Polite Dissent

The best part of my surgery rotation during medical school was the two weeks I spent working with the vascular surgeons. It was during this part of the rotation where I got my first chance to sew up an incision. Vascular surgery cases were long and very technical, but fascinating. They involved repairing or bypassing arteries and veins throughout the body. Surgeries could easily last all day long.

The head vascular surgeon was Dr. Peterson. He was a brilliant physician, but very quiet and reserved. An extremely nice man, he was one of those people who always managed to say exactly the wrong thing. I spent much of my mornings with him explaining to patients and their families what he really meant to say.

One afternoon we were in the operating room doing a carotid endarterectomy. In this surgery, a carotid artery that is narrowed with plaque is cleaned out. Sometimes, a piece of the saphenous vein (the long vein in the leg) is used to replace the carotid if the artery is too badly damaged. That was the case this afternoon, and Dr. Peterson had removed and inverted a portion of the saphenous vein and was now beginning to attach it to the carotid artery.

“Scott,” Doctor Peterson said. “Why don’t you sew up the site on the leg where we harvested the vein?”

I readily agreed, and moved from the neck of the patient down to his leg.

I looked down at his leg. There was about a 4-inch incision to sew up. It wasn’t too deep, so a single layer of stitches was all that would be needed. When repairing the skin, surgeons prefer to use a style of sewing known as the subcuticular stitch. This involves using a series of stitches that are placed just under the skin. It is a running style of suturing, meaning that there is a knot at each end of the incision as opposed to a knot on each stitch, which is known as an interrupted suture. Absorbable suture is used for subcuticular stitches so that they will dissolve on their own and don’t need to be removed. Surgeons claim that they use subcuticular suturing because it gives better results; other experts say that results from subcuticular stitches are no better than any other technique, it’s just that surgeons are too lazy to remove their stitches later on.

The nurse handed me a forceps, a needle-driver, and a length of absorbable suture. I made a stitch at the lower end of the incision and tied a knot. Next, I made a small stitch on one side of the incision, then one on the second side, then the first again, and so on. Think of the way a shoe lace alternates from one side to the other as you lace up a pair of shoes; that’s what subcuticular suturing is like. I was doing my best to make sure that the two sides matched perfectly, but it’s hard because the stitches are at an angle to the incision (again like the shoe lace).

Finally I reached the end of the incision, tied the second knot, and cut the needle off the thread. I stood back, relieved that I had finished. That’s when I looked up and realized that everybody in the operating room had been intently watching me. The main part of the operation had been over for half an hour! It took twice as long for me to sew a short incision as it did for Dr. Peterson to replace and repair the carotid artery.

Dr. Peterson looked critically at my work, and then looked at me. “Don’t worry,” he said kindly. “The patient will be too concerned about the small surgical scar on his neck to notice the big one on his leg.” He patted me on the shoulder and strolled out the room.

I can suture much better now. Really.