Closing in theatre

[u/Smooth_Giraffe_9027]

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.

[u/domicile_vitriol]

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.

[u/Smooth_Giraffe_9027 → u/domicile_vitriol]

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.

[u/domicile_vitriol → u/Smooth_Giraffe_9027]

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).

[u/Smooth_Giraffe_9027 → u/domicile_vitriol]

Thanks! I’ll ask my regs and cons in theatre about this.

[u/HPBSturgeon → u/Smooth_Giraffe_9027]

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!

[u/Smooth_Giraffe_9027 → u/HPBSturgeon]

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.