Suturing simulated skin 07 Needle insertion - forehand

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Suturing simulated skin 07 Needle insertion - forehand

This subsection has text and images from an interactive multimedia training program on basic 
surgical skills called PrimeSkills in Surgery.
You can use this subsection on its own or follow the whole program (further details at the end of 
this subsection).


Introduction.

Needle insertion - Forehand.

Check the needle holder.

Check the needle.

Check the suture.

Address the incision.

Brace the dissecting forceps.

Brace the needle holder.

Inserting the needle into the right hand skin edge.

Pull the needle out of the wound.

Elevate and rotate the left skin flap.

Insert the needle into the left skin flap.

Pull the needle and the stitch through the left hand skin edge.



Introduction


The detail of the information given here is actually what an expert surgeon does when stitching.


Learning it should be easy, leading to an effortless smooth technique.


Needle insertion - Forehand.


Cut a 5cm. incision in a Jiffy padded bag with a scalpel.


Or print out the Suturing Doily, stick it onto a Jiffy padded bag and incise the wound on the top left hand corner.


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To print out a copy of this screen, if you are using Mozilla Firefox:

Click on File in the top left hand corner of your computer screen.
Click on Print preview.
Scroll down to page 3 to check the Hemostat Exercise doily is there.
Click on Print preview again to return to this screen.
Click on Print.
Select Page 4 of 25.
Click OK.
The screen will be printed.


If you are using other programs, the instructions are rather similar.


Hold the needle holder in your right hand.


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Check the needle holder.


Check there is no resistance at the hinge in the needle holder.


Resistance here will prevent you feeling accurately what is going on at the needle holder tips.


Load the needle onto the needle holder using dissecting forceps.


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Check the needle.


Check it is the correct needle. e.g. Ethicon W 9890.


Check the needle holders grasp the middle of the needle.


Check the needle is at right angles to the needle holder or pointing 20 degrees forwards.


Check the needle is held within 3mm of the end of the needle holder jaws.


Check the needle does not swivel in the jaws when the needle holder ratchet is fully closed.


Fasten the needle onto the needle holder with the maximum number of clicks on the ratchet.


Remember when stitching to use the ratchets.


If you are under stress, you may forget, resulting in a loose swivelling needle.


Check the suture.


Check it is the correct suture.


Check the suture is free from correctable zigzags.


Zigzags make the suture springy, more difficult to handle and more difficult to prevent tangles.


To correct zigzags hold the suture between finger and thumb near the needle and at its far end.


Pull the suture tight.


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A Vicryl stitch will lengthen slightly as it loses all its zigzags.


Zigzags on sutures of other materials will improve partly on pulling.


Simply sliding your fingers down the suture will not tension the suture enough to remove the zig-zage.


Lay the suture out to your right to avoid tangles.


Pick up the dissecting forceps.


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I prefer a medium, non-toothed forceps.


Toothed forceps may tear the tissues.


Non-toothed forceps may crush the tissues.


Fine forceps may not be strong enough.


Coarse forceps may take up too much space.


Hold the forceps between left thumb and index finger like a pencil.


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Do not hold the forceps like a fork.


This is too clumsy.


You will lose much of the finger, hand and wrist actions that are esential for using forceps.


Check they are the correct forceps.


Check the points are not crossed.


Check the teeth of a toothed forceps mesh correctly together.


Check the tips stay closed when squeezing the forceps hard.


Check the jaws spring apart to give a comfortable pressure.


Force the jaws apart to increase the angle and hence the pressure as needed.



Address the incision.


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Plan to stitch with a forehand movement of the needle holder.


A backhand stitch is more difficult.


It is slower.


It leads to the needle holder crossing the operating field.


It is a temptation and a pitfall for the beginner.


It is a sign of a beginner's inexperience.


Plan to stitch towards yourself.


Virtually all stitches can be inserted forehand towards the surgeon.


It requires considerable attention to rotation of the wrist, elbows, shoulder or hips.


These may feel unnatural to beginners at first.


Persist.


Moving to the opposite side of the operating table may be required.


Learning to stitch back hand is described in the next subsection.


See File:Suturing simulated skin 08 Needle insertion - backhand



Brace the dissecting forceps.


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I.E. Use any of the following techniques of bracing as shown here for scissors.


A finger of either hand touching the simulated skin.


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The little finger can touch the opposite hand as well.


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One hand touching the other.


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A wrist of either hand touching the work bench.


Either elbow touching the work bench.


Either elbow tucked into the waist.


Your pelvis leaning on the work bench.


Brace the needle holder.


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Use the same methods as for the dissecting forceps.


Inserting the needle into the right hand skin edge.


Elevate the right or upper skin edge.


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Use the forceps.


The aim is to display the depth of the wound where the needle will appear.


Lift and roll the skin edge slightly to display this.


The less pressure with the forceps the better.


Avoid bruising, crushing or tearing the plastic skin.


Steady your hand if necessary by touching the table with your left little finger tip.


