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| Dr. Joel Aronowitz |
Dr. Joel Aronowitz: “I want to show you a little trick for the aspiring surgeons in training. After surgery, if you have an opportunity to have access to excess tissue, this is tissue left over from an abdominal plasty, and what we can do is create our little surgical field and do a little surgery for practice before it really counts on a specimen.
So this does not need to go to pathology and its excess is just skin and fat, and what we're going to do is do a little pretend surgery for practice of suturing. So first thing, we'll make an incision here, and we can also use this tissue to practice. Here I've made an incision into the dermis.
Now we're going to go a little deeper using the belly of the into the subcutaneous fat. Now we have a nice clean incision, and we want to practice suturing this back together. So, what do we need? A suture scissor, a needle driver, a needle driver, a pickups with teeth, and a marking pen is also very helpful. So, step one, we made the incision. Sometimes it's helpful when we're practicing to create little hash marks here that line up the skin edges properly, and then when we're a little more advanced, we probably don't need to make these hash marks. So, we’re going to use an excess suture here. First thing I want to show you is a simple stitch. So, simple stitch. We're going to hold the tissue by the dermis immediately adjacent to where we want to insert the suture.
Now, instead of letting go of the suture, if we continue to hold the tissue, then the needle is not going to move, and we can easily pick up that needle with either needle holder or our fingers. Now we have a nice bite here, square. We can see where we need to go right at our hash mark. We're now going to pick up the suture again and do it in reverse. So, we're going to pick up the tissue by the dermis like I showed you before. We're going to go in deep and get a nice square purchase so that we have the same amount of tissue in our stitch on this side as on this side, and then we're going to do a tie. So, now I'm going to show you a tie using my hands, a hand tie. So, it doesn't matter how you create that loop. There's all kinds of fancy ways with your finger. You can watch the YouTube on that, but basically all you're doing is creating two throws and bringing it down square. What does square mean? It means bring it down like this as opposed to like that. So, the untangled look is square. Now as I pull those together gently, gently, gently, my skin margins come together without excess tension and with the square knot going straight across.
So, there's two throws, and I'm going to put down one throw square and I can adjust my tension a little bit, and then I'm going to put down another throw square and another throw. So, I have with a stitch that's a simple stitch, I'm going to have four knots if it's a braided stitch like this mercilessly.
If it's a monofilament, I may want to put five or sometimes even six throws because a monofilament will tend to come unravel. So, now we're going to do a mattress suture. So, this is going to be a vertical mattress meaning all this, all of my stitch is going to be going in this direction. So, I'll show you a vertical mattress. First, I'm going to pick up my tissue by the dermis here.
I'm going to go in relatively far from the margin. Now, I'm going to go straight across. Again, I'm going to try to pick it up by the dermis so I don't crush the skin. Remember, if I keep holding on to the tissue with my pickup, then the needle is not going to be able to go anywhere. So, now I have my simple stitch.
Remember, we just learned how to do a simple stitch. We could tie that like so, but maybe we're having trouble and when we bring it together, the margins of the skin are inverting like like this. So, if that happens, a vertical mattress is very helpful. So, then with the second stitch, we'll come close to the edge and make it relatively superficial. We're near the margin. And now, we can avert the edge.
So, I’m going to bring that together and see how that averts your tissue. Now, all I have to do is three more throws to complete that knot. And if it's too tight, all I have to do is separate it a little bit. If I want to tighten it up a little bit, just pull that. But I want to make this loose enough that I'll be able to get in later with a scissor and cut that stitch when it comes time to remove the suture. So, that's a vertical mattress. Now, let's look at a horizontal mattress. So, now let's have a look at a horizontal mattress suture. So, remember a vertical mattress suture went up and down. Now, we're going to do a horizontal mattress suture. So, that's going to go like this. So, we're going to first, we’re going to hold on to the dermis. We're going to go in. We're going to go in straight down at a right angle. Then, we’re going to go across the tissue exactly where we want. You can even, if there's a little blood, you can even mark it like this and your suture can put a little bit of blood here on the other side so you can see where it belongs.
So, we’re going to go across. And then, instead of going back in line with our previous stitch, we’re going to go this way horizontally. And then, again, just go the same pattern backwards now from deep to superficial.
Now, like with most of our stitches, we’re going to do double throw and that's a horizontal mattress. You can see that does not bring your tissue together too well, but there's some times where you want to use a horizontal stitch.
