Palming the needle driver is a high-efficiency technique used during continuous suturing to maximize speed and economy of motion. This method involves holding the instrument entirely within the palm, avoiding the use of the finger rings which restrict movement. By bypassing the traditional thumb-and-ring-finger grip, a surgeon gains a greater range of rotational dexterity, which is essential for placing many stitches quickly and smoothly. This technique transforms the needle driver from a restrictive lever into a fluid extension of the hand, allowing for a near-instantaneous transition between needle passes.
Essential Tools and Needle Loading
The success of the palming technique begins with the proper selection and preparation of the instrument. While most standard needle drivers featuring a box lock and ratchet mechanism can be palmed, instruments with a smooth, responsive ratchet are generally preferred. The instrument must allow for easy manipulation within the hand, as the finger rings will not be used for control.
Preparing the needle involves grasping it at a precise location for optimal tissue penetration. The needle should be held approximately two-thirds of the distance from its tip to the swage (where the suture material is attached). This placement ensures enough of the needle’s arc is exposed to pass cleanly through the tissue without excessive force.
The needle must be clamped at a near 90-degree angle to the jaws of the needle driver, perpendicular to the instrument’s long axis. Loading the needle closer to the swage risks bending it in dense tissue. Loading it too close to the tip compromises the length available for the suture pass. This careful loading provides the necessary leverage for the fluid motion of the palming technique.
The Step-by-Step Palming Technique
The initial step in palming is to position the needle driver in the palm of the dominant hand, using a modified tripod grip on the shaft. The index finger typically rests near the box lock, providing control over the instrument’s tip. The middle and ring fingers stabilize the shaft against the palm. Crucially, the thumb and ring finger remain outside the instrument’s rings, which is the defining characteristic of this technique.
To unlock the ratchet mechanism, the thenar eminence (the fleshy pad at the base of the thumb) is used to apply pressure to one of the finger rings. This pressure must be directed sideways or slightly upward, creating a distracting force that disengages the ratchet’s teeth. This allows for an immediate release of the needle without the time-consuming process of separating the thumb and ring finger to open the rings.
Once the needle is released, the instrument is rapidly rotated within the hand to prepare for the next pass. The index and middle fingers guide this rotation, flipping the driver over so the jaws are positioned correctly for the next stitch. Freedom from the finger rings allows this 180-degree turn to occur in a fraction of a second, minimizing the delay between suture throws.
To re-engage the needle for the next pass, the instrument is closed with a firm, quick clamping motion of the hand, locking the ratchet once again. The needle is then driven through the tissue using a pronating or supinating wrist motion. This uses the full range of forearm rotation to follow the needle’s natural curvature. This continuous flow of grip, release, rotation, and regrasp makes the palming technique significantly more efficient than the traditional finger-ring method.
Refining Your Technique and Avoiding Errors
Mastering the palming technique requires consistent practice to develop muscle memory for the thenar eminence release. New users often apply excessive grip pressure, which can lead to rapid hand fatigue and an inability to smoothly perform rotation. The goal is to maintain a secure but relaxed grip on the instrument’s body, reserving firm pressure only for clamping.
A common initial error is fumbling the driver during the rotation phase, often resulting from an overly loose grip or poor coordination. Practicing dry runs without a needle, focusing solely on the smooth, quick flip of the instrument, builds dexterity. Experimenting with different driver sizes can also help, as a slightly smaller or larger handle may fit the specific geometry of the hand better.
To improve the speed of needle placement, focus on synchronizing the wrist’s rotational drive with the release and regrasp of the needle driver. The needle should be picked up and repositioned immediately as it exits the tissue. This transforms multiple disjointed movements into a single, continuous action, achieving the economy of motion that defines expert continuous suturing.