Interact CardioVasc Thorac Surg 2005;4:289-291. doi:10.1510/icvts.2004.104174
© 2005 European Association of Cardio-Thoracic Surgery
Work in progress report - Cardiac general |
Techniques of needle stance exchange in situ
Amir-Reza Hosseinpour,
Graham Hilton and
Samer A.M. Nashef*
Papworth Hospital, Cambridge CB3 8RE, UK
Received 13 December 2004;
received in revised form 11 April 2005;
accepted 12 April 2005
*Corresponding author. Tel.: +44 1480 364299; fax: +44 1480 364744.
E-mail address: sam.nashef{at}papworth.nhs.uk (S.A. Nashef).
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Abstract
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It is possible to alter the stance of a suture needle in situ (without withdrawal from the operative field). We describe five techniques by which this can be achieved.
Key Words: Surgical technique; Anastomosis
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1. Introduction
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Correct needle positioning in a needleholder (needle stance) is crucial for accurate suturing. Every suture has an optimal needle stance. In an anastomosis, needle stance may vary by 360° as the suture line progresses. Needle remounting outside the operative field after every suture slows the progress of the suture line. Conversely, manoeuvres which adjust needle stance within the suture line or in its immediate vicinity (stance exchange in situ, or SEXI manoeuvres) are faster and more elegant. To our knowledge, there is no account of these manoeuvres in the surgical literature. Surgeons who intuitively practise some or all of these techniques discover them only after lengthy experience. We describe here 5 SEXI manoeuvres with the aim of facilitating surgical training.
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2. Techniques
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For clarity, the two stages of the needle pass are consistently termed as follows:to ‘advance’ the needle is to enter the tissue
to ‘withdraw’ the needle is to exit the tissue
2.1. The tissue anchor
This is a basic SEXI manoeuvre, which is rapidly discovered by trainees. It consists of withdrawing the needle on the needleholder at the end of a pass, then anchoring the point of the needle against nearby tissue while reducing the grip of the needleholder just enough so that a push or a pull will reverse the needle stance from forehand to backhand or vice versa. It is easy to learn but lacks controllability and is not particularly elegant (Video 1).
2.2. The Tak manoeuvre
This is used when two sides of an anastomosis are close enough to each other for the needle to be passed through in a single forehand or backhand pass (without remounting) but each side of the anastomosis requires a slightly different needle stance or angle. The technique is to advance the needle through one side using the appropriate stance. Then, without releasing it from the needleholder, or withdrawing the needle from tissue, the grip of the needleholder is reduced slightly. The needleholder is then pushed or pulled to achieve the optimal stance for the other side of the anastomosis, advanced through this side and withdrawn through both to complete the suture (Video 2). The manoeuvre does not allow backhand–forehand exchanges, but allows the full range of angles within either a forehand or backhand stance. It is demanding to learn, but looks elegant on execution. It is also remarkably rapid, taking only a fraction of a second to achieve an optimal suture pass. It was popularised at our institution by Mr Vinay Tak (now at St Louis, Missouri, USA).
2.3. The Saatvedt swing
This requires a forceps, and may disturb ‘purist’ surgeons who believe that needles should only be held by needleholders. At the end of the tissue pass, the needle is held with the forceps at a point about 1 mm proximal to the tip and withdrawn leaving a short (<3 cm) length of suture between the tail of the needle and the tissue. The forceps is then rotated (clockwise or anticlockwise) in a horizontal circle hovering above the suture exit point, causing the needle to twist within the forceps. When the desired needle stance is reached, the rotation is stopped and the needle gripped with the needleholder for the next shot (Video 3). This manoeuvre was introduced to us by Dr Kjell Saatvedt from Norway. It is easy to learn, elegant, and allows any needle stance angle, both forehand and backhand.
2.4. The Large flip
This SEXI manoeuvre changes the stance from forehand to backhand and vice versa using only the needleholder. In this technique the needle is advanced through the tissue and withdrawn using the needleholder until its tail end just emerges. It is then released and left sitting on the tissue where it emerged. Next, it is approached with the open needleholder, at an angle of approach close to but not 90°. When the needle is between the open jaws, the needleholder is then rotated clockwise or anticlockwise. The resulting torque on the needle flips it from forehand to backhand or vice versa (Video 4). Once flipped, it is gripped with the needleholder for the next pass. The jaws of the needleholder must be open during the flip: premature gripping is the main reason for failure. This manoeuvre requires dexterity, but is easier if the position of the hand is ‘thumb up’ rather than ‘index finger up’. This technique was popularised at our institution by Mr Stephen Large.
2.5. The pirouette
This is another technique of stance exchange using the needleholder alone. It is useful when a stance exchange is required after the needle and thread have been withdrawn from the tissue. It is a combination of the Saatvedt swing and the Large flip (Video 5) and is difficult to learn. The Saatvedt component of the pirouette relates to the fact that the needle is slightly swung around the exit point of the thread, but with two differences: the needle is held with the needleholder, not the forceps and it is held at the midpoint, not the tip. Because the needle is not held close to the tip, it does not change stance with the swing alone and requires extra help, provided by rotating the needleholder as in the Large flip. To execute the manoeuvre, withdraw the needle to the desired height above the tissue, apply slight circular traction to create a fulcrum at the point of exit of the thread, slightly open the jaw of the needleholder and rotate the needleholder to execute the ‘flip’. When successful, this technique baffles onlookers, as it appears that the stance has been reversed in mid-air while the needle is still in the jaws of the instrument.
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3. Comment
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Technical surgery has evolved to high standards over the years. Further improvements can occur in small increments from ‘fine-tuning’ existing techniques, such as by reducing the number of moves between sutures. These manoeuvres contribute towards the objective.
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[Abstract]
[Full Text]
[PDF]
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Abstract
1. Introduction
