Some basic technique questions

[NewIntern]

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Need clarification some things I was told during my rotations

1.Never put your fingers through the holes of the needle driver when suturing but instead the right way to do it is to palm the needle driver, that includes when opening and closing the needle driver (open and close it by the palm technique not with your fingers through the holes).

2.Never directly handle the needle with your fingers when reloading it on the needle driver. But then I see some residents and attending do just that sometimes especially when rushing to close.

3.When doing an instrument tie you have to alternate the direction you spin the suture aroud the needle driver for each throw. So if you spin the suture clockwise for your first throw it has to be counterclockwise for the next throw and so on. But again some residents rotated the same direction each time but only alternated which way they pulled the sutures through for each throw. Does it really affect the knot made whichever way you do it?

 

[Buzz Me]

Some attendings have specific preferences about "fingers in" or "fingers out" when you're using the needle driver. I tend to palm the driver.

I always teach junior residents and med students to try and avoid handling the needle with their fingers - less change of a needlestick that way.

 

[Dr.LeoSpaceman]

I've found that nearly everything is attending dependent.

And the basic rule of thumb I've picked up this year is don't do anything unless you know you can do it well. The OR is not the time to "practice" something. If you've never palmed, don't do it for the first time standing in the room with an attending. Also, don't do anything that might be considered "slick". I'm pretty confident in my ability to throw a one handed surgeon's knot, but I'd never do it in front of an attending without expecting them to have a seizure.

1.Never put your fingers through the holes of the needle driver when suturing but instead the right way to do it is to palm the needle driver, that includes when opening and closing the needle driver (open and close it by the palm technique not with your fingers through the holes).

I feel that I have more control when I palm, but some old school attendings will consider this an "advanced" move, and may get pissed if they see you doing it as an intern. Sort of like some may be irritated if you try to one hand tie. I've also had an attending that never palmed himself, and said it gives you less control, so he wouldn't let me.

2.Never directly handle the needle with your fingers when reloading it on the needle driver. But then I see some residents and attending do just that sometimes especially when rushing to close.

It's true you're not supposed to, but sometimes it is easier.

3.When doing an instrument tie you have to alternate the direction you spin the suture aroud the needle driver for each throw. So if you spin the suture clockwise for your first throw it has to be counterclockwise for the next throw and so on. But again some residents rotated the same direction each time but only alternated which way they pulled the sutures through for each throw. Does it really affect the knot made whichever way you do it?

Yes, you have to alternate the direction you wrap around the instrument, otherwise you're just throwing the same half throw over and over again. Not good. And trying to visualize what you describe about pulling the free end through in different directions, that gives you the same half throw with half of them not laid down flat.

 

[NewIntern]

I'm pretty confident in my ability to throw a one handed surgeon's knot, but I'd never do it in front of an attending without expecting them to have a seizure.

I've heard of students not supposed to be throwing one handed knots but I'm surprised that as a resident you saying you're still not supposed to. Is there a generally accepted PGY where it is ok to be doing one handed ties?

Yes, you have to alternate the direction you wrap around the instrument, otherwise you're just throwing the same half throw over and over again. Not good. And trying to visualize what you describe about pulling the free end through in different directions, that gives you the same half throw with half of them not laid down flat.

The few times they let me close in the OR I sometimes got confused which way I had wrapped and which way I had pulled on the previous throw probably because I was trying to go as fast as I could so I wouldn't slow things down. Is there a trick/method to keeping track of which way you wrapped/pulled on each throw so you can do the opposite on the next throw?

 

[Pir8DeacDoc]

I'll echo what others have said, there are as many ways to suture and hold instruments as there are attendings.

Generally speaking as long as you square the first throws to make sure it lays down, there's no specific need to continue to throw square knots. I was taught on plastics as an intern to square up the first one and then throw granny knots from then on.

 

[treehorsio]

re: what PGY level makes it "ok" to throw onehandeds..there's obviously not an exact year. However, I think I "got away" with it later in my intern year. BUT the head of plastics NEVER allows one handed knots. He thinks it's lazy.

What I would say is, first time on a rotation, give it a case or two with all two handeds. If the attending says, do onehandeds, you're killing me, then you can switch. otherwise, start gradually doing it on your own. Once they are more comfortable with you and your knot tying skills, they probably won't mind. If they AREN'T comfortable...they'll let you know.

 

[Amy]

I have small hands, and find opening/closing the needle driver easier with my fingers in the holes. Then again, I was never taught that I should do it differently. I generally don't have my fingers in the holes while sewing.

NewIntern, I fear that you may soon regret your screen name choice. 😛

 

[Winged Scapula]

I have small hands, and find opening/closing the needle driver easier with my fingers in the holes. Then again, I was never taught that I should do it differently. I generally don't have my fingers in the holes while sewing.

