Surgeons are masters of their craft, using their hands and tools to cure ailments with immediacy. But to be proficient in the operating room, a high degree of dexterity is required. Here’s how to get there.
Why should you even care about improving your dexterity now? After all, isn’t there plenty of time to practice with your hands in the future, once you’re a senior medical student or a surgical resident? There are a few reasons why you should prioritize it sooner than later:
First, if you want to go into surgery, you’ll need to impress your seniors and secure strong letters of recommendation. While your letters aren’t solely based on your technical skills, it definitely helps.
Second, your opinion of surgery will be highly influenced by your early experiences during your third-year clerkships. If you struggle with your hands, you’re going to have a bad time. If you’re highly proficient, I promise you it will be more fun and more rewarding. Also, I have seen a surgical resident who had to repeat a year in residency two separate times due to lacking technical ability.
And third, surgical technique is taught primarily based on two factors: comfort and current ability. Your attendings and residents will want to push you slightly past your comfort zone in order to learn. If you demonstrate comfort and competence with the basics, you will be trusted with more fun tasks, beyond just retracting. The average medical student and intern is just retracting, and maybe they’ll be lucky to tie a knot or two. Statistics apply to populations, not to individuals, and it’s on you to be the outlier. As a medical student, you can absolutely tie knots and suture on the majority of cases you scrub into, but only by demonstrating technical proficiency.
Improving your skills in the operating room comes down to two main factors: mindset and technical practice.
Your mindset in your journey toward technical mastery in the operating room comes down to whether you can find enjoyment in it. After all, if you enjoy something, you’re more likely to want to practice, put more time into it, and accelerate your progression. If you don’t enjoy it, then practicing will feel like pulling teeth, and you’ll spend less time and energy on it.
Therefore, the foundational mindset principle to improving your skills in the operating room is to enjoy the process. How can we do so?
If you initially hate it, it’s usually because you don’t feel very good at it, and the ratio of effort to skill progression is skewed. Keep at it, and dive deep. Once getting past the initial hump, most students are able to find some level of enjoyment in honing their surgical skills.
The pursuit of mastery can be incredibly rewarding, particularly in areas where you can see measurable improvement. Tying surgical knots and suturing aren’t as measurable as your body fat or strength in the gym, but you can find ways of tracking progress. You could track the time it takes you to tie 10 knots. If you used to be slow and tie sloppy knots, you’ll be stoked when you’re faster and have perfectly symmetric and tidy knots. And when your attending gives you more responsibility in the operating room, you’ll know you’ve gained their trust and demonstrated an upward trend in proficiency.
Finding an area of surgery that you truly enjoy will make the application of this skill set that much more rewarding. Just like studying physics is more fun when you’re able to apply it to your passion of Formula 1 racing, practicing surgical skills knowing it will help you for your future career as an orthopedic or neurosurgeon makes it that much more enjoyable.
The technical practice in the operating room follows a simple stepwise progression.
As a medical student, you’ll initially primarily be retracting. It’s not necessarily easy, it’s definitely not fun, and it can often be tiring. That being said, get used to it, get proficient at it, and don’t complain. Understand why you’re retracting and do your best to make the surgeon’s job easier. Reading up on the nature of the procedure beforehand can help you understand the rough order and progression of steps so you can anticipate steps and know what’s going on.
Next, you’ll be tying knots, which is much more complex and nuanced than most students expect. Good knots use the least amount of suture to securely hold tissue. With too little suture or poor technique, the knot is likely to fail, resulting in wound dehiscence, meaning the surgical incision comes apart after it’s been stitched together. With too much suture, there’s excess foreign body material in the patient, which results in suboptimal inflammation and infection risk.
To practice knot tying, you’ll need a knot tying board.
Start with a simple two-handed throw, ensuring your knots are square. Be slow and deliberate with your movements to solidify foundational technique. Don’t worry about adding speed now, that’ll naturally come later. Once you’re proficient, make sure you can reverse your hands such that you can swap the roles of your dominant and non-dominant hands.
Next, learn how to do one-handed throws. Your non-dominant hand will be stationary, holding one piece of the suture or string. The dominant hand will be doing the throwing motion. Again, once you’re proficient, switch hands and reverse the roles of your hands.
The reason it’s critical to be well versed with both hands is that surgery is never as perfect as your practice environment. You’ll be in a suboptimal position, or there will be equipment in the way, or the knot must be thrown deep in a body cavity. For these and other reasons, you should be well versed in various different knot tying techniques and with both hands.
While you practice, again focus on fundamentals and go slowly. Every knot should be square without any air knots, meaning gaps in the suture between knots. As you get more comfortable, you can experiment with slightly more advanced techniques. For example, you use a slip knot when there’s a small aperture limiting the distance you can pull apart the suture. Similarly, if there’s tension across an incision, you would use a surgeon’s or friction knot, where you first do a slip knot to hold the tissue together prior to the locking throw. You can practice these various scenarios with one of the knot tying kits I’ve linked below, as they simulate cavities and tension across an incision.
Once you’ve graduated from the multicolored string in your kit, you’ll want to grab some actual suture or ties. Find expired ties in your hospital and continue your practice, but this time you can do it just about anywhere. I would do it on my water bottle handle while sitting in a lecture and the drawstring of my scrub pants.
And finally, grab some OR gloves and put cooking oil on them to simulate the slippery and fluid filled environment that is surgery.
The final skill set to practice is suturing. Again, you’ll need a specialized kit, and I’ve included my favorites in the description. You’ll need a needle driver, forceps, practice tissue, surgical scissors, and suture. Be sure to purchase a separate high-quality needle driver, as the ones in suturing kits are almost always subpar.
Similar to knot tying, there’s a logical progression to follow. You’ll begin with simple interrupted sutures. Again, slow down and focus on the fundamentals, with attack angle of 90 degrees to the tissue, consistent spacing, depth, and tail length when you cut. Now is also the time to practice instrument ties, which is where you tie knots using the needle driver.
You’ll then advance to other suturing techniques, including running subcuticular, deep dermals, vertical mattress, horizontal mattress, and more.
As I’ve covered on my Kevin Jubbal, M.D. channel, you should also be able to palm a needle driver. Inserting your fingers into the finger holes is actually slower and limits your range of motion. Palming the needle driver is a pro move that allows for better control, efficiency of movement, and speed.
As you get more comfortable with these various tools, you can practice flipping them backwards into your palm so you can still user your thumb, index, and middle finger for other movements. Again, the operating room is all about efficiency of movement, and saving a few seconds by flipping the tool into your palm rather than placing it down is another small way to further optimize.
Dexterity isn’t something you’re necessarily born with or not. Like with most things in life, it’s something you can practice and improve. The techniques we’ve already covered will be the primary drivers of improvements in the operating room. However, if you’re hardcore and want to optimize even further, here are some additional considerations.
First, your non-dominant hand is likely far less dextrous than your dominant hand. Most of us aren’t ambidextrous, but again we can train ourselves to have greater control of our non-dominant hand. I’m right-handed, so to address this, I would brush my teeth or pick up and open items with my left hand.
Second, if you have hobbies that require precision and dexterity, lean into them. Some of my favorites have been origami, sketching, painting, and building small model cars.
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