Why do some surgeons “wet their hands?”

[Minimal Charge Disease]

Hi there MS1 here. I was on a Vascular rotation and saw many surgeons asking saline to be squirted on their hands prior to tying knots whilst most surgeons in other specialties I’ve rotated in like OBGYN, Gen surg and plastics do not though they also tie knots. Might be a dumb question but why do they wet their hands?

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[Dr.LeoSpaceman]

Hi there MS1 here. I was on a Vascular rotation and saw many surgeons asking saline to be squirted on their hands prior to tying knots whilst most surgeons in other specialties I’ve rotated in like OBGYN, Gen surg and plastics do not though they also tie knots. Might be a dumb question but why do they wet their hands?

It has to do with the type of suture being used. Monofilament suture (PDS, prolene/surgipro, maxon) does not "slide" very well when dry. Wetting the hands can make them easier to handle and tie, especially when using finer suture. The fact that you only saw it on vascular has to do with the fact that finer monofilament sutures are commonly used for vascular procedures, and less common in others.

 

[Jolie South]

It has to do with the type of sure being used. Monofilament suture (PDS, prolene/surgipro, maxon) does not "slide" very well when dry. Wetting the hands can make them easier to handle and tie, especially when using finer suture. The fact that you only saw it on vascular has to do with the fact that finer monofilament sutures are commonly used for vascular procedures, and less common in others.

Yes, this. I also like when my hands are wet when I am just handling a needle driver for an anastomosis. It somehow helps with the fine motor feedback from the driver.

 

[BovieToMe]

Additionally, we tie with a lot of double armed suture and the irrigation helps the suture slide and the needles don't get caught up in the knots when you hand tie.

 

[SKWang]

Hi. I'm a vascular surgeon. Yes to all of these these previous mentions. Small monofilaments, double armed, etc. Also keep in mind that we are tying on arteries which do not take well to too much tension as you can pull on other tissues. Therefore, jerky motions while tying due to excess friction or poor technique is especially frowned upon. Also, as blood dries on gloves, it tends to make it sticky compounding this problem. Lastly, dried materials on gloves can be sharp enough to theoretically fray the prolene suture, which can be a leadpoint for anastomotic disruption over time with continued systole.

 

[TypeADissection]

I will often say when tying, "Squirts please." If the surg tech is late with the water or busy, I'll say, "That's OK. I'll just use my tears."

 

[LucidSplash]

My fellowship didn’t allow it/mocked you for asking for it. Which is dumb of course. But I still don’t expect it when my scrub does it. It’s nice but you can learn to work without it, but there really is no reason to learn to work without it except for stupid dogma. Don’t get me started.

 

[Jolie South]

My fellowship didn’t allow it/mocked you for asking for it. Which is dumb of course. But I still don’t expect it when my scrub does it. It’s nice but you can learn to work without it, but there really is no reason to learn to work without it except for stupid dogma. Don’t get me started.

I had one attending that would say that you can’t rely on it and shouldn’t get used to it.

All others were constantly asking for it.

If my tech can’t figure out squirting my hands, I mean they are a special person with bigger problems.

 

[ThoracicGuy]

My fellowship didn’t allow it/mocked you for asking for it. Which is dumb of course. But I still don’t expect it when my scrub does it. It’s nice but you can learn to work without it, but there really is no reason to learn to work without it except for stupid dogma. Don’t get me started.

Did they want more broken sutures??

 

[LucidSplash]

Did they want more broken sutures??

No, the perspective is that it is unnecessary, and they wanted to teach you to do what needed to be done with the least amount of stuff in the field that wasn’t strictly necessary. So there were a lot of standard vascular things we didn’t use/do, or did so rarely. No laps over the retractors when sewing anastomosis, no vessel loops. And generally no one ran your suture for you.

I mean it works, you can learn to live without it and I hardly break my suture. But just silly imho. I was really happy to be able to start using vessel loops again for thrombectomies. But I got used to not using them for everything else. And I operate pretty much independently in that when I don’t have a resident, the scrub techs are always a little nonplussed that I don’t want them to help me by running suture or retracting anything because I’m used to doing it myself. So I let them squirt my hands so they have something to do, even though I don’t really need it.

Endo cases I’m still getting used to not having the controls on the bed and running the table myself. Honestly I would prefer that but my partner has been here for 10 years without me so I’m trying not to do too much different from him so as not to rock the boat. I already do awake eversion CEAs and that is blowing everyone’s mind lol.

