I’m approaching the end of my intern year, and I thought I’d share some tips.  If rising MS3s or MS4s are looking for advice for practical suturing, here it is.  I hope more senior people will add to this if there are any glaring errors or subtleties I’ve missed.  There are a few points that I’ve learned that might help people perform better on neurosurgery subIs or intern rotations…

First...focus on the skin.  This will be your baby as an intern or sub-I.  If you do a good job, it will impress your supervising residents, etc.  A good skin closure is the only thing a patient sees...as is a bad skin closure.  Unfortunately, a good skin closure starts with a good subQ closure, so keep this in mind.  If you are asked to close skin, pay attention to how it is done at your institution.  At my hospital, we close almost all wounds with a running, non-locking abosrbable suture.  When doing this stitch, pay special attention to make all stitches the same width the same depth (evenly spaced, of course).  If for some reason, your supervising resident hosed you and the skin edges aren’t even, you can fix this with your skin stitch (I recommend you do this quietly and not make a big deal of it.) To do this, take a big bite on the lower edge that you want to bring up, and a small bite on the high side that you want to bring down.  This should result in a level edge.  I know it’s nauseating to hear old axioms again, but remember the point of skin closure is to approximate the edges, not really provide structural strength, this comes from the deep layers.  Don’t jack your skin suture so tight that your cause ischemia to the wound edge.  Take all of this with a grain of salt.  If your hospital uses staples, dermabond, running nylon, whatever, when in Rome...I will say that you should learn to do a running subcuticular stitch.  This will help when closing neck wounds and for breast cases on general surgery rotations.

If you are lucky (or cursed) enough to be asked to close subQ, make sure you bury your knots (inverted sutures, whatever you want to call them).  To do this, enter from the deep tissues and go to superficial tissue (making sure to grab a good galeal bite if closing a crani)...make your needle exit at the dermo-epidermal junction (dermis is softer and fattier, epidermis is whiter and more fibrous).  Drag your suture directly across the incision and make a superficial bite directly across from your first bite again at the dermo-epidermal junction (at exactly the same depth).  Roll that needle to get a good purchase of deep tisues (again making sure to get good galeal purchase if closing a crani) and bring both ends of the suture together on the same side of the stitch.

If you are asked to tie...make sure you know what you are doing.  I would prefer a student tell me that they are still learning to tie and volunteer to cut sutures than to throw air-knots and sabotage a closure.  Knowing your limitations is a very important part of the self-evaluation process that makes a safe surgeon.  Also, the end of a 4hr crani isn’t necessarily the best time to ask to be taught how to tie, so a bit of context-sensitivity can be improtant here.  As a right-handed surgeon, the most useful knots I’ve learned so far are one-handed ties with my right hand.  The logic is simple--these throws allow me to keep my forceps in my left hand, hand off the needle driver, then tie without unnecessary instruments shuffling.  If you are starting out, and don’t necessarily want to impress general surgeons, learn to throw consistent square knot that way, it will serve you well under most circumstances.

I’m not going to BS and say I am an expert at this yet, I still mangle my fair share of needles trying to do seemingly simple closures, but this is hopefully a launghing point to help get some info out there that I wish I’d been told at the start.

Thanks man! I like the detail in your post. We could definitely use more posts like this for the interns starting this year.

The most effective advice I received that helped me prevent air knots (if tying one-handed) is to maintain firm upward tension on the “post” (in your left hand if you’re tying right handed), when tying your second throw. This allows your second (critical) knot to slide down the post allowing you to snug down a tight knot. If your second knot is thrown the same way as the first knot, you also have a chance to snug down the first knot a bit more with your second knot, eliminating any slack. If the post isn’t tight as you throw your second knot, it can catch before it gets all the way down -> airknot -> student is relieved of subsequent knot-tying duties for that case. Make sure you tighten the knots in the plane of the incision. This prevents the wound edges from interfering with a tight knot - especially important for fascia.

The following link shows the steps in sequence for several knots, including the two-handed and one-handed square knot (key); it is what I used to learn. Only right-handed is shown for the one-handed knot. I have heard some say that if you are right handed, it is actually good to be able to tie left handed so you don’t have to put down the instrument in your right hand…

http://www.ruralareavet.org/PDF/Surgery-Knot_Tying.pdf

Great points. Additionally, be careful when pulling the needle out of tough tissue. If you meet resistance and try to force it out, you will win, but when it frees, the needle can thrust towards your left hand. It would not surprise me if most sticks happen at that moment. Maintain the curve. A cutting point passes more smoothly than a tapered.

related question: was anyone expected to tie left-handed one hand knots on a sub-I? On my M3 general surgery rotation, they told us to only tie right-handed.

I think you are only expected to tie a good knot quickly, in whatever fashion you prefer.

The worst thing you could do is to tie that air knot, or to say you know how to tie knots, then fumble around as the resident makes a mental note not to let you tie in the next case…

Stem Cell - 16 May 2009 11:50 PM

I have heard some say that if you are right handed, it is actually good to be able to tie left handed so you don’t have to put down the instrument in your right hand…

I heard that too, and paid attention and actually became more facile tying with my left hand than my right.  However, when you are closing by yourself (which will be 99% of the time as a neurosurgeon), the instrument in your right hand is the needle driver, which you hand off to the scrub after each stitch, and you’ve got forceps in the left hand.  It’s easiest to tie right handed in that situation because you aren’t fumbling around with the forceps.  This is a realization I’ve come to within the past two weeks, after alot of unnecessary motion for most of this year.

this is a very helpful thread. thank you.

this may seem like a silly question, but do any left handers encounter difficulty in any of the surgeries or would you guys think they encounter difficulties? I’m left handed but don’t want that to be a handicap for me when i start this.