 

[Lem0nz]

Thank you for the well thought out replies.

I did do the FUSE course in residency. It was very helpful in understanding the basics of the energy devices and, in particular, the generators. The information on technical trouble shooting from it was also very worthwhile, so I will add from my own experience in trying to figure this out for anyone else reading this thread and feeling like me that FUSE was worth the time though it was a little dense.

For some background, I'm in an SSO fellowship and the majority of my training has been in HPB which I originally wouldn't have thought I would ever really do, but now that I am I love it but find myself wondering about a lot of things I just never had a good background in (came from a community residency program that struggled to meet their liver/panc numbers). Never really learned about the difference between RFA, microwave, what the settings on the argon mean and how to use them, how to choose between things like the CUSA, aquamantis, etc. I've spent time in four high volume places now and asked some of these questions and am finding that even experienced surgeons often don't know the answers to these. Did some time at MSK and they still were clamp clamp clip clip clip metz. Other places I watched them go across everything with the ligasure impact and that was that. At my own fellowship we'll often use RFA for margin augmentation for limited resections but I just find myself questioning how much of this is helpful to the patient or how much is made up. There is *so much* to learn about all of these things, so much data, and the reps are all biased. Learning to navigate that is tough.

At the end of the day my own personal conclusion is that we as surgeons are blessed that the human body is so incredibly resilient and can heal from almost anything we do to someone - the how and why really probably doesn't matter most of the time. Puzzling out what actually improves rates of leaks, bleeding, and stenosis when we put things back together from what we just got lucky on is a real struggle.

Anyway, thank you again. I would like to add some more specific questions:
- Does that textbook go over needle nomenclature and selection for sutures?
- Does anyone have a good reference on how to utilize the settings on the argon? Both for hemostasis and for tumor ablation? For tumor ablation in particular the only thing I could find was an old paper in the gyn-onc world that talked about cooking ex vivo tissue with it on the back table and sending it to path to see the effect, and this was in a single patient. The device is so old everywhere I've gone that I haven't found the rep who owns it and can speak to it.

 

[mikeGR]

Thank you for the well thought out replies.

I did do the FUSE course in residency. It was very helpful in understanding the basics of the energy devices and, in particular, the generators. The information on technical trouble shooting from it was also very worthwhile, so I will add from my own experience in trying to figure this out for anyone else reading this thread and feeling like me that FUSE was worth the time though it was a little dense.

For some background, I'm in an SSO fellowship and the majority of my training has been in HPB which I originally wouldn't have thought I would ever really do, but now that I am I love it but find myself wondering about a lot of things I just never had a good background in (came from a community residency program that struggled to meet their liver/panc numbers). Never really learned about the difference between RFA, microwave, what the settings on the argon mean and how to use them, how to choose between things like the CUSA, aquamantis, etc. I've spent time in four high volume places now and asked some of these questions and am finding that even experienced surgeons often don't know the answers to these. Did some time at MSK and they still were clamp clamp clip clip clip metz. Other places I watched them go across everything with the ligasure impact and that was that. At my own fellowship we'll often use RFA for margin augmentation for limited resections but I just find myself questioning how much of this is helpful to the patient or how much is made up. There is *so much* to learn about all of these things, so much data, and the reps are all biased. Learning to navigate that is tough.

At the end of the day my own personal conclusion is that we as surgeons are blessed that the human body is so incredibly resilient and can heal from almost anything we do to someone - the how and why really probably doesn't matter most of the time. Puzzling out what actually improves rates of leaks, bleeding, and stenosis when we put things back together from what we just got lucky on is a real struggle.

Anyway, thank you again. I would like to add some more specific questions:
- Does that textbook go over needle nomenclature and selection for sutures?
- Does anyone have a good reference on how to utilize the settings on the argon? Both for hemostasis and for tumor ablation? For tumor ablation in particular the only thing I could find was an old paper in the gyn-onc world that talked about cooking ex vivo tissue with it on the back table and sending it to path to see the effect, and this was in a single patient. The device is so old everywhere I've gone that I haven't found the rep who owns it and can speak to it.

There are many ways to transect liver parenchyma and many technologies. There is no high-quality evidence for or against any of the commonly used techniques. The newer energy devices usually have some semi-industry sponsored small trials that are not very convincing, you can even find meta-analyses of these for some fields (at least for liver and ENT). There are some consensus papers for liver resections that basically recommend using a combination of the 2 categories below.

In general, liver resection really has 2 parts:
1) Transection: The classic technique is clamp-crush to "crush" the hepatocytes while preserving tubular structures (vessels, ducts)- easy, quick, and cheap. More sophisticated technologies include the CUSA (probably the slowest technique, and the device is oftentimes finicky) and Water-Jet (increasing popularity). Again, these devices just destroy the hepatocytes, while preserving small structures/fibrous bands.
2) Sealing: There are many ways to deal with vessels and ducts of various sizes (after you've crushed the hepatocytes), and the traditional one is tie/suture/clip. Sealing energy devices (aquamantys, ligasure, harmonic, thunderbeat, etc) can do the same, perhaps a bit more efficiently, for small vessels. I was taught that energy devices don't seal ducts well, so I tie these when I can see them (2.5x loupes). Staplers are good for large vessels (misfire can be detrimental for extrahepatic hepatic veins). Some surgeons actually do a big part of the liver transection just using staplers - not the most elegant or precise technique but it often works and is much faster. Cautery and argon also have value in controlling superficial bleeding - to be honest, I personally don't use the argon much (the equipment adds complexity to the case).

In terms of MWA and RFA - again, no great clinical studies, but it is established that MWA is more predictable and has a more uniform ablation zone than RFA, with less heat sink effect. I think most places that are serious about ablation have turned/are turning towards MWA (there are also some newer fancy 3D guidance systems to make ablation fool-proof). It blew my mind when I first heard people use RFA for "margin augmentation", but apparently some centers do that. I don't think there's any evidence for it and frankly, if you think you need extra margin, you should probably take a surgical margin. Same about argon ablation, no evidence and I wouldn't in good conscience use it for oncologic purposes if there are any other options. I trained with Paul Sugarbaker, "father" of CRS/HIPEC and brilliant surgeon (of a different era) and we often did almost the entire case with the cautery at max and the ball tip. He also used to "ablate" small bowel mesentery deposits with the cautery- this is a bit more understandable IMO (non-curative intent surgery, unacceptable morbidity of resection). I suppose I could see someone using argon in a similar setting for oncologic (rather than hemostatic) purposes. But of course, none of the opinions expressed here are based on hard data - it's just my personal opinion (or educated guess).

As a sidenote, I was looking for nomenclature of surgical instruments and found this gem. A bit old, but it includes the vast majority of the instruments we use for open surgery on a day to day basis. It also includes info about surgical needles, but I've found that the suture manufacturers (mostly Ethicon and Covidien) have pretty detailed manuals/catalogs online for needles and sutures.

 

[swoopyswoop]

Anyone willing to make a pDF of that book? It looks like hundreds of dollars since it's out of print!