 

[Minimal Charge Disease]

Thanks to everyone who helped answer I'm starting to get interested in Vascular. I was wondering what the contemporary bread and butter of the specialty is with regard to operations. Particularly interested in open aortic surgery (Thoracic and abdominal), would I be able to be a surgeon that regularly does open aortic surgery given the current endo era?

PS, I know there are some threads that explore this but it may be outdated.

 

[ThoracicGuy]

Thanks to everyone who helped answer I'm starting to get interested in Vascular. I was wondering what the contemporary bread and butter of the specialty is with regard to operations. Particularly interested in open aortic surgery (Thoracic and abdominal), would I be able to be a surgeon that regularly does open aortic surgery given the current endo era?

PS, I know there are some threads that explore this but it may be outdated.

Much of the aortic work is moving to stents. You'll have some selected open cases, but that won't be the majority.

 

[Minimal Charge Disease]

Much of the aortic work is moving to stents. You'll have some selected open cases, but that won't be the majority.

Should I then do Cardiac surgery if I want to do open aortic surgery?

 

[ThoracicGuy]

Should I then do Cardiac surgery if I want to do open aortic surgery?

The only open aortic work is valves and aortic root repairs for the most part. Cardiac surgery wouldn't do any stent repairs of root disease or dissections, though who knows what the future could bring. Some may do thoracic aortic diseases, but many leave that to the vascular guy as well. It's just that open aortic treatments are just not that common anymore.

 

[LucidSplash]

Thanks to everyone who helped answer I'm starting to get interested in Vascular. I was wondering what the contemporary bread and butter of the specialty is with regard to operations. Particularly interested in open aortic surgery (Thoracic and abdominal), would I be able to be a surgeon that regularly does open aortic surgery given the current endo era?

PS, I know there are some threads that explore this but it may be outdated.

Open aortic work is alive and well in major centers, but not so much outside of them. Much has moved Endo but the pendulum will likely swing back a bit unless tech improves dramatically. The farther off IFU, the worse the late outcomes. We had gotten very aggressive as is typical with new tech but now we have amassed enough maturity of the tech combined with data to know that it isn’t always the best choice.

That being said, I wouldn’t consider open aortic work “bread and butter” vascular surgery. That list includes AV access (creation, revision, troubleshooting, maintenance), peripheral arterial disease, carotid surgery/stenting, veins, EVAR. Fixing cardiology and interventional nephrology ****ups.

Maybe TEVAR depending on your setting.

 

[TypeADissection]

Open aortic work is alive and well in major centers, but not so much outside of them. Much has moved Endo but the pendulum will likely swing back a bit unless tech improves dramatically. The farther off IFU, the worse the late outcomes. We had gotten very aggressive as is typical with new tech but now we have amassed enough maturity of the tech combined with data to know that it isn’t always the best choice.

That being said, I wouldn’t consider open aortic work “bread and butter” vascular surgery. That list includes AV access (creation, revision, troubleshooting, maintenance), peripheral arterial disease, carotid surgery/stenting, veins, EVAR. Fixing cardiology and interventional nephrology ****ups.

Maybe TEVAR depending on your setting.

Agree once again. Our hernias and gallbags are dialysis access, peripheral revasc, carotids and AAAs (mostly EVAR).

My fellowship program has an abundance of complex aortic work both open and endo. This has allowed me to get comfortable doing ruptures both endo and open as well as doing a lot of the fen work for juxtarenal disease and some of the fancier parallel grafting for those that aren't amenable to a fen. Having said that, unless you're Rich Cambria or James Black at Johnny Hopkins or in a similar position, open aortic surgery will not be your bread and butter. But to be honest, I've become very disenfranchised by the big open whacks. The operations are fun but long with a lot of things that can go wrong. The postop ICU care becomes exhausting and often depressing as you watch people slowly spiral down the failure to thrive pathway and eventually die in a SNF somewhere. I love open aortic surgery and it will be a component of my practice when I become an attending but mostly for occlusive disease, which is a totally different operation compared to aneurysm work. Hope this helps. Cheers.

 

[Minimal Charge Disease]

Thank you all, would it then be better for one to pursue cardiac surgery for open aortic surgery (TAAA, arch cases, TAD, root etc etc)

1) Do you forsee the swing back to Open Surgery for AAA (30-40% of AAA) with the difference in long term outcomes esp in IFU violations? Now the NICE guidelines are recommending open surgery first approach?
2) I enjoy the idea and feel of operating in the abdomen, the VS in my institute did a lot of spine exposures, would I be able to develop a busy ALIF practice?

