Pathetic question: but how do I "cut" sutures properly in the OR?

[ej37]

This is pathetic, I know. But how do I know if the suture is supposed to be cut very short, or leave a tag? I have been getting yelled at for leaving too long of a tag, or too short of one multiple times. Also, the damn scissors my hospital uses must be dull as hell, either that, or I just suck at cutting. I realize this is a pitiful question to be asking- but I tried searching and can't find anything. By the way, I'm currently on a plastics rotation, but am about to start an Ortho rotation, if that matters.

Thanks!

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[LucidSplash]

This is pathetic, I know. But how do I know if the suture is supposed to be cut very short, or leave a tag? I have been getting yelled at for leaving too long of a tag, or too short of one multiple times. Also, the damn scissors my hospital uses must be dull as hell, either that, or I just suck at cutting. I realize this is a pitiful question to be asking- but I tried searching and can't find anything. By the way, I'm currently on a plastics rotation, but am about to start an Ortho rotation, if that matters.

Thanks!

So, the answer is really "as long as the attending wants them." Some sutures need tags and some don't. But honestly? Some people will tell you they are too long or too short no matter what you do. The best policy is to ask the first time in a series of cuts of the same type and then do it the same way from that point on.

I find that using the scissors so that the top of the screw which holds the scissors together is pointed upward, and tilting the scissors slightly helps. Here, a lot of our scissors are a bit dull at the tips and sometimes I have to moved farther up on the the scissors to make the cut the first time... even though everyone will tell you to cut at the tips.

 

[filter07]

Blue suture of any kind = leave a tail. Thicker suture 1cm. Super thin suture 0.5cm.
White suture of any kind = no tail
Clear suture = no tail
Clear yellow suture on face = 0.5cm
Black suture inside body = no tail
Black suture on skin = 1cm

Scissors with screws pointed towards ceiling, cutting forearm supported by other hand, tips only
If leaving no tail: slide down to knot, tilt sideways, cut.

 

[Fah-Q]

Skin suture --> leave a tail
Not a skin suture --> no tail

 

[SLUser11]

This is pathetic, I know. But how do I know if the suture is supposed to be cut very short, or leave a tag? I have been getting yelled at for leaving too long of a tag, or too short of one multiple times. Also, the damn scissors my hospital uses must be dull as hell, either that, or I just suck at cutting. I realize this is a pitiful question to be asking- but I tried searching and can't find anything. By the way, I'm currently on a plastics rotation, but am about to start an Ortho rotation, if that matters.

Thanks!

The classic surgery joke is that there are only two lengths of suture tails: too long and too short. It's funny because it's true. No matter what you do, some attendings (and residents) will simply be unhappy with the length of your suture tails.

That being said, you've heard some great advice, the best of which was to ask the attending how long he wants the suture tail to be. Once that is done, prepare to be amazed by the discrepancy between the quoted length (e.g. 2mm) and the actual desired length.

In general, anything that needs to be retrieved later should be left long, which usually consists of prolene or nylon skin sutures. Anything that is monofilament, and therefore prone to unraveling also needs a long tail, which is usually the PDS or prolene used to close the abdominal wall. Anything braided and/or absorbable can be left short, which is usually monocryl or vicryl sutures in the skin and in the peritoneal cavity. Silk sutures, which I rarely use, can be left short.

As for the scissors being dull, usually it's operator error, but there are some crappy pairs out there. I agree with the screw facing upward, which I refer to as "knuckle to knuckle," since the knuckle of the scissors is up and so are your own knuckles. Also, placing some downward pressure with your thumb and simultaneous upward pressure with your 4th finger will help the cutting.

 

[Winged Scapula]

Kudos to my colleagues for excellent advice.

Are there any objections if I move this to the Clinical Rotations forum? 1) its where it belongs and 2) I think it would benefit a greater number of students there than here

 

[tussy]

Always better to have it too long than too short. No problem to ask ?how short before you cut (but don't ask every time, just the first time).

another rule of thumb: braided suture = short (2-3 mm) monofiliment (the shiny sutures like proline and PDS) leave it longer (10mm). Also, anything on a vessel should be a little longer.

I'm still waiting for the clerk who can leave a "goldilocks tail" (not too long and not too short).

 

[Substance]

I remember when I was a student I absolutely hated this kind of crap.

Have there been any outcome studies on suture length?

 

[EtherBunny]

Whip out your autoclaved chain saw and cut the mothaf***er!





Just make sure that you leave tails!

 

[SLUser11]

Are there any objections if I move this to the Clinical Rotations forum? 1) its where it belongs and 2) I think it would benefit a greater number of students there than here

No objections from me. Hopefully, by now, we all know how to cut sutures.

 

[geauxg8rs]

as a med student my attending told me there were only four lengths the suture could be cut:

1. too long
2. too short
3. too f-ing long
4. too f-ing short

 

[45408]

I remember when I was a student I absolutely hated this kind of crap.

Have there been any outcome studies on suture length?

Not sure we need a study about this. Short tails on skin suture make them difficult to remove. Short tails on a monofilament for abdominal closure makes it more likely that it will unravel and cause them to dehisce/eviscerate. Having received one emergency phone call to rush a patient back to the OR because a knot broke after some admittedly questionable technique (not by me), I'd prefer never to receive another.

 

[SLUser11]

Not sure we need a study about this. Short tails on skin suture make them difficult to remove. Short tails on a monofilament for abdominal closure makes it more likely that it will unravel and cause them to dehisce/eviscerate. Having received one emergency phone call to rush a patient back to the OR because a knot broke after some admittedly questionable technique (not by me), I'd prefer never to receive another.

