 You will get loads of kids with head injuries and drunkards and gunshots, booms, name it. And your attending is going to say, what are you studying there? Come on, do it. Finish off those sutures. You're just sitting there. Finish off those. Okay, don't even talk to me. I don't have time. And he'll just leave you alone. You say, look, I don't want to be a surgeon. You can't say that you have to learn how to do all these techniques, right? So let me explain to you how to hold a needle holder. We don't have the rest of the material, but we are going to do some other technique. Let's say I'm a surgeon and you are assisting me. I'm busy doing my job here. I just extend my hand. How will you hand me this instrument? Do it. I don't have time. I'm not looking at you. You're not proposing to somebody, are you? You're not supposed to be so jetty. You're supposed to take it like this. Imagine you are a surgeon. You're supposed to slap it in my hand like that and make sure I get it and I feel it. Okay. So do it that way. I'm doing something here. Really slap it in. Yes. Now I know that he's giving me the right instrument. It's not, I just leave it like that, you know? Because I can't look here and there. So that's the way to hand over to the surgeon. Okay. So this is a needle holder. This is how we hold the needle. And those are, I think, some met force. I think their best is already attended the suturing technique. And the metfights are looking at them very obviously, you know? Because they have not attended the suturing techniques. But we are working towards that. The parts of a needle holder are as follows. These are the jaws of the needle holder. This is the box type of joint. This is the handle of the needle holder. These are the rings of the needle holder. And this is the ratchet. The ratchet has got three clicks. One, two, three. Depending on how tight you want to hold the needle holder. Now when you take a look at a needle holder, you will find that it's quite similar at first appearance to what's known as a hemostat. That is the one with which you hold blood vessels. But there is some significant differences. At first glance, when you're giving a full tray and you're just told to handle it, you might pick up the hemostat. It happens quite often. You try to do a suturing with a hemostat. How should you differentiate a needle holder from a hemostat? It looks pretty same. The hemostat, the jaws will be very long. The box of that joint will be further closer to the handle. And it will be much more delicate and smaller. So these are some of the differences. Otherwise, pretty much many things will be similar. The reason why the needle holder has got a very short jaws is because it wants to get a good grip of the needle. This is a needle which is used for suturing. Now if all of you come a little closer, then you can see a little better. And because we are all a small happy family here, we are all, and that's the way I like to look upon it as the way to hold the needle in the needle holder. In fact, this is pretty much what I'm going to tell if I do manage to get a class with you. The long axis of the needle should be at right angles to the long axis of the needle holder, first point. Initially, the best place to hold it is somewhere in the middle with the apex of the needle, if you're right handed, most of us are right handed, pointing inwards because you're holding it with your right hand. If you're a left handed person, then obviously you'll hold it this way, but then most of us are right handed. And it should not be angulated like this or like this. It should be at right angles, that's the first thing. Second thing, where to hold? Should we hold it outwards or should we hold it inwards? Average place is to hold it in the middle, but there will be different situations, maybe you may need to hold it outwards or you may need to hold it very close to the tip. But that will be when we start doing the suturing in the next session, I'll actually tell you because we don't have the suturing material. Given two clicks, usually two clicks are required, if you use too much pressure, the needle will tend to straighten out. So you have to balance how much force you're using. And if you use too little pressure, then the needle will wobble like that. So the force that you apply to hold the needle holder, needle should be optimum. After you've held the needle on the needle holder, how to hold the needle itself, the needle holder itself? There are two ways of doing it. I'll show both of them are equally acceptable. The ring finger should go into the lower loop, not this, not the middle finger, not the index finger, not the little finger, the ring finger. The thumb will go in the upper loop. And only the distal parts of the phalanx, distal part of the digits should be in the loops, not like this. Now why? If I hold like this, if you notice, I'll have a much wider range of movement. On the other hand, if I do like this, you see how little range of movement I have. You see, everything's got a practical utility. So we should hold with the tip of our digits. After we've held it, the middle finger will give support from below at the place where the ratchet is located. And the index finger will give control like this. So this is one way of holding. So this is one way. The other method of holding, which I prefer, which is equally acceptable, is after I have caught the needle holder, you can hold it in the palm of your hand like this. I get very good control this way. I prefer this way. Both are equally acceptable. So these are the bare bones. Just a few quick words about the needle itself. As you see, most of the needles that we use today nowadays are all curved needles. There are, of course, straight needles also, but generally it's used. Now curved needles, there are two types. One is known as a cutting curve needle and the other is known as a round-bodied curve needle. Now how do we differentiate between a cutting and a round-bodied? If I were to take a cross-section through this needle, just imagine a cross-section, and if I have to look at it, end on. If the body appears circular, then it's called a round-body. And if the cut section looks triangular, then it's called cutting needle. So when do we use the cutting needle? When do we use the round-bodied needle? The round-bodied needle is used for delicate structures like peritoneum, misentery, and all these intestine. And the cutting needle is used for tough structures like the skin. You might say, no, my skin is very changing and delicate. Well, skin is not so delicate. Skin is a very tough structure. So for skin, we use cutting needle. Otherwise, you will not be able to, you try to do suture the skin with the round-body needle and trust me, it is very difficult. So cutting needle is used for tough structures. There are many other details. We will not go into all that. The material, suture material itself, it is already attached to the needle. This is called swaging technique. It's swaged. You don't need the thread, but nowadays it's not done. Most of the material that we use for suturing the skin is nylon or proline. So this is nylon. Proline will be blue in color. They are all synthetic monofilament material. The problem with this is that they tend to slip. So we have to put multiple throws, unlike linen or anything, which you can just put two throws, two knots and they will tight. But here, if you put two, they will slip. And by the time the patient comes back to your removal, there will be no switches for you to remove because the wound would have already opened up because the switches would have already opened up. So with monofilament material, synthetic material like nylon or proline, we have to give multiple throws. So these are the bare-bone essentials of the needle holder and the needle. Now what I'm going to do is, since we don't have the full suturing set with us, I want to utilize the time. I'm going to show you technique of knot-tank. Knot-tank techniques with the left hand and with the right hand. So these are the trays that you see in front of you are the Ethicon. This is a company which makes all these material, actually. They have to utilize these places. So you have to see very closely. This is a typical tray. And let's say this is the suture material, which you are using for tying the knots. Follow me. This is a little dicey, but once you have got it down, it won't be so difficult. This actually came from my office, so it will go back to my office. Once you have looped it, I'm showing the knot-tank techniques only with my hands because we don't have the material for suturing. I'll show you the technique for suturing with the needle holder when we have the full set with us. Take the smaller end between the thumb and the next finger. The long end is on the other hand. Okay? Watch. I make a loop like this. I'm going slowly. When I do it very fast, you won't be able to see it. So, small end, let it go over your other three fingers. Then bring the long end over your other three fingers. When I did that, now I bend my middle finger and catch hold of this, the previous one, the one which is already there and rotate my hand. This is the first one. And the next one, I take, I do the same thing again. And I get a square knot. See the knot? This is a square knot. So now you'll have to do it. And then I'll show you the next knot-tank technique.