HomeGuideSurgeon Explains How to Tie Surgical Knots

Surgeon Explains How to Tie Surgical Knots

Transcript

Oh, you are shaking.

What is incorrect with you?

I am nervous!

Oh my god.

I am Annie Onishi.

Annie is a trauma surgeon.

She’s explained operating rooms

and surgical procedures in approach critique.

As I inform my healthcare students,

vitals are crucial.

We often speak about them,

we often wanna know what they are,

and yes, we ask what they are on the typical.

And I am Peter Rubin.

Peter is a Wired contributor who covers

culture and technologies.

Annie is going to teach Peter

how to suture and tie surgical knots

working with unique supplies ranging

from straightforward to tricky.

[light music]

Hey Peter, you wanna know

about surgical knot tying

and suturing approach?

‘Bout time I cross it off my bucket list.

Let’s get you to some scrubs.

Fantastic.

[light music]

The very first point we’ll find out these days

is surgical knot tying.

How substantially does this have in prevalent

with tying a friendship bracelet?

This is one hundred%, the very same activity

as tying a friendship bracelet.

Oh my god, I am gonna get the marshmallows.

Let’s do this.

So ordinarily, healthcare students

will find out this for the duration of the very first handful of days

of their surgery rotations,

and it is an activity that is mastered

more than hours and hours of practice.

So, there is essentially two sorts of knots.

There is the two handed knot,

and the one particular handed knot.

These days, I am gonna be teaching you

the one particular handed knot.

Is that ’cause it is less complicated?

Turns out it is not less complicated,

it is just far more applicable in common practice.

This is a know that we tie everywhere,

regardless of whether it be, we’re fixing

the inferior vena cava for the duration of a significant trauma case,

you are sewing tiny arteries on the heart,

or even issues as basic as you are closing

skin of a tiny laceration in the emergency space.

It is all the very same knot.

[light music]

So Peter, to assist you find out knot tying,

these days I brought you the surgery

resident starter pack.

So, is this like an official education tool?

Is that what men and women are gonna commence working with

in med college?

This is quite darn official.

When students are very first understanding how to tie knots,

they use multicolor, significant bore yarn

just like this.

The explanation the color’s valuable,

it will show you that you knot

is lying completely as you tie it.

And a one particular handed tie, there is essentially

two knots, there is a forehand throw

and a back hand throw.

Okay.

All proper, so what I am gonna do,

I am gonna take the white string

and hold it in my left hand

so that my purple is crossed.

See that?

Um hm.

Okay.

My forehand throw has an overhand grip like this

like you are riding the pony.

Okay, okay.

Can you ride the pony a tiny bit?

Ridin’ the pony.

Ridin’ the pony.

So, with your strings crossed,

you are gonna generate a 4 shape.

Do you see the 4?

I do.

Now, your index finger is gonna go

by way of the 4 and loop this tail

and bring it by way of the 4.

Loop that tail and bring it by way of the 4.

Just like that.

Just like that.

The complete point?

Bring the complete tail by way of.

Entire tail by way of.

Now, with your proper hand and your left hand

you are gonna place the knot down

and it should really be good and square.

That is outstanding Peter.

Excellent.

I am a medical professional!

You are a medical professional.

So, that is your forehand throw.

Okay.

Now for your backhand throw,

left hand comes back to neutral position

with the proper string.

Adjust your grip on the purple string

to a karate chop grip.

Okay.

Now, use your middle finger

to get the tail by way of the 4.

What?

Keeping tension Keeping tension.

on that white tail.

And bring it by way of.

Bring it by way of.

Oh by way of like that! Yes.

Now, you need to have to cross your hands.

Okay.

So, let’s attempt it once again.

Okay.

And then you alternate, forehand, backhand.

Okay.

Exactly where are you probably to use

this sort of knot chain?

