UW General Surgery Technical and Professional Skills

Technical Skills Manual

Author: Karen Horvath

 

You have two, maybe three years to develop the basic technical skills that will stay with you forever. So by the time you’re an R4 there’s not much that can be changed in your habits even with constant reminders and badgering from the faculty. Therefore the key is to practice the right way every time and to practice the same way every time. In this way, you’ll lay down the patterns in your brain allowing you to operate efficiently with elegance and grace or, “with the force.” Another way to look at this is that you want to make the transition from unconscious incompetence — to conscious incompetence — to conscious competence — to unconscious competence. As the great English surgeon Kirk said, “perfect practice makes perfect.”

The same way every time

Although there may be more than one correct way to do something, there aren’t an infinite number of acceptable ways… just one or two. Find out what your options are (e.g. placing a tie on a passer around the front or around the back). Practice doing it both ways in the beginning. Watch your motions and analyze the number of steps it takes. Ask a colleague to watch you. Choose the correct method that feels good in your hands and conserves movements (i.e. the fewest number of steps). Then practice, practice, practice… the same way every time.

Don’t get boondoggled

Just because others (even attendings) may do things incorrectly, don’t do the same. Maybe they didn’t have a great technical skills curriculum during their training. The reason why it’s correct to do certain things a certain way is because it works in all situations with the most reliability.

You want to learn the correct way and practice the correct way from the beginning – so by the time you really need your operative technique to work (a ruptured AAA), it’ll be second nature. Lots of wrong things do work much of the time, but when you’re working in that deep dark hole, that’s when the little wrong things make a difference and lead to problems. For example, when you’re tying the knot for a tie on a passer, the correct technique is to always push the finger down towards the tip of the clamp (thus the left finger if the clamp is facing left and the right finger if the clamp is facing right). It is incorrect to push down your knot towards the back end of a clamp. If you’re doing a inguinal hernia repair and you do it incorrectly, no big deal if the tissue in the clamp gets avulsed from the clamp as your finger goes down (though why you need a tie on a passer when you’re doing an inguinal hernia repair doesn’t make much sense either). However, if you put the wrong finger down when that clamp is on a little branch off the Vena Cava and the same thing happens… that’s a different story. So once again… practice the right way and practice the same way every time so your technique becomes second nature and works in the worst of times without you needing to consciously think about it.

  • Speed in the OR #1: Economy of Motion. The way you gain speed as a surgeon is not by doing things quickly. You gain speed in OR through economy of motion or conservation of movement.
  • Speed in the OR #2: Pre-emptive Hemostasis. Another way to gain speed in the OR is through pre-emptive hemostasis as opposed to reactionary hemostasis (courtesy of Halsted and Moynihan).
  • Speed in the OR #3: Anticipate the Next Step. Another way to gain speed in the OR is to anticipate the next step. This is usually attained at the Chief resident level… but maybe with this technical skills curriculum, we’ll be seeing it emerge sooner?

Observe and Analyze

During your first year of practice go to the OR and watch other surgeons solely for technical pointers. For example, go to the OR and watch the CT surgeons (who do the same operations over and over). Most CT surgeons have perfected the concept of economy of motion. Count how many steps it takes them to do a certain maneuver. Analyze what other surgeons do correctly and incorrectly and take mental notes. Copy the ‘slick’ things you like and practice them on your own.

Focal length: Maintain it.

Your job is the patient and the operative field. The scrub nurse’s job is the Mayo stand. When you ask for something keep your eyes on the field and hold out your hand in the appropriate position: palm facing the ceiling for an instrument, palm facing the floor for a suture tie. Don’t look up and down at the scrub nurse every time you ask for something. When you use loupes, this concept is even more important since a bobbing head leads to headaches as your eyes try to accommodate.

Reloading your needle

This combines a number of concepts from above. Maintain your focal length. When you’re doing a running suture, practice different ways to reload your needle within the focal length of the operative field. In general, this should not be in mid-air, but against something (the drape, the patient). Reloading in mid-air uses your extensors, which are less reliable muscles. If you’re in a hurry (patient is bleeding) or you’ve had too much caffeine or are tired or have just exercised (all are items that magnify tremor), reloading a needle in the air is prone to error and delay. So, practice reloading your needle in the field buttressed against something. Then, do it the same way every time.

Pursestring sutures

If you want to tie it, start towards yourself.. since you’re going to end in the same place you start. Otherwise you’ll end up crossing the field and trying to tie on the opposite side (unless your attending can’t stand it and ties it him/herself). Think about a pursestring. Practice. Do your pursestring either clockwise or counterclockwise and do it the same way every time. Watch yourself and count your steps. Try and minimize your steps… can you cut out half of your needle reloads by anticipating the next needle placement? If you think about it, a pursestring suture will always have about 4-6 needle placements. If you think about it and practice it enough, you’ll see that you can predict exactly how the next needle should be loaded on the driver in advance. If you don’t understand this… ask Dr. Horvath or Dr. Wright.

Know your tools

It’s your responsibility to understand how to work the instruments and gadgets you use. It’s also your responsibility to understand their limitations and ways they can cause injury to your patient if used improperly.

All surgeons have a tremor

Brace, brace, brace. Surgeons who do a lot of microsurgery are familiar with the literature on this. The key is to minimize your tremor as much as possible. Brace your elbows against your body. Brace your hand on the patient, on a retractor, on your opponents hand… anything.

Don’t try and do things in mid-air (e.g. reloading a needle). Brace to get your extensors out of the picture and gain accuracy. You may also find that minimizing caffeine and not lifting weights prior to a big vascular case with a small anastomosis helps.

Universal precautions

There are three acceptable methods. Ask Dr. Horvath if you don’t know them. Practice all of them and see which one you like. Think about the advantages and disadvantages of them. Then, practice the one you choose and use it… the same way every time.

Height and gravity

Are things difficult? Stop. Look around you. Is the table at the correct height? Are you using gravity to your advantage? Table height is especially important when doing laparoscopic surgery (your elbows should be flexed so that the forearm/arm angle is about 90-120 degrees). With laparoscopic surgery, this ‘minor’ detail can change you from a struggling bumbler to a facile surgeon.

Exposure

During your 4th and Chief EVATS years, go to the OR and watch how surgeons obtain exposure. Take notes and keep them to try for yourself later. How many retractors? Where do they put them for a thoracotomy? For a splenectomy? Ask the faculty you work with to discuss their method. Most surgeons have a set way to expose for different procedures and as you know, exposure and set-up of the operative field is the key to an operation. The idea behind exposure is to expose your organ in full view – and then operate on it.

Cognitive Task Analysis & Mental Imagery

There are some exciting new data strongly supporting the value of these tools. Cognitive task analysis is when you break complex tasks down into steps (eg. the 10 step lap chole). Mental imagery is practicing a procedure mentally in your mind. This is used by most faculty who will ‘dream’ about a case the night before – planning the access and exposure and even doing the operation in their mind. You can do mental imagery as a trainee by utilizing the Ciné-Med Online Video Library or SCORE and getting your mental image of the case… then practicing over and over in your mind.

Read the following articles on cognitive task analysis and mental imagery:

Teach others

It’s amazing how much you’ll learn when you help others. All of a sudden you’ll be able to see lots of little things you’ve never seen before and you’ll start thinking about your own technique in ways you’ve never considered. You’ll see that this concept has been built into the EVATS rotation since it’s so important. The senior EVATS residents (R3-R5) are expected to hold regular teaching sessions with the junior residents (R1-R2).

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