While it hasn't been widely studied, one of the few articles that I'm familiar with points out that for running sutures on the fascia, perhaps granny knots are better than square knots. I'll admit that I haven't read the article in over 5 years, and I've recently lost access to the wonderful Texas Medical Center Online Library...

In my opinion, the number of knots on a fascial PDS or prolene suture is not too important as long as it's somewhere above 6 or 7. Therefore, I would further say that the length of the tail doesn't matter much, since a little unraveling probably doesn't matter.

Most times when you go back for an early dehiscence, the knots are intact. Usually the sutures have pulled through the fascia, but when it's a technical issue, it's usually trauma-related (e.g. "freeing up" the subQ from the fascia to facilitate skin closure and accidentally bagging the suture). I've never actually seen an unraveled knot as the cause of a dehiscence.

That being said, I still routinely put 10+ throws in there....not sure why.

 

[dpmd]

That being said, I still routinely put 10+ throws in there....not sure why.

You like to practice knot tying or counting

I think often times the student gets yelled out for failing to cut it precisely as long as the surgeon wants down to the micrometer. It is rare for the ridiculously too long to occur. I have seen too short turn into cutting some of the knots off which probably deserves a yell unless it is their very first time in the OR or something. I remember a lot of variations in people's internal ruler so if I really care about length of the tail I will either cut it myself (if it was a tricky area to sew and the student is not so good) or have them show me where they plan to cut but wait for approval (if I have showed them the proper way to hold the scissor and brace their hand as described earlier, and they were teachable). Otherwise I just use the generic long or short and unless it is their first time in the OR they have some idea which is which.

 

[Fah-Q]

If you are worried about a knot unraveling (never seen that happen) on a running closure of the abdomen, why not use interrupted sutures? Seems like a dehiscence would be less likely if you have ~25 knots to unravel rather than just 1 knot.

Please educate me on why a running closure is preferred for the belly.

 

[45408]

If you are worried about a knot unraveling (never seen that happen) on a running closure of the abdomen, why not use interrupted sutures? Seems like a dehiscence would be less likely if you have ~25 knots to unravel rather than just 1 knot.

Please educate me on why a running closure is preferred for the belly.

The knot didn't actually unravel the one time I saw the suture fail, but it did snap. The knots were intact.

We use a running closure because it's a lot faster than interrupted sutures, but if we're ever concerned, we'll just interrupt it.

 

[SLUser11]

Please educate me on why a running closure is preferred for the belly.

Now, there is literature on that topic. To start, a running suture is a LOT faster. Secondly, it hypothetically does a better job of evenly distributing tension across the entire wound. Thirdly, since we already mentioned that the knots never unravel, there's not a big advantage. When the suture breaks, it's usually a technical error that can be avoided.

The INLINE study addressed this issue, and concluded that a full-thickness running stitch with a slowly-absorbing suture was the best technique. They then made the bold statement that, "no further trials should be conducted." I was personally unsatisfied by the data in that trial, as they were constantly comparing apples to oranges.

That's the best explanation I have. To be honest, I think there's a role for both running and interrupted closures. For primary closure of a midline laparotomy, I think a full-thickness running stitch with a #1 PDS is appropriate.

 

[Substance]

So make the sutures long. So what's too long?

 

[Buzz Me]

As WS alluded to earlier, the OP is an M4 and this thread belongs in Clinical Rotations as it pertains to a med school issue. Residents, fellows and attendings can certainly reply there.

 

[PTPoeny]

One trick I have found is to pause for a beat to give time for the surgeon to say something once you are in place and ready to cut. My favorite was one time I was in a surgery with two attendings at the table at and both said they wanted the sutures cut at one centimeter but one was yelling at me for cutting too long and the other too short for exactly the same knot...

 

[Bacchus]

Wouldn't it be nice as a student if the suture was incremented like ETT or NGs?

I just asked before every knot to make sure. Even if I got an "ok" before cutting I'd sometimes get a groan or comment even though 1 second earlier it was OK.

I often voiced I didn't want to be the guy to cut the suture too short on a running stitch and have it unravel. It probably made people think I was dumb, but it decreased my worriment.

 

[Lolscan]

This is pathetic, I know. But how do I know if the suture is supposed to be cut very short, or leave a tag? I have been getting yelled at for leaving too long of a tag, or too short of one multiple times. Also, the damn scissors my hospital uses must be dull as hell, either that, or I just suck at cutting. I realize this is a pitiful question to be asking- but I tried searching and can't find anything. By the way, I'm currently on a plastics rotation, but am about to start an Ortho rotation, if that matters.

Thanks!

Easy ask the attending if he wants it "too long" or "too short". Typically long is 1-2 cm and short is 1/2-1/4 cm. Don't try to get it right because you will always get **** for it.

 

[mmmcdowe]

My technique was to place the scissors where I thought they wanted them, pause for about half a second to give them time to object, then cut until I was sure that I knew how a given attending/resident wanted it.

 

[oregano42]

For plastics, I've learned that while suture tail length so they don't come unraveled is important, they mostly give a damn about foreign body reactions/spitting stitches which messes up the cosmetics. Unless it's buried below the fat (or it's external/they're leaving a part of it external to be removed at a later date), you're not going to leave a tail (the slide down and cut on the knot method). And even the tails you do leave for internals on tummy tucks etc. are short.

Still, best policy is to ask if you don't know (the first time)...which can be as simple as placing your scissors and asking "here?" And, after the one or two of the same case with a specific surgeon, you'll know what they want where. Sometimes they'll explain why they specifically want what where and then you can extend that to similar situations.