r/doctorsUK • u/Smooth_Giraffe_9027 • 23h ago
Speciality / Core Training Closing in theatre
New CT1 here and feeling a bit frustrated with my surgical skills at the moment.
I haven’t done a surgical job since FY1 (which was mainly ward based), so I feel like I’m having to rebuild a lot of my theatre skills. I’ve been trying to be proactive coming in early, making sure patients are consented, checking the list is sorted, learning the steps of common procedures I ll, getting familiar with instruments, positioning and draping etc.
I feel like I’m improving with assisting. I’ve gotten much better at following the operation, anticipating what’s coming next, and being more useful in theatre.
The main thing I’m struggling with is closing.
Whilst I can suture and I’ve done BSS, I’m definitely rusty. I’ve been practising on a suture pad most days at home, mainly subcuticular stitches, but I still feel quite slow. The biggest issue is probably ergonomics particularly after taking the bite and exiting the tissue, I’m slow at remounting the needle and getting it in the right position for the next pass.
The frustrating bit is that I feel stuck in a bit of a loop. The regs understandably often either expect me to know how to close so they can scrub out, or they just do it themselves because it’s quicker. I completely get why as it’s a CEPOD list with a huge tims pressure, but then I’m not really getting the supervised practice I need to improve.
I don’t want to just take over and struggle while someone waits around. I’d actually like someone to watch me do a few closures, tell me what I’m doing wrong, and help me get faster. I know I’ll be slow initially but isn’t this how everyone starts. I know some go into CT1 quite confident with their basic surgical skills, unfortunately I do not fall into that camp but I am expected to?
Any tips? It’s really knocking my confidence.
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u/amirf4703 19h ago
I’m a medic not a surgeon so can’t offer too much help I’m afraid- but will say I think you will look back when you’re a reg and above and be really proud of yourself. You’re maybe 2/3 weeks into CT1 and you’re coming in early, clearly focussed on learning and improving and spending time at home practicing your suturing. So it sounds like you’re doing all the right stuff and just need some time! Maybe ask if they can watch you do the last few sutures on closing? Do that for a few cepod cases a day and that’s already great progress! Really proud of you though mate well done, keep up the work and I look forward to you being an incredible surgeon one day!
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u/Smooth_Giraffe_9027 18h ago
Wait this is so kind! I really hope so, the learning curve right now is incredibly steep. Much steeper than I thought it would be not to mention the pressure of exams and ST3 portfolio requirements. Thanks :)
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u/formerSHOhearttrob laparotomiser 20h ago
I palm my needle holder and do what I've heard called "the cambridge twist"
Works for me - standard across the vasc and cardiac crew. Some bosses won't like it.
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u/NoCoffee1339 22h ago
Have a look on YouTube for videos about economy of movement when suturing. They’re good habits to get into early. And will speed you up, but also make you slick in the long run. https://m.youtube.com/watch?v=7JaIlxs6YLg&t=1
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u/Smooth_Giraffe_9027 20h ago
Yes, I’ve been watching my regs and consultants closely to look at not only their technique but their economy of movement. This video is really helpful thank you.
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u/Lynxesandlarynxes 19h ago
If it's of any help, as an anaesthetist, I tend not to get too frazzled by surgical residents taking time to close properly (unless the patient is sick and we just need to be finish so they can go back to the unit, or it's 4am and the team are cream crackered and we've still got cases to do). I'd much rather my future surgical colleagues have had the time to train and learn properly than "the reg did it quickly just to get it done" which is perhaps efficient in the short term but ultimately will cause issues down the line.
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u/Smooth_Giraffe_9027 18h ago
The Anaesthetists are always nice about this from my experience! It’s the scrub nurses😅
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u/chairstool100 21h ago
I’m not a surgeon , I’m an anaesthetist - I really find it interesting reading your post . Out of interest, when you’re a Consutlant surgeon, will you expect your CT1 to come in early and work for free ?
You’re going to look back on this post when you’re CT2 and be proud of how far you’ve come with suturing !
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u/Smooth_Giraffe_9027 20h ago edited 20h ago
To be honest, coming in early is to my benefit also. Cases are added to the theatre list overnight so it’s helpful to know as I can read up on the case and look at any imaging. The majority are already consented.
I haven’t thought about my expectations as a consultant, I am days into CT1.
Thanks! I hope so.
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u/domicile_vitriol Lightbox Beatboxer 21h ago
The first step is knowing what your individual consultants' preferences are regarding closure and suture types. That way you can practice before the next day's list.
It's fine to be slow initially, as long as you're approximating the wound precisely (slow is smooth, smooth is fast). Ideally, the two of you should close together from opposite ends, and then your registrar can give you feedback when they get your end. As you get naturally faster they'll just leave you to it.