Choose the site and depth of the needle bite.


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Plan to enter the "skin":


2 mm. from the end of the wound.


7 mm. from the edge of the wound.


Plan to exit the depths of the wound 5mm. deep to the surface.


Do not try to pass the needle through both edges of the wound at this stage.


You will not succeed, get needle pop-back , and will probably bend the needle as well.


Do the passage of the needle one edge at a time for at least 50 stitches before contemplating a double passage.


Insert the needle into the right hand or upper edge.


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The needle track is a semicircle through the first skin edge, across the depths of the wound and up through the second skin


edge.


The needle should pass vertically through the skin and run horizontally across the depths of the wound.


(Eventually emerging vertically through the surface of the second wound edge).


Pop the needle vertically through the skin of the wound edge.


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If the needle will not pass through:


Try a little harder.


Check you have a cutting needle, and not a round bodied one.


Check the end of the needle is not hooked.


Push the needle to emerge in the depths of the wound.


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Let the curvature of the needle find its path through the tissue.


A minor clockwise curving force from the needle holder is all that is needed.


If the needle point does not appear:


Increase the curving of the needle holder.


If the needle point does still not appear:


Remove the needle and place the needle holder further towards the point to give more strength and a more favourable


angle for the needle to run well.


If the needle holder bends the needle:


You are using a rotation force instead of a curving action.


Push the needle holder rather than rotating it.


Relax.


The needle may be mounted too far back.


Hold the needle nearer its point.


Use a new needle.


Do not straighten or use a bent needle for fear of breakage and loss of the end in the wound.


All beginners will bend the needles at first.


Just keep improving your technique.


Be gentle.


Take your time.


The recommendation of holding the needle two thirds of the way back from the point leads to the needle bending, particularly


for a beginner.


End up with 3mm. of needle point showing in the depths of the wound.


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If there is less than 3mm.:


The point will be difficult to grasp with the forceps.


The forceps may bend or break the point of the needle.


The point may pop back into the tissues when stitching real tissues. (pop back)


Push the needle further in with the needle holder.


To correct these problems:


Resite the needle holder further away from the point and push the needle again.


If the needle point does not appear:


Increase the curving action of the needle holder.


If the needle point does still not appear:


Remove the needle and place the needle holder further towards the point to give more strength and a more favourable angle for


the needle to run well.


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Push the needle further in with the needle holder.


Next, keeping the needle in the wound using the dissecting forceps, resite the needle holder further away from the point and


push the needle again.


Pull the needle into the wound.


Grasp the needle as it appears between the 2 skin flaps.


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Use the dissecting forceps.


Continue pulling with the dissecting forceps.


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If the forceps slip, take a firmer grip as far away from the point of the needle as possible.


Exposing a shorter length of needle will prevent firm gripping by the forceps and later the needle holder, plus a risk of the


needle tip being bent or broken by those instruments.


Release the needle holder.


Grasp the needle in the depths of the wound with the needle holder.


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Ideally grasp the needle at its mid point.


Alternatively, anywhere from the mid point to 2mm from the tip is satisfactory.


Pull the needle out of the wound.


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Use a curving, not rotating, movement with the needle holder.


Keep pulling until there is just 5cm of stitch left above the skin for an instrument knot, or 25cm. for a hand tied knot.


Resite the needle holder on the needle.


If not already done, place the needle holder on the mid point of the needle as before.


Make sure the needle is at right angles or 20 degrees forwards.


A backward facing needle hampers stitching.


Elevate and rotate the left skin flap.


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Precautions as before.


Insert the needle into the left skin flap.


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Site the needle opposite the first half of the stitch.


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Push the needle through the left hand skin edge.


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Use a clockwise curving movement with your wrist.


Pop the needle through the skin, 7mm. from the edge of the wound.


Push the point at least 5mm. through the skin.


Pull the needle out of the wound edge with the dissecting forceps.


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Rotate the needle holder 90 degrees anti-clockwise at this point.


(This will prevent your wrist running out of rotation as you curve the needle out of the wound with the needle holder).


Hold the emerging needle with the needle holder.


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Grasp the needle at least 7mm. from the point to avoid bending or damaging the needle tip.


Pull the needle and the stitch through the left hand skin edge.


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Use a clockwise curving movement of the needle holder with your wrist.


Pull the stitch through the second skin edge until there is no slack stitch in the depth of the wound.


Make sure you do not pull out the length of stitch protruding from the first skin edge.


If the end of the suture disappears into the wound:


Re-insert the suture.


To knot the stitch go to Suturing simulated skin 09 Knot -general


Next subsection, click on Suturing simulated skin 08 Needle insertion - backhand
Last subsection, click on  Suturing simulated skin 06 Needle insertion - general
Return to Suturing simulated skin 13 Mattress suture
Surgical Education and Training page, click on Surgical Education and Training
Whole program on WikiSurgery, click on PrimeSkills in Surgery
Whole program on CD-ROM, click on Michael Edwards