So, this is a knot that we tie everywhere,

regardless of whether it be we’re fixing the inferior vena cava

for the duration of a significant trauma case,

you are sewing tiny arteries on the heart,

or even issues as basic as you are closing skin

of a tiny laceration in the emergency space.

It is all the very same knot.

It is just a matter of what you are tying,

what type of suture [crosstalk].

So, you are performing this as a chain.

Now based on the suture material you are working with,

the most knots you would ever tie

is like eight or ten.

Okay, now here’s the difficulty.

Quit, freeze.

Here’s the distinction in between me and you.

Appear exactly where your purple string is

versus exactly where my purple string is.

Oh, you got it about the complete hand [crosstalk].

And that is gonna give you a tiny bit

of tension to make this guy less complicated.

Oh, but I nonetheless got ham hands.

You can do it.

You can do it.

These cannot be ham hands.

Verify this out [crosstalk].

Oh my god, I am gonna employ you.

Just like the name of the knot.

Excellent.

I appear at yours and I see friendship.

Friendship.

And right here I see ranker and years of bitterness.

Certainly.

So, I have a feeling that the answer

to this is going to be all the things.

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But, what am I performing incorrect?

I assume the difficulty is coming

as the knot is going down.

You are not applying even tension,

so your knots are ending up stacked

as an alternative of square.

When we teach the healthcare students

how to do this, they are just performing it continuously.

You obtain tiny strings tied to all the things.

The mouse, the laptop, their pants.

Oh, yeah, you actually never have to do substantially

when you cross back more than to the forehand do you?

Yeah, you got it down.

Now what takes place when the ends

commence finding brief?

Then you are completed.

And I am completed.

Appropriate.

Oh.

This is superior to find out the mechanics

of the knots.

Okay.

This does not sit like true suture.

So, why never we move on

to a thing far more tricky.

I essentially brought some suture material

to show you.

Okay.

[light music]

So, the way that suture is labeled

is zero is sort of the middle set point.

And a thing like a six-O is tiny, tiny.

That suggests six zeros all in a row.

The easiest point to tie is O silk.

And is six-O the thinnest you can use?

Certainly not.

It goes all the way down to like ten-O.

But that is made use of on quite fine issues

like a vein or an artery or a nerve.

So, for you, Peter, we’re gonna use

sort of the elementary college, O-silk.

This is the very same precise point as your yarn,

but what is gonna make this a tiny tougher

is that your suture’s finer.

So, you are gonna have to operate tougher

to hold superior tension and to make it sit good.

So, once again, the mechanics are the very same.

It is actually significant that you, sort of,

stick to the knot down with your finger

to get the knot to sit precisely exactly where

you want it to sit.

All proper Peter, so let’s see.

So, I had this forehand throw.

You see that?

Excellent.

Jargon.

And use your, there you go.

Yes, you see how your, that was quite instinctive.

What you did, your hand sort of,

crawled up the suture.

That is fantastic.

Now, karate chop.

Excellent.

I known as it, now in my brain,

this is ham hands since I have ham hands.

No, you have wonderful hands.

You have healing hands.

Do not, never, never do that.

So, Peter, I essentially assume you are prepared

for the subsequent curve ball.

Oh boy.

Which is, let’s get you to do this

with gloves on.

So, there is no, like, in-in between.

It is going from the education wheels.

Hell yeah, man.

To the grand prix.

Okay.

So, do physicians essentially do the point

exactly where they are like [glove snapping],

Yeah, let’s do this.

Oh, one hundred%, each and every time.

Okay, let’s do this then.

Okay, so let’s get began.

So, Peter, this is just gonna be the very same point.

Very same knots.

But I just want you to get a sense

for how it feels unique when you cannot

essentially really feel the suture material

straight on your skin.

It is practically like numbness.

Wow, hey, guess what?

I am even far more terrible.

I did not assume this was attainable.

Hmm.

Hmm.

That is not a sound you like to hear.

It is just fascinating.

A million unique men and women tie it.