Thank you for entertaining my crystal ball questions.

 

[TypeADissection]

Thank you all, would it then be better for one to pursue cardiac surgery for open aortic surgery (TAAA, arch cases, TAD, root etc etc)

1) Do you forsee the swing back to Open Surgery for AAA (30-40% of AAA) with the difference in long term outcomes esp in IFU violations? Now the NICE guidelines are recommending open surgery first approach?
2) I enjoy the idea and feel of operating in the abdomen, the VS in my institute did a lot of spine exposures, would I be able to develop a busy ALIF practice?

Thank you for entertaining my crystal ball questions.

1. As of now I don't see a major swing back towards open aortic surgery for elective infrarenal aneurysm repair. These aren't benign procedures and a lot of things can go wrong when you're doing open aortic work.

2. I think developing a busy ALIF practice will depend on where you go and how busy the spine guys are at doing that. We do a lot of that here as well (at least one every Thursday) and it is a nice technique to know how to do. I interviewed at a couple of private practices and they were all about handing off that portion of their practice to me and letting me the RP exposure guy.

I don't have enough knowledge about the aortic work in the cardiac realm to comment, and @ThoracicGuy has already added some clarity in regards to the volume. My understanding is that once again, there aren't that many dudes out there like Bavaria, Gleason and Cosselli who can make a permanent living doing central aortic work unless you work your way up in a major academic center that gets those kinds of referrals. That kind of practice will definitely not be happening in a private practice setting. You won't have the manpower to round and manage the minute to minute ICU care afterwards and the admin is gonna want you doing procedures that generate revenue.

*Complete opinion that I refuse to take any responsibility for*
If you're dead set on open aortic work being a mainstay of your practice and life. Here are your options:
1. Do an integrated vascular surgery residency and then do a CTS fellowship. This gives you the background to do the endo wire/stent work and open arch stuff because you know how to put people on bypass.
2. Do an integrated vascular surgery residency and then do the complex aortic fellowship at Toronto (or similar program) where you can learn to put people on LHB while also learning the complex fen stuff.
3. Do an I6 CTS and depending on your comfort level do an advanced aortic fellowship afterwards at a place like Houston or Penn.

I'm sure there are other options out there but these are the ones I can think of off the top of my head that would give you the background to have the skills to maintain an open aortic practice. Remember that no one is just going to give it to you. You're gonna have to work your way up and have the resultant success where people think you're good enough to keep referring patients to you. Hope this helps. Cheers.

 

[Minimal Charge Disease]

Thank you for all your comments. I will explore vascular more in my upcoming selective rotations and see if its a fit for me outside of aortic surgery. Although seeing a procedure like below, it's hard not to be mesmerized by its beauty.

 

[TypeADissection]

Bruh. I live to operate and I f**king love vascular surgery but these cases lose their luster. Best of luck in your decision making. Vascular Surgery is a dope field and if that is where fate takes you, you'll find a dynamic field on the bleeding edge of tech advancements, fine technical procedures and a job market that can't get enough of us. Cheers.

 

[Circ Arrest]

Thank you for all your comments. I will explore vascular more in my upcoming selective rotations and see if its a fit for me outside of aortic surgery. Although seeing a procedure like below, it's hard not to be mesmerized by its beauty.

Interesting. That would not have been my pick for a beautiful and mesmerizing aortic case, but each to their own.

 

[habibimarwan]

I learn many things today I didnt know before! Thank you!!

 

[Minimal Charge Disease]

Much of the aortic work is moving to stents. You'll have some selected open cases, but that won't be the majority.

Dear @ThoracicGuy and others,

May I ask what the bread and butter is for Thoracic (non cardiac) surgery. Are most cases VATS and is open surgery in the decline similar to vascular? Thanks and stay safe everyone <3

 

[ThoracicGuy]

Dear @ThoracicGuy and others,

May I ask what the bread and butter is for Thoracic (non cardiac) surgery. Are most cases VATS and is open surgery in the decline similar to vascular? Thanks and stay safe everyone <3

My typical cases include lung resections, esophageal surgery, lung decortication, bronchoscopy and ebus, and more.

I'd say most of my lung cases are vats. Open cases are there, but the minority. Open surgery has its place and is the first choice for some cases.