Saturday, March 10, 2012

How to Use a Scalpel and Make Dr. Halsted Proud

We all know how to hold a 15 blade scalpel, as shown above, but the 15 blade is not always used to its best advantage.  Many people still hold the handle vertically as they are inscribing their cuts, and paradoxically (perhaps to gain more control over the blade) flattening out the blade when at the tip of an ellipse.  Here's a short primer on how to handle a 15 blade:

Think of a scalpel blade as a saw.  Since there are teeth on a saw, you draw the saw across the wood so as to use the teeth to cut the surface of the wood.  If you look at a scalpel blade, there are similarly little serrations on the blade similar to the teeth of a saw.  So, rather than imagining that the super sharp blade  separates the tissue, think of the serrations as cutting through like a saw.

When inscribing either an arc or a straight line, keeping the blade perpendicular to the skin but the handle at a fairly small (< 30 degree) angle, draw your scalpel down the line you have either pre-drawn or imagined in your mind.  This allows the scalpel blade to work like a keel, keeping the line straight and preventing the pushing of tissue ahead of the blade, making a nice, clean cut.  Use the belly of the blade (which, if you are holding the scalpel correctly, you will) and draw your hand toward you if possible.

If, on the other hand, you are making an arc that is more sharply angled, or if you are approaching the tip of the ellipse, bring the handle up more vertically, closer to forming a right angle with the cutting surface.  This will make the cutting surface the shoulder of the blade, which allows for finer, more sharply angled cuts, but requires more control from the surgeon.  One uses less of a stroking motion with the blade, and usually there is more pressure applied to the blade when using it thusly.

As an additional point, when cutting ellipses on a flat surface (the pretibial region is an exception to this), the usual ration of length to width is 3:1.  If I'm operating on an engineer, I tell them it is Pi:1, because that intrigues them enough to make them stop asking questions about the current of the hyfrecator.

If operating on a concave surface, we tend to shorten the length of the incision, and if on a convex surface, we lengthen it.  We usually, but not always, work parallel to the relaxed skin tension lines and we try to, of course, evert the wound edges on closure, but that's a story for another day.

Back in the day, William Halsted was the head of surgery at Johns Hopkins, and was in many ways the father of modern surgical training, but he had an annoying habit.  If any of his "boys" held the scalpel wrong or used it incorrectly, he would rap them sharply across the knuckle with whichever instrument he was holding at the time, which as you can imagine, hurt like a son of a gun. Amazingly, he was never killed by one of his "boys", and lived to the ripe old age of seventy.  As a side note, his teaching method may have been explained by his alleged addiction to cocaine.  Apparently, it made him jumpy.


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