That is the other point you like to hear.

Properly they just.

Hmm, that is fascinating.

Just about every unique particular person tends to make

their personal exceptional error when they are

understanding how to do this.

This is, your euphemisms are the finest.

Preserve going, you are performing excellent.

Okay.

What do you got there?

In true life your hands are wet.

Oh, hey, okay.

So, this is what like the bodily fluid?

Of your selecting.

Of my selecting?

And so essentially, silk,

since it is a braided suture,

does not make as well substantially of a distinction.

Yes, I believed it would be a lot worse.

But if I give you a monofilament,

which is like a plastic one particular strand,

that will be tougher with your hands wet.

But you are performing actually superior.

Yay!

You have actually, I assume, mastered the mechanics

of the knot tying.

You would just need to have some polishing

in terms of your tension, your knot placement.

So, what is gonna be subsequent right here.

What are we gonna do?

So, I have just the point.

Have these creepy skin models

with a bunch of unique sorts of incisions.

What?

Yep!

[light music]

It is strong and it is kinda a tiny providing

but it is dense.

It feels kinda true.

So, I have for you [crosstalk] right here

a suture kit, and a 4-O biosyn

on a cutting needle.

And a cutting needle’s what we use

to close skin with.

This is an absorbable monofilament.

Okay.

4-O, so that is a tiny smaller sized

than what you have been operating with.

So, the very first point you have right here

is a needle driver.

And each and every surgical instrument locks in location.

So, practice that mechanism.

And then, true surgeons never place their thumb

in that hole.

Push it with the but of your hand

and then close it.

And then you also need to have these pickups.

These are rough approximations

of Adson forceps with teeth.

So, these have teeth on the finish of it

that assist you grip skin.

These are not tweezers.

These are not tweezers.

These are not tweezers.

These are known as pickups.

Pickups.

And then that is the needle in there.

Okay.

So, be cautious.

And you are gonna.

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Oh, you place your thumb in the hole.

Just for that component.

Oh, hypocrisy.

Excellent.

Take the complete point out?

Yep.

Oh, wait.

Wait.

Wait.

Wait.

Wait.

Wait.

Wait.

Wait.

Okay.

Okay.

Okay, so now, the way to adequately hold the needle,

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use your pickups to assist you.

So, I am gonna hold my needle

halfway back at a 45 degree angle right here

and at the quite ideas of my needle driver.

All proper, so now we’re prepared to close skin.

So, what I am gonna teach you now,

is known as the operating subcuticular closure.

Okay.

Say it with me.

Operating subcuticular closure Operating subcuticular closure

Okay, and this is a good way

to make the skin come with each other

and there is no stitches visible.

Okay.

So, I am gonna choose up the edge of the

quote unqoute, skin.

Okay.

Take one particular bite sort of proper in the apex

of this skin.

Is bite also a technical term?

It is.

I am gonna then what is known as

shield my needle.

Okay.

So, now, the sharp in the needle

is protected against this pickup.

Oh, okay.

And I am just gonna do a couple

of one particular handed ties.

Normally 3 or 4 for this.

I am alternating.

And then, when you get to the finish,

I will show you what to do.

You wanna attempt?

No.

But, I guess I have to.

I wanna hold it.

Yeah.

Exposed like there?

Confident, yeah.

Confident, there we go.

Excellent.

Back to the failure euphemisms.

Now, release your needle driver.

Oh.

I never know.

Specifically, push it from behind.

‘Cause you never normally wanna

touch the tip of this needle

’cause you never wanna either break it

or make it dull.

So, what you are gonna do is shield your needle.

That is it, fantastic.

Pull by way of.

Excellent, and now you are prepared to tie.

Do 4 single handed throws like you discovered.

Okay.

Okay, now the colour of the skin,

Appropriate.

and the colour of the filament,

Yeah.

there is not a lot of contrast

goin’ on right here.

Can I cheat with this?

No.

