 Now, while the Cape Town Southeasterly wind is trying to blow away my office, literally, in today's talk about Sujji, I want to talk to you about this, this ugly bent needle. Just a bit of informal surgical talk, just between me and you. This is not a lecture, I'm not standing on the stage, you're not feverishly writing down what I'm saying so that you can regurgitate this in the exam. Just me and you having a chat. Take what I say always with a grain of salt, and that grain of salt is what happens locally at your institution. Listen to whoever teaches you first. Discuss things with them before you attempt anything on or with a patient. Now, our final year medical students here at the University of Cape Town have to go through what is called an exit oscure, an objective structured clinical examination, so at the end of the year, after all the written exams and the clinical exams and the oral exams, they have to come to the simulation lab and they go through eight stations and one of those stations is a surgery station and they have to suture a simulated laceration. Now, they are prepared for this because they can book some time in the simulation lab and they can go down and practice this, there's a nice little rubric and they follow that rubric. They come to this exam though, they do very well in this exam, especially the surgical exam. They all know how to suture but you do see there's a bent needle after the exam in so many cases and that's just actually unacceptable. Now, surgery is as much an art as it is a science. Now, if it was all scientific, I would love it, I love science. I love the structure of mathematics and physics. So, lots of artistic things to surge as well and it works for some. Anyway, there is a bit of art to it. Now, just as one specific painter, quite differently from someone else, I don't know, painters at all. Picasso, that was famous, he was famous. Anyway, they all had different strokes and you also have to develop your own stroke. Now, it is as much for you as it is for the patient, the more comfortable you are, the better work you're going to deliver, the better for the patient outcome and that's what it's all about. It's all about the patient and their outcome. So, you are going to be taught in a certain way. You are going to place your needle holder straight up, orthogonal or perpendicular right there to the needle and with this little arch in the needle, you're going to put it two thirds the way back and that's where you're going to hold it. That's perfect. If you have to do that for your exams, please do it. It's the proper way. You learn the proper way first and then you develop yourself as this artist, the artistic expression of your surgery for the sake of the patient. Now, once you've done this, once you've mastered it and you've done the exams as you're supposed to do, wherever you are, learning how to do this, throw that all out. There are better ways to go about this. Now, think about placing the needle two thirds the way back. Very nicely, you are told to roll your wrist and by rolling the wrist, this reverse cutting edge of the needle will glide through the tissue. Really? I mean, not all skin is as soft as that little simulation dummy done in the simulation lab. Some people have really tough tissue to deal with and as you roll your wrist, there's physics at play. That poor little needle is not strong enough to take all the stresses and strains and pressures that you're putting onto it while you're trying to roll. It is going to bend at the spot where you are holding it. That's just physics. Nothing you can do about it because what happens as this rolling motion doesn't work, you start applying a force as well and the force that you're applying, that's in a whole different direction in which the needle is pointing. Now, that doesn't really have anything to do with the bending but that just cuts through the tissue and damages the tissue as well. So now we have this bending of the needle, we have this ragged edge cutting of the tissue, that just doesn't work and that shouldn't happen. You should not finish a job, a switching job and there's a bend needle. That just shouldn't happen. So what you want to do is you want to move it a bit forward. You want to go halfway down your little metal suture. If you do it halfway, this little bit at the front is much straighter. If you now apply a punching force, remember there's a sharp needle in the front. You can stab with that needle and if you stab with that needle, you create very little cutting where you're trying to go through the tissue. So if you go forward, that little front piece is a lot shorter and instead of having to apply this rolling motion where you're going to go, where things are going to go horribly wrong, you can now just punch. So if you lift up your tissue, you can punch through the tissue. The force that you're going to apply is almost in the same direction as what the needle is pointing, very little angle between them and that is fantastic. Now there's another little thing that goes wrong and that is how you keep your wrist. Now again, you are told put your needle holder, orthogonal or perpendicular to the needle. Now if I want to do that and I'm suturing and I'm keeping it straight, look where my wrist is, all bent. If on the other hand you put it at an angle, your needle holder at an angle and you now hold on to it, your wrist is completely straight and that's what I like to see, a straight wrist when I'm working. But if I'm working perpendicular to the line in which I'm working, the laceration which I'm working, I'm going to just place the needle in this direction. So the needle holder at a 30 degrees or between 30 and 45 degrees depending on the situation, how you're standing with relation to that laceration, that is really where you want to do things. So I have a few little tips and tricks for you. Do as you told, pass your exam, learn the basics first but then develop your own style for always the sake of the patient.