The Agony Of The Final Stitch

It had been a long, very long, day. The abdominal operation started before most people had even gotten up to brush their teeth. Around the time many will be hitting the bars for happy hour, we are finally starting to close the belly. The attending surgeon and chief resident begin closing up the abdominal fascia. I am anticipating a quick closure so I start lightening up the anesthetic. Thank God. The only thing I've had to eat all day was an energy bar that I snuck in under my mask hours ago. I haven't even had anything to drink during the entirety of the procedure. It's just as well since nobody bothered to give me a bathroom break.

When they finish, the attending congratulates the chief for a case well done. They shake hands across the table, hand the skin suture to the intern, and leave the room. I look at the operating site. The incision is about ten inches long. How much time could this possibly take? The intern grabs the needle holder and starts to make that tricky first stitch in the corner of the wound. Trying to get the suture to go right at the apex of the incision while hitting the layer of dermis, the intern makes several passes through the skin while being guided by the junior resident. After a few fumbles and do overs because of an air knot, he is finally able to proceed with closing the skin.

With the medical student following his suture, the intern progresses at an agonizing pace. Each stitch is performed with great deliberation, taking exponentially longer to make than an experienced surgeon. All the while the junior resident is guiding the intern, pointing to the exact location where the next stitch has to be placed. The student tries to follow as best as she could but a couple of times she still manages to cause the intern to loop his suture, almost forming a knot. I test my train of fours. Yup, four out of four. This patient is going to wake up any second.

The minutes tick by. Struggling inch by inch, the intern eventually makes it to the trickiest part of the skin, the umbilicus. This is the area that baffles most new surgeons since the wound is semicircular instead of linear. The pace of the closing slows down even more as the young surgeon tries to align the round skin wound a millimeter at a time. Then it happens. The patient starts taking spontaneous breaths and fights the ventilator. "Anesthesia, the patient is bucking!" yells the junior resident. I look over the drapes. They have less than four inches of skin to close so I better not give any more muscle relaxants lest I can't wake up the patient at the end of the case. I quickly draw up a syringe of propofol and bolus the patient to stop his movements. The patient calms down and they continue with the case.

The intern eventually makes it around the navel. Now it's a straight line down to the end of the incision. Then suddenly they stop. The intern says he has to switch sides with the medical student since now he has to suture going in the opposite direction. The student obediently switches sides and the intern asks for another skin suture. He again takes his time securing that crucial first knot deep in the corner of the skin. I can see the patient is trying to breathe on his own again so I give another bolus of propofol. If I give too much propofol here at the end I won't be able to wake up the patient either so I have to be careful.

At last, he makes his way up the abdomen so that now the two sutures are side by side on the skin. The medical student snips off the two needles and the intern starts to tie the ends together. Then...SNAP. He pulls on one end too hard and breaks the suture, leaving it too short to tie the knot that will close the skin. I think my bladder ruptured right then and there.

Now the junior resident steps in. He grabs a third stitch and continues the procedure by tying the new suture to the shortened suture. He then finishes up the closure until once again two ends are facing each other, waiting to be tied. I am so relieved until he hands the the loose ends to the intern for the last knot. I groan under my mask. Keeping my fingers crossed, I watch as he tentatively makes that essential tie. Too loose and the air knot will allow the skin to gap open. Too tight and he could break the stitch, making us start all over again. The nurses have already finished counting their instruments three times. They're holding wet laps in anticipation of cleaning up the patient. The cleaning crew keeps peeking into the room to see when they can finally come in. All eyes are on the intern and the two delicate 4-0 vinyl sutures he is holding in his hands.

He ties the sutures and meticulously cinches the knot down onto the skin. No air knot. No snap. Triumphantly, he finishes making a line of knots. One, two, three, four knots he makes in quick succession. He cuts off the ends and tucks the knot under the skin. It's finished. The nurses quickly wash the patient and puts dressing over the fresh wound. The patient opens his eyes as soon as I turn off the gas. I hardly even have to give any reversal agents to counteract the muscle relaxants. We get the patient off the operating table in record time and head to the recovery room. My lips are parched, my stomach is rumbling, and my bladder feels like it's about to go supernova. Thank goodness July only comes around once a year.