Right here, I am just gonna assist you.

‘Cause the point of this workout

is to sew, not to tie.

Oh yeah!

You are performing so superior.

I am so proud of you.

I am performing superior.

All proper, so, we’re gonna pretend

that I did that.

Appropriate.

And now it is anchored.

Yep.

So, then a operating subcuticular closure,

if you use your imagination, is gonna finish up

like a series of C’s in the plane of the skin.

So, then your subsequent bite, you are gonna evert

the opposite side of the skin.

You are gonna enter the tissue, sort of,

precisely opposite to exactly where you came out.

And once again, you are just gonna kinda run along

the dimension of the skin just like so.

You are gonna use the back of the needle

to push it along.

And if you are super slick, you will load

your needle when it is held down

there for ya.

Hmm, and so the only knots

are actually to anchor it at the starting?

Specifically.

Oh appear at that [crosstalk].

So, you are gonna choose up on this side.

But, I did it that way.

That is okay.

So, turn your physique.

So, yep, that is it.

So, when you are the operating surgeon

you can hip verify men and women,

you have to get your self comfy.

Out of my way!

There is a patient on the table.

Okay, so you are essentially gonna

come along this dimension.

Okay.

Yeah.

Like so.

Once again, use your pickups to place the tissue

exactly where you want it to go.

I get to place the tissue exactly where

I want it to go.

Yeah.

I am stuck.

But that is sufficient to get it out, I hope.

Yeah.

And, you know, in true subcuticular tissue

you wanna come out inside the wound

so that the stitch gets hidden Oh!

but that is okay.

For our purposes, that is your very first bite.

That is fine.

The point of this closure is that

you never see any suture.

So, am I going across or am I going along?

No, now you are going across.

Now, I am going across.

But, once again, use your pickups

to show your self exactly where you wanna go.

So, move along, make far more progress.

Which suggests take a bite with your pickups

closer to your physique.

Excellent.

Like so.

And I come across right here?

Appropriate, but this is in this dimension.

Oh proper.

Appropriate.

And now with this hand push the tissue.

Exactly where are you?

There you go.

That is fantastic.

Excellent.

Yeah. Let go.

All proper, video’s more than.

[laughing]

Let go.

Pull this out.

Oh, hey it closed.

Appear it is closing.

I know.

All proper, now I need to have [crosstalk].

But at this price, it is gonna heal

prior to you even finish.

Yeah, yeah, yeah.

Even if they never appear fantastic,

these have a tendency to heal up okay.

But, you can make this appear like

absolutely nothing ever occurred.

Which is kinda the.

Which is not what is taking place

to your patient.

Oh, properly, they are gonna have

a good memento of their time with me.

That is proper.

All proper, so let’s assume

that the rest of this is gonna go flawlessly.

Like that.

Like this.

Like this.

So, Peter, after you get to the finish,

you are gonna close this with what is known as

an Aberdeen Hitch.

Okay.

So, take your post.

Once again, we’re protected right here.

And get your proper hand by way of that loop.

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And you are gonna go grab your post.

And bring it by way of your knot.

Do not let your loop get as well tiny.

Oh, okay.

Okay, so I got one particular.

Excellent.

Do an additional. Do an additional?

Tension on the post.

Do not let the loop get as well tiny.

Pull on that and that’ll go down.

Pull on just the bottom one particular.

Just this one particular, there you go.

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Just that bottom one particular.

Excellent.

And then one particular far more.

A single far more.

Place that complete point by way of.

Yes.

Yep, good.

Incredibly superior.

Oh no!

Okay, go ahead.

Spoke as well quickly.

Okay, now reload your needle.

All proper, so now you are gonna

bury this knot.

So, just take a bite behind it

and come out more than right here.

Do I wanna evert like that?

Quit holding your pickups like that.

Come on buddy.

Oh, oh no.

Oh no.

Oh god.

So, just choose this up.

That is fine.

