As we enter July and the arrival of new interns & sub-interns, and graduate our junior residents from the level of learner to teacher, I thought it would be worthwhile to share a few common suturing errors that I’ve observed over years of giving basic suturing workshops to trainees.
This is a top ten list, presented as a two-part post, and featuring a few illustrative Tiktok videos along the way.
- Handling the needle with your fingers.
Even in a simulation or workshop setting without patients, where an accidental needle stick would in theory lead to little risk, I always impress upon learners that all needle handling should be performed strictly with instruments. This includes removing a suture from its packaging, exchanging a needle from a needle driver to forceps, and disposal of remaining needles. Learners will find this difficult to do and will tend to revert to grasping and pinching with fingers—actively correct this bad habit and validate that using instruments only for needle handling is difficult (at first).
We all have a personal needle stick story, colored by the associated mental anguish and administrative hassle it caused—feel free to share yours with learners to impress upon them the risks of this bad habit!
Don’t forget to mention the perils of needle re-capping after injecting anesthetic as well!
2. Driving the needle towards the wound, instead of perpendicular down in to the wound.
Intuitively, new learners will direct a curved suture needle towards a wound rather than driving it down at a 90 degree angle perpendicular to skin when performing a simple interrupted suture. This makes intuitive sense to someone trying to bring a wound together, but is improper technique that should be corrected.
Explain to your learner that doing this will result in the needle taking too shallow of a course through the tissue. This may unintentionally invert the margins of the wound, which is an undesired effect since small valleys and dimples in wounds will capture shadows, and make a scar appear more prominent. Conversely, an everted wound, which is achieved with a 90 degree throw, will deflect shadows and result in a less noticeable scar, especially as the wound contracts over time to become planar. Highlight the curved shape of the needle and how it is designed to traverse the wound at just the right depth, provided it is placed at the correct angle.
3. Grasping the suture needle improperly.
Grasping the needle correctly with the needle driver allows optimal control in order to achieve the proper throw. New learners will sometimes use the needle driver to grasp the needle at its midway point, or at an oblique angle which sets them up for difficulty when placing the suture.
Demonstrate that a needle driver should grasp the needle 2/3 of the way back from the needle tip, towards the swaged end (the end anchored to the suture). The needle is best grasped at a 90 degree angle.
4. Forgetting to set the knot
New learners are instructed on the pattern, “loop twice around for the first throw, then once around for subsequent throws.” By the time they have reached an EM sub-internship, they have generally learned and practiced this in a general surgery rotation. What they may be missing is the “why”—here is is a good opportunity to fill in gaps in knowledge, to reinforce the skill.
The “why:” that first double loop throw sets the knot, creating a flat “surgeon’s knot” which prevents slippage of the first throw when tension is applied to the wound edges. This is unnecessary with subsequent throws.
5. Move the instrument, not the suture!
Learners will sometimes try to loop the suture around the needle driver, holding the instrument stationary, rather than holding the suture stationary and moving the needle driver to create the loop. This will create a poor economy of movement and slow the steps of tying the suture. Further, since the dominant hand generally holds the instrument, it is much more dexterous to move this hand. Not to mention, the non-dominant hand is holding the suture end attached to a needle, and moving that around can be dangerous as the loose needle could cause injury.
Instruct learners to hover the needle driver immediately over the center of the wound. Then, in a clockwise fashion, loop the instrument around the swaged end of the suture, finally grasping the tail end of the suture in the jaws of the needle driver before pulling the hands across the wound to allow the knot to lay flat. For the following throw, instruct the student to again hover the needle driver over the center of the wound, but point out that this time the instrument will move counterclockwise to accomplish the same task.
Building muscle memory for this step in instrument tying is essential for confident and efficient suturing.
That’s all for Part I! In Part II, five more common errors you want to identify and correct in your learners (or yourself) before they become bad habits.