Saturday, June 30, 2012

Tying Knots


Last week in surgery one of the surgical techs commented on how fast I could tie knots. I was a bit surprised, to tell the truth, because I’ve never considered myself a “fast” surgeon. During my training I was always impressed by those surgeons who were technical wizards, whose fingers could dance across a patient’s insides and dissect quickly, cleanly and precisely. I had always thought of myself as more of a plodder, working methodically towards a defined goal, doing my best to stay out of trouble while trying to accomplish the task at hand.

I try to have a plan for every operation I perform, simple or complex, and then find the safest way to reach the end, attempting to anticipate each potential pitfall and sidestep them as much as possible. I usually say “I’m not a slow surgeon, I’m not a fast surgeon; I’m a half-fast surgeon.”

But what of the knot tying comment. The first thing any medical student learns about the technical aspects of surgery is how to tie knots. During my medical school days, if one wanted to do anything in surgery besides become close friends with the end of a retractor, one had to demonstrate the ability to tie surgical knots.

This skill always began with a friendly surgical intern, at least one friendly enough to take pity on a helpless ignorant medical student. Such an intern would demonstrate and instruct the proper way to tie knots. First two handed tying and then the cooler one handed techniques, The student would then procure several yards of suture and spend the night tying knots to armchairs, tables, dogs, cats, fellow students and anything else that was handy. Armed with this newly perfected skill, the student would enter surgery the following morning poised to demonstrate this newly honed talent. Of course, it was necessary for the operation to be done. The tedious bowel resection would drag on and on, until the attending or Chief Resident would announce to the second year resident that it was time to close. If the Chief Resident left the OR, the second year would hand the suture to the intern who would then close the abdomen. The first layer closed would be the fascia, the most important layer. The fascia is the layer with the most strength and its closure would always be under the watchful eye of a senior resident; third year medical students never were allowed to close this layer. But, next would come the subcutaneous tissue, a layer that added no strength to the closure; a layer composed mostly of fat which could be sutured or not. There is some theoretical benefit to closing this layer, eliminating so-called eadspace, but it mostly allowed interns some practice in suturing.

So the intern sutures this layer closed and then, the big moment, asks the medical student to tie the knot. The student carefully pulls on each end of the suture and throws the first knot; so far so good. The second knot is thrown and it settles about a centimeter from the tissue, leaving a big gap and the suture doing nothing, the first knot having loosened up while the second knot was being tied. The student then tries to cover up this error in technique by cinching down on the suture, hoping it will slide down to its proper resting place. Instead the suture breaks and the intern is force to start over, muttering something about the suture breaking due to the “jerk’ at the end of the string.

But, after this initial false start, the medical student is given a second chance. For some reason, living tissue is very different from the arms of chairs. This time the student ties the knot and holds tension as the second knot is thrown and manages to get it cinched down to the tissue, only this time the extra tension causes the suture to tear completely out of the flimsy fat, leaving our hapless student holding a suture with two perfectly tied knots, but holding nothing but air together.

At this point most interns would instruct the student to practice a bit more while finishing the work themselves. Most medical students, having been thoroughly humiliated, would try to spend the remainder of their surgical rotation reading Schwartz while planning a future in dermatology. The exceptional, intrepid student, however, perseveres. If said student is extremely bold he will ask for one more chance. Given this opportunity the student then ties three perfect knots, the tissue stays together properly and this student spends the rest of the day with a smile on his face, having taken the first small step that leads to a life surrounded by gowns, masks, gloves, blood, guts, worry, success, failure, life and death. A future surgeon is born.