At this point, the patient has healed miraculously.

Is awake.

Is thanking me profusely.

Yep, prepared to be discharged property.

So, then your assistant cuts this.

And then, after you are completed with the suture

you pass it off to the scrub protected.

And you say needle back.

Needle back, thank you.

And that is that.

And appear how good.

Appear how wonderful that is.

The point you did 80% of.

[laughing]

The point of this is that the suture is hidden

so they never need to have to get them removed.

And that they just dissolve.

All proper, Peter, are you prepared

for the subsequent lesson?

Yes, please.

Okay.

[light music]

Nurse, bring in the sufferers.

I’ve by no means observed something rather like this medical professional.

Most serious case I’ve observed but.

All proper, what are we gonna do with this?

I assume there is currently some sort of point goin’.

I see a tiny bruise.

Properly, I assume very first, we’ll make

a tiny laceration then we’ll close it up.

At times you have to hurt issues

to heal them.

So accurate.

Two bananas had been harmed in the generating

of this video.

Yeah, and is this how you would

make an actual incision?

No, usually an incision is with a firm hand

and a straight line, and just all the way down.

Yeah.

It just depends on what type

of operation you are performing.

And so, exactly where would you see this?

This is, in a skinny guy

like you, inguinal hernia.

Fantastic.

Yeah.

Properly, let’s just pretend I am stitching up

my personal inguinal hernia.

There you go.

Okay.

So, for this specific model, it is finest to close

a banana laceration with a basic,

interrupted nylon suture.

Orthopedics surgeons will use it.

ER docs will use it.

But, it is sort of a easier,

far more straight forward way to close.

Okay, so this is just gonna pickup

on the skin, take a good bite,

come proper across.

So, how substantially space should really I leave behind

for the knot.

You wanna pull by way of ’cause you are gonna

place a couple of these in.

So, and then, which is my post?

Is this my post?

Yeah, shield needle very first.

Oh, shield your needle.

So, the filament that we’re working with,

what type of grade is this,

what thickness is this?

So, this is a 3-O nylon.

So, nylon is a monofilament, non-absorbable suture.

And 3-O is slightly bigger than

the 4-O you had been just operating with.

All proper, so we got it knotted, type of.

So, then I would essentially trim your tails

and you would place in a separate knot.

That is the interrupted.

Oh, so each and every time.

As opposed to operating.

So, as you can see, I did what you did

and then I reduce my tails and then I began once again.

This is known as an interrupted closure.

Is that a trim the tails?

Begin more than.

Excellent.

All proper.

What are your pickups performing proper now?

Two hands.

What are your pickups performing?

Gonna rip.

Cautious.

Okay, so when it is actually brief,

you do a thing that the orthopods

and the ER docs do, but the common surgeons

never do, which is known as an instrument tie.

So, it is the very same knot, but you are

just gonna do it What?

with your instrument.

And once again, common surgeons

never normally do this.

Why did not you show me that one particular?

Mainly because it is cheesy and it is not good

and it is not delicate and it is not civilized.

It appears less complicated.

It is less complicated but it is not civilized.

So, I imply, you have got the standard capabilities down,

the knot tying, the suturing.

I assume the issues that would

get constructed up to be a tiny bit far more

realistic is a wide open physique cavity,

blood everywhere, everyone’s yelling,

patient’s not performing properly, you are actually nervous,

you are exhausted, that is most likely

a tiny bit far more true life.

This is suboptimal skin circumstances

we’re dealing with right here. Certainly.

Yeah, your resident may perhaps have to redo

your skin closure on this one particular.

But some sufferers are far more tricky than other individuals,

I would not take it as well personally.

Properly, Annie, thank you for taking the time

to show me all this stuff.

May well it by no means come in handy but I am glad

that there are men and women like you

to make positive that it does.

Really should often shake hands with your assistant

prior to you leave the OR.

That is what that is.

[people clapping]

[light music]

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