So, that’s a horizontal mattress. Usually, you’re going to use a vertical mattress. Let's go over that one more time. So, we’re going to start further back, go superficial deep and the opposite side superficial, deep superficial rather.
And now, again, we could tie this as a simple suture, but we want to evert the skin margins. So, we’re going to go into the skin margin here, close, very small bite, close to the margin. And if you go too far back with this last pass, the skin margins are not going to come together. So, you've got to make it fairly small bite, that last bite.
And you can see that'll bring your tissue together very nicely with minimum amount of tension. This is ethyl on or nylon, black nylon. This is a monofilament suture and it will tend to unravel like most monofilaments. So, if you're going to use a monofilament, you want extra knots. Here's the stitch and you can see how that everts your skin margins.
You want to make sure there's enough distance between your first and your second pass here so you can get a scissor in there later to take that stitch out. If it's too close, it’s going to be too hard to take that out. The other problem, you don't want to make this too tight because you don't want to strangle the tissue and end up with hash marks here. Nobody's going to appreciate that. So, let’s practice this one more time.
Simple stitch, superficial to deep, very square. I've got an even amount of tissue here in my stitch. Then I'm going to take a look and see where do I need this to be to line these margins up. So, I've already created a little cheat here with my hash mark. So, I know it needs to go like this. In real life, there's a lot of pushing and pulling that goes on after an incision is made. It's necessary to be careful about lining one side up with the other to make sure you line it up properly.
So, I'm going to pull that down with just enough tension on that stitch to bring the margins of the skin together and then no more tension because if there's excess tension, it will strangle the tissue in between and the patient will get a hash mark that is a scar going this way from my suture.
So, there's a vertical mattress suture and a simple suture. Now, let's practice a running suture. So, we can begin here with a simple stitch and then we're going to do our first stitch as a simple suture.
Bring the skin edges together. Now, I'm going to cut just the short one. But before I cut it, here's a little trick. We can actually use a hemostat if we have one, but we can put a hemostat on the end of this and use it to hold tension so that we have some counter tension.
So, we're not going to do that in this case, but just a good little trick to have. So, now I've cut the short end and now I'm ready to go. Someone can follow me by holding that stitch at about the, that's 100 yards, about the 30 yard line, about a third, and I can do this freehand or I can hold the tissue, which is more precise, so that I can do this freehand. I am inserting my needle exactly where I want and I'm going to come straight across. Now, if I come straight across underneath, then I'm going to be traveling on the outside.
So, I'm going straight across here and then look what happens on the outside. When I do that, then I'm going to be traveling on the outside, so it's going to be slanted. So, I'll do one more stitch so you can see that. So, I need to do my advancing here on the outside, just like lacing up a shoe.
You can do the same thing. You can either travel on the inside of the lace or on the outside. So, now there's going to be a slant this way because of my traveling. Now, let's say I want to have the stitches look neat and going straight across, so what I'm going to do is I'm going to travel underneath.
By travel, I mean how much I'm advancing. So, then all of my stitches are going to be all my stitches are going to be going straight across as opposed to at an angle.
So, we want to have them evenly spaced and the same amount of from the wound margin apart so it looks neat and tidy and with just enough tension to hold that together and not making it so tense like that that it's all puckered because that's going to create extra injury to the skin and our scar is going to have little hash marks as a consequence.
So, just enough tension to hold that together and also appreciating the fact that post-operatively there's in real life there's going to be a little bit of swelling that happens which will bring your tissues together a bit as well. The other trick is to take out the stitches on time. If you leave the sutures into lawn, the epithelium will grow down along the suture tract and create a little punctate scar and that usually happens on the face after about five days and elsewhere in the body a little bit more than that. For example, on the tummy about a week to 10 days on the lower extremity about 10 to 14 days. So, taking out the whatever it is that's how you get those hash marks.
Those little punctate scars is the epithelium growing down. So, just a few little tricks. It's practice, practice, practice with suturing. It's just a simple manual skill. You can learn how to do it. Take advantage of every time you have an opportunity to use a little extra suture. You have a real life specimen that doesn't need to pathology that you can use.
Be really good about grabbing in needle holders and pickups and scissors some extra suture material and practicing a little bit and if there's a more experienced surgeon around, scrub tech, somebody who can help you ask a little advice you get little tips of the trade. So, I hope that helps and I look forward to seeing you back here in Aronowitzland soon where everything is exactly the way I like it but by now.”
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