NewIntern, I fear that you may soon regret your screen name choice. 😛

I had the same trouble with the large needle drivers. Since I switched to the small PRS ones, I can open and close with my palm (if I want to impress someone, but I usually don't care and just do whatever feels best).

 

[Buzz Me]

Is there a trick/method to keeping track of which way you wrapped/pulled on each throw so you can do the opposite on the next throw?

Not really. Once your hands are more comfortable and your movements more efficient, you'll be in a "groove" and will feel the natural "flow" of the motions. Then you'll just naturally alternate. LOTS of practice helps.

 

[filter07]

Need clarification some things I was told during my rotations

1.Never put your fingers through the holes of the needle driver when suturing but instead the right way to do it is to palm the needle driver, that includes when opening and closing the needle driver (open and close it by the palm technique not with your fingers through the holes).

Depends on institution and practioner. I did med school at a program where people have been palming for decades. Then I went to residency, and a CT surgeon chewed me out in the middle of an open-heart surgery for not putting my fingers through the holes.

2.Never directly handle the needle with your fingers when reloading it on the needle driver. But then I see some residents and attending do just that sometimes especially when rushing to close.

using your fingers to grasp the needle is a bad habit, and one you should not start if you can help it. that being said, this rule is broken commonly depending on the circumstances.

3.When doing an instrument tie you have to alternate the direction you spin the suture aroud the needle driver for each throw. So if you spin the suture clockwise for your first throw it has to be counterclockwise for the next throw and so on. But again some residents rotated the same direction each time but only alternated which way they pulled the sutures through for each throw. Does it really affect the knot made whichever way you do it?

The best way I know how to teach someone you how to do an instrument tie is to put the needle driver directly over the wound/knot, parallel to the incision. you then wrap the long suture over the needle towards the short end. the short end should be short enough such that it points in the opposite direction of the wound and doesn't flop around. You then maneuver the needle driver to grasp at the short end and pull it towards the other side. On your next knot you again place the needle driver directly over the knot and wrap the long suture over the needle towards the direction of the short end, which should now be on the other side. Repeat back and forth. When I teach newbies how to do this, I have them not maneuver the needle driver too much, as this can easily confuse them regarding how to circle the suture around the needle driver, and which side to pull the short end.

[YOUTUBE]http://www.youtube.com/watch?v=jVlmKxpfcOY[/YOUTUBE]

 

[SLUser11]

The best way I know how to teach someone you how to do an instrument tie is to put the needle driver directly over the wound/knot, parallel to the incision. you then wrap the long suture over the needle towards the short end. the short end should be short enough such that it points in the opposite direction of the wound and doesn't flop around. You then maneuver the needle driver to grasp at the short end and pull it towards the other side. On your next knot you again place the needle driver directly over the knot and wrap the long suture over the needle towards the direction of the short end, which should now be on the other side. Repeat back and forth. When I teach newbies how to do this, I have them not maneuver the needle driver too much, as this can easily confuse them regarding how to circle the suture around the needle driver, and which side to pull the short end.

This.


The whole clockwise/counterclockwise thing confuses people. If you want a square knot, you're going to have to square it....otherwise the alternations don't matter as much since you're just doing a bunch of half-hitches....I also teach the students to place the needle driver over the wound with their hand pronated....

Also, there tends to be a difference between what I teach and what I do....Do I always square my knots? No, but I want the students to do it....

 

[maxheadroom]

I had the same trouble with the large needle drivers. Since I switched to the small PRS ones, I can open and close with my palm (if I want to impress someone, but I usually don't care and just do whatever feels best).

All I need in life is a pair of Websters, an Adson, and some Tenotomies.

 

[Pir8DeacDoc]

All I need in life is a pair of Websters, an Adson, and some Tenotomies.

I love the instrument that functions as a needle driver and suture scissor (no idea the name). First learned about it from our plastics guys and it's not a part of our ENT facial plastics set, but I think when I go into practice I'll get it. Just too painful to wait for the ST to cut suture or to lay things down and cut it yourself when you are closing a big wound.

 

[maxheadroom]

Olsen Hegars. Nice, but sometimes tricky to use. You'll accidentally cut a whole bunch of suture before you master them. Hence, I use Websters.

 

[Winged Scapula]

All I need in life is a pair of Websters, an Adson, and some Tenotomies.

Olsen Hegars. Nice, but sometimes tricky to use. You'll accidentally cut a whole bunch of suture before you master them. Hence, I use Websters.

Not more than 10 minutes ago I had this exact conversation while watching a friend remove a BCC. She was using the Olsen Hegars and I remarked how much I liked them but had cut the needle off more than once, so tend to use the Webbies.

When I close I use the Webster, Adson and palm the Tenotomy to cut suture with.