VET SCHOOL SUTURE TUTORIAL - SPAY AND NEUTER | BellaVet

Hey guys, welcome back to BelleVet. Today I have another suture tutorial for you and this one will kind of be the last missing piece as far as the patterns you might need during a routine spay or neuter. My other two suture tutorials go over simple interrupted, simple continuous, forward interlocking and intradermal. So with the sutures that you'll learn today and with those ones that you've already learned in the other two suture tutorials, you should have everything you need. So yeah, let's get started. So I'm just opening, I'm using a nylon monofilament. I have left is a 3-0, so this is a smaller suture size that might be used in a small dog or a cat. And I've gone over some of the basics in my other two suture tutorials. So this one will mainly be a continuation of that. And I hope you all like my henna. I was in my best friend's wedding this past weekend, so that's why my hands are a little bit more interesting than they normally are. And it's always a great idea to wear the gloves that you'll be doing surgery in, whatever glove size you are. It's really great to practice to have that kind of added layer in your fingers. Today I didn't have any, but if you're at home and you do, it's a great idea to practice with some of those. And so I'm just making one little suture to anchor. I have a hair tie that I cut here and this, in neuters and in spays, you are tying off vessels, the vessel that goes from the aorta to the testicle and to the ovary. And so this will kind of be my stand-in for that. And I'm just going to anchor it to my suture practice kit. Okay. I'm just going to do a simple interrupted to have this be anchored because might as well practice. I'm going to do a surgeon's throw. Not that you normally need to do surgeon's throws, but for this practice kit, it's got a lot of memory in and of itself. And so just to get a better suture, I'll be doing that. And something that I picked up from another surgeon recently was to do your throws up and down instead of side to side, because in side to side, you start crossing your hands like this and it gets really awkward really fast. And if you go up and down, you'll still get a secure knot, but it will be much less awkward, which means it'll be more efficient. Okay. So now that we have our artery, our pedicle, our hair tie anchored, we can start practicing something called the Miller's knot. Okay. So the first knot that we'll go over today is for ligating your pedicle or your testicular artery or ovarian artery, also known as a pedicle. And it's called a modified Miller's knot. And this knot is used a lot because it is what is called a friction knot or a binding knot. And this type of knot, it just offers added security and it's basically a special way to do that first throw. And so something that a surgeon that I've been working with recently also said is a way to do surgery faster and in a less awkward manner is whenever you put your instrument down, lock your suture with your needle drivers because you're never going to use one without the other, at least not routinely. So why not have the end of your suture locked in so that you're never fishing around for it and it's always where you need it to be. And these are called rat tooth forceps and I don't know if you can see the tip of them. There we go. And so rat tooth forceps are a pretty harsh type of forcep. I typically use Addson Browns, which I'll put up a picture of, but I also talk about in my previous videos and they're just a much more gentle way of tissue handling. These ones I tend not to use unless what I'm grabbing with is leaving the body and not coming back. But this is what I have in my suture practice kit, so it'll be fine for practice. Yeah, so usually in surgery, if you are, so let's pretend we're doing a neuter and this is a testicle and the testicle is up here. We have made an incision, gotten the testicle out, and now we want to remove it. So what we usually do is we clamp, if you're doing like a closed castration, you clamp the tunic that the testicle sits in, which includes the spermatic cord and the artery. And you just typically have several different clamps here. Usually I do a three clamp technique where I put three clamps on. I usually go to get my suture, I remove the most proximal or the closest clamp, and there's a crush mark there. There isn't in my hair tie, but there will be in a real vessel. Or if you're in a veterinary office, another thing you could use is an old line from an IV bag that will actually show the clamp and it might be a little bit closer to actual tissue. But my first ligature, I would crush in my clamp. But I'll leave this here just so, you know, it's a good thing to practice on because in real life, it does get awkward with how it's positioned. So I usually leave it in this position while I am, I'm going to scooch this a little closer so we can pretend it's my first ligature. I usually do two. First step, we're going to take our suture and pass it behind what we want to ligate. And then we're going to do that one more time. So we're passing it behind what we want to ligate here. Now, it's a little awkward for me with the suture kit because it's kind of sticky and it sticks to my suture, but then we're going to go through our loop, we're going to pass over our suture and grab, maybe, grab our free end. And there you have a Miller's knot. You're going to tighten it down and you're going to choke up, so you're going to clamp your needle drivers and then take them and really make that first ligature pretty tight. And then we're going to do that again for a second. And we're going to clamp and we're going to choke up. Usually count in my head to three or five or something like that. And then we're going to do that again to our third throw. And I always like to think our first three throws are our security and then everything else after that is our insurance. So I'm going to do three more for a total of six throws or three knots. So one, still making it tight, but I don't choke up quite as much. Two and three. And there you go. That is your first ligature. If your needle drivers have scissors in them, you can use that. The scissor will be right there. These ones don't. And so I'll use some little suture scissors. And there we are. And then you do that one more time. So just for completion, you would be here. So you've removed the clamp that sat there and you tighten it. And let's say we've got another clamp here. Sometimes I like to remove this clamp, put it in front of the other one if there's still space and I'm not leaving too much tissue in the body. And there we are. So we're going to do that all again. We're going to pass behind and we're going to pass behind again. Mind the memory of your suture. Here we are. And then we're going to go through our loop, wrap around and wherever our free end is, we're going to grab it. Sometimes you can deliver your free end to your needle drivers instead of having to use your needle drivers to go and find your free end. And sometimes it's helpful if you've got a lot of other stuff going on and you say, you know, you're not moving around more than you want it to. You can take the back of your ligature. I will use this clamp to check and say, oh, yep, that's where I want it. There's no extra fat or any extra vessels or structures