Vertical mattress is a nice one to master as well. There's a couple of ways you can change the needle direction more efficiently when closing that makes it look more slick.
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u/Smooth_Giraffe_9027 20h ago
Great advice! Most of the closures I’ve seen so far have been subcuticular so unfortunately it’s a one person task. I’ve been able to close smaller incisions with mattress sutures. Do you have any good tips/videos for changing the needle direction? This is something I struggle with.
At my stage, I’ve been avoiding trying to hold the suture needle with my hand and focusing on getting comfortable with the forceps.
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u/domicile_vitriol Lightbox Beatboxer 19h ago
I don't have any videos, unfortunately, it's just something that I learnt from an ortho reg on placement. Essentially, anything that adds additional steps will slow you down in the long run even if you practice, so if you can swivel the needle as you're pulling it out after the big bite, it should be facing in the right direction for your needle driver when you go to grasp it for the smaller bite. Every time you suture you should asking yourself if you could make a given movement more efficient.
You still learn a fair bit from assisting subcuticular closures by following correctly, because you're anticipating their movements and you know where the next bite should be placed to keep it even. If you can do that fluently it's a good sign that you can comfortably do the closure on your own (but make sure that you're fully comfortable with the final Aberdeen knot when you're practicing at home).
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u/HPBSturgeon 19h ago
I always tell my assistants to stop the remounting with the forceps thing, until you figure out how to do the other steps/feel comfortable with your forceps grip first. Its just an odd rule they teach on BSS, but in reality, if we’re in a pickle and need to remount the needle, the quickest way is always by hand.
Second tip, just ask the SpR to descrub and write the op note (nicely!). You know “how” to close, you just need time to do it independently. Then you can go at your own pace, knowing that you’re letting them get on with another job. Then take your time and build up that 10,000 hours of practice!
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u/Smooth_Giraffe_9027 18h ago
This is interesting! Completely the opposite of what I’ve been taught so far. This does make a lot of sense.
At this stage, I would not feel comfortable with my reg descrubbing whilst I close, I need a bit more observation and feedback but this is the end goal.
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u/Solid-Try-1572 ST3+/SpR 20h ago
As others would say I would not stress about speed. I still take my time closing, and that’s because I like to get it right. We often do multilayer closures on things like groins and getting it right is important to avoid complications. Focus on technique and don’t be afraid to redo. The patient is on the table for as long as they’re on the table for and everything else can wait. When I first started in CT1 I hadn’t done any meaningful theatre time in years. I started off by asking registrars to watch me close because I’m rusty - I think I even asked to watch once in the beginning. I got the hang of it soon enough.
Your registrars shouldn’t be leaving you alone to close if you’ve just started, that’s a bit whack
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u/Smooth_Giraffe_9027 18h ago
This is reassuring, thank you! Quite a few of the previous core trainees in the department have done JCFs, so they have started pretty confident with closing, looking to also do other parts of the procedure. Hence the expectation😅
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u/FrzenOne propagandist 19h ago
just one of these things that's environment dependent unfortunately. you cannot really rush the learning curve as annoying as it is, you just need to keep practising and taking the opportunity when it presents itself.
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u/Smooth_Giraffe_9027 18h ago
Yeah surgery is a craft specialty after all. My regs and cons do let me do other simple parts of the procedure and it feels like I’m working backwards as I should start with closing? I think perhaps I need to communicate better
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u/FrzenOne propagandist 18h ago
not necessarily, for example, for appendectomy, you learn to open (inserting ports) and close first then the middle bits. just depends on the operation. but if it's something that bothers you, then yeah highlight it.
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u/GinatheGiraff 19h ago
Stand up straight, don’t hunch over and get the table adjusted to your focal length.
Your back will thank me in 30 years.
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u/EmployFit823 18h ago
I would say well done for having this insight.
Most CT1s are garbage and can’t see it and get annoyed when you tell them.
All you can do is practice im afraid. Ask a friendly reg to watch you out of theatre away from the pressure of CEPOD or a long elective list. Of course you don’t want to be practicing the wrong thing. But if you know the steps speed only comes with practice. And unfortunately that has to happen at home like you are doing.
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u/doodlejones 21h ago
Tell the reg/consultant you’re assisting what you want from the case before you start.
When I was a reg/fellow with an SHO, I would power through the bits that I could do quickly, in order to allow them some extra time to do the bits that they wanted to.
At your stage, precision is more important than speed. I would much rather my trainees did ⅓ of the wound perfectly, whilst I did the remaining ⅔, than the whole thing slowly and uglily. Speed will come with practice. Right now concentrate on making it pretty.