in the way of where I want to go and say, yep, that's where I want to go. And then this will help you stay in place while you tighten. Usually I'd have these a bit closer together, but just for the sake of showing you guys. And so we're going to choke up and tighten down that first throw. And then we're going to do it five more times. One, this is two. This is three. You can choke up with your thumbs if you want. And then we'll do four, five and six. Six. Keep in mind, I'm not a board and surgeon. I am a veterinarian who does routine surgeries. And sorry about that. I'm a fairly new grad, but so I am learning and perfecting things right along with you guys. So yeah, I always like to think of medicine as see one, do one, teach one to an aspect. And learning this and refreshing it helps me. And then teaching it to you guys helps me too. So as soon as you have it done, teach it to a friend. And then that will help you learn it better yourself. And so I will bring these up a little bit closer. Here we go. So you can get a better view. So there's two on this side and then look more tight on that side. So these can be used in neuters or spays or tying off most vessels that are large. And so next up is the circumferential ligature, which is more simple than the modified millers, but it doesn't give quite as much security to your knot, but it is still a perfectly fine knot to use. So to get started with this one, you just go behind. And I typically don't use a surgeon's throw on this. I typically only use surgeon's throws if I'm trying to oppose skin and there's just a bit more tension on it than is ideal. And a surgeon's throw for me is really just to get that first throw opposed properly and then use single throws after that. So I don't really have a need routinely to use a surgeon's throw for this. So just a normal one going over our needle drivers, grabbing our free end and pulling down tightly. Again, you can use that trick where before you tighten down, you can look to see what's behind your knot, make sure it's in the right place you want it to be, and then partial tighten and then fully tighten from there. And then we'll do that two more times, really tight knots. And then three more. There we have it. And so for me, I'd always do a second one here. So definitely try doing these ligatures with your clamp this way, with your clamp that way. See which one you like. I usually like it this way when I'm actually doing surgery for placing my knot and figuring out where I want it. And then I flip over for actually tightening down and doing my throws because it kind of keeps everything in a nice orderly place. Okay. So the next thing I'm going to show you guys is the cruciate knot. And this can be used, I think of it as basically any time that you would want to use a simple interrupted, but you want to maybe place things a little bit faster. So if your intradermal pattern, which I did here, it's in my last suture tutorial, let's say you weren't able to bear your knot perfectly, or you wanted to put in another layer for some reason of skin sutures, you could do that with cruciate knots. And so basically how it goes is you take a bite and you pull through. And then you take a second bite a little bit further down. Obviously the size of your patient, the size of your suture will be dependent on how far you go apart from each other. Actually try to make it pretty symmetrical. And so this will be your first. Sorry about that. Okay, so it should look something like this. And tighten it down a little bit. And with skin sutures, you want to make sure that you don't tighten them all the way down to the skin because skin does swell with healing with that inflammation after surgery. So one thing that you can do is you can put your instrument under it and obviously use your best judgment as you are tightening down, but that'll usually give you a pretty good guide of how tight to make it. And then you'll do, that's my first throw. And so this will be two, three, four. Some people do four, some people do six. I like to do six for now. Five and six. So here we go. And then we just cut our tails. And the tails, sometimes with skin sutures, you are wanting to leave those a little bit longer because you will be removing them one day when, in about 10 to 14 days at our incision check. And yeah, so sometimes it's nice to have a little bit longer tails so that you can identify the stitch and get it out a little bit easier when it's time. So I will do one more of those and I'll do it with a bigger suture size. So hopefully you guys can see it a little bit better. So this is a silk braided suture. So not typically what I would use, but it's a bigger size. So hopefully if you're having any trouble seeing what I'm doing, hopefully this will help. And it gives a little bit more contrast to my suture board. And what you'll notice about silk braided suture is that it has a lot less memory than monofilament, than my monofilament absorbable suture does. And so that's nice in and of itself. So this is 3-watt, it's a little bit, or sorry, this is 2-watt. The blue here is 3-watt. So this size of suture might be used in a slightly larger patient. So here we go, taking our first bite. And sometimes you'll want to come all the way up in between, just depends on how much tissue you're working with and what your circumstances are. I tend to like to do both bites in one because it's just a little less awkward for me. There's one. It could have been a little bit more perfect here had I been a little bit more straight. And this side is a bit longer than that side, but that's why it's practice. Practice makes perfect. Okay, and then we're taking our second bite here and pulling that through as well. One thing you want to be careful with is you don't want to have this end be in here because then it won't be a symmetrical knot. Okay, and if you pull down to the skin like I just did, you can always loosen things up a little bit. No big deal. So there's one, two, three, four, five, and six. There we have it. And definitely put into practice doing your throws up and down versus side to side, and you'll see how less awkward it is going up and down. And just so you guys know, I'll do a couple more throws a bit slower so you can kind of see what I'm doing if you're confused. And so you always throw over your needle drivers, and then you grab your free end, and you want this to be a square knot, not a half hitch. You don't want to pull one side at a tighter tension than the other. You want to pull them at the same time so it is a symmetrical knot because that is more secure than a half hitch knot that is not symmetrical. And so here we go. Okay, I hope that helps you out. Of course, there are other types of suture techniques used in spays and neuters, but these are some of the most common ones. Let me know if you guys want me to do any others in the future, like transfixing ligatures or stick ties or anything else like that. I'll try to find some synthetic alternatives. Or if you guys would like to see me do any surgeries, let me know and I'll see if I can make that happen for you as well. But happy practicing. And if you liked this video, be sure to give it a like and subscribe and also hit the little bell notification icon in the lower corner so that you never miss the next time I upload a video. Thanks so much, guys. Bye.