Ron Barbosa MD FACS Profile picture
Sep 15 14 tweets 7 min read Twitter logo Read on Twitter
🧵regarding the comparative ability of different parts of a Blake surgical drain to actually drain fluid.

Here I've used an ice cube tray model to explore whether the different parts of the drain act the same.

We will also explore some properties of the Blake as we go.
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Before the experiment, some basics.

The Blake drain has 3 parts:
- the 'fluted' part, which is the part that actually drains
- the drain tubing that connects to the bulb
and
- the 'transitional part' between them. The black dot is here. We will look at this in more detail. Image
Here's what the different parts look like in cross section.

The fluted part basically has 4 channels which are separate. This will be important later.

The 'transitional' part still has 4 channels. It is noticeably stiffer than the 'tubing' section, which has only one channel. Image
Note that there is a 5 cm distance from the black dot to the fluted (functional) part of the drain.

This means that the black dot can be visible externally, but so long as the fluted part still remains internal, the drain will still function. Image
Now for the model:

I hypothesized that the more proximal portion of the drain (1-2) would work better (have better suction) than the distal portion (6-7).

The seal in between sections was maintained with the help of tape and Elmer's glue, and then adding Play-Doh.
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Now the suction has been activated.

The *initial* results were as I expected. The proximal compartments (1-3) drained first and drained the most, with the distal compartments (6-7) barely drained.

Still, there has been *some* drainage, as evidenced by the brown dye diffusing. Image
Initially, I had thought the drain might stop working altogether once it became exposed to air in the proximal-most compartment (#1).

And indeed it did start entraining air, but the drain still kept working, though slower. Image
At this point, the distal compartments started draining, even when all were exposed to the air.

The fluid salvaged from the bulb at first was clear, but later on, it started becoming brown-tinged (R pictures).

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The drain kept working despite one of the channels being exposed because of the design of the Blake:

It has 4 channels that are separated from each other...essentially it is 4 drains that happen to be all in the same tube. The channels that were submerged were still working.
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Now for the important part:

I then tried keeping the proximal compartments filled all the time, *so that they were never allowed to fully evacuate*.

The proximal boxes kept draining, but the distal boxes were drained only slightly, and most of the dye remained here.
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This is probably the most important concept in the 🧵.

The drain's behavior is such that if the proximal area (blue) is in an area where it has a steady output, then most of the drainage will occur here...and the distal (red) area may not drain well (or perhaps not at all). Image
Generally speaking it is best to avoid having too much excess drain tubing, *especially proximally* where it is most effective.

In the L picture, the area of interest (yellow) is small, and there is a lot of excess tubing. On the R the drain is trimmed to a more suitable length.
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It is also worth noting that if the proximal portion of the drain gets clogged with debris, then the drain will be entirely nonfunctional, as I showed in the 'salad dressing' experiment from a year ago (link below).

x.com/rbarbosa91/sta…
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Limitations of the study include the fact that ice cube trays may not act exactly like the human body.

Ice cube trays were obtained from the Dollar Store (Beaverton, OR). Elmer's glue was obtained from Target (Beaverton, OR). Play-Doh was borrowed from Henry.
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More from @rbarbosa91

Sep 2
🧵regarding the Aberdeen knot:

a surgical knot that may be used to secure a continuous suture. It is thought to be more secure than a square knot.

We will cover how to do it, what *not* to do, and also a little-known modification that may make it even more secure.
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Again: an Aberdeen knot can be used at the end of a continuous (running) suture as an alternative to a square knot.

With a square knot, you have to tie one strand to the two other strands in the loop, either by hand (upper R) or with an instrument tie (lower R).

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The Aberdeen knot is different. Instead of tying to the 2 strands, instead you'll use the single strand to go through the loop that is made by the other 2 strands.

Here, I'm holding the loop open with my R hand and using one of my R fingers to grab the string.
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Read 16 tweets
Aug 25
Brief reminder that the 3 different lumens of a 'triple lumen' central line are *not* equivalent in terms of flow rate.

The distal (brown) lumen usually has a greater diameter and a much higher maximum flow rate than either of the other 2 lumens.

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The catheter itself tells you this in 2 places:

On the ends, it tells you the maximum flow rate by pressure injection is 10 ml/sec for the distal lumen and 5 ml/sec for the other two lumens.

Also on the tubing the distal lumen is marked '16 Ga' and the others are '18 Ga.'
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The packaging shows you a cross section of the lumens, and again you can see the distal one is the largest and has the highest flow rate.

If you are giving something that needs to go in fast (fluid/blood/etc) then the distal lumen is preferred. Image
Read 4 tweets
Aug 22
🧵regarding the idea that the 1st assistant in a surgical case should always try to have *both* of their hands in use at all times.

Like many of my 🧵's, this is oriented toward people early in their surgical careers. I will try to argue that this is an important concept.
(1/ ) Image
Here, I am assisting an (invisible) surgeon performing an abdominal procedure on a teddy bear.

In the L picture, one hand is empty. It just *looks* odd.

On the R, I have something in the other hand, and all of the sudden it looks more normal. We will now explore this concept.
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Here, someone is assisting Theodor Kocher in an operation in 1914.

The assistant's R hand is holding a retractor, but the L hand is just sitting there idle, doing nothing (red arrow).

Surely there is something better that the assistant could be doing with this unused hand. Image
Read 14 tweets
Aug 1
🧵regarding some techniques for reloading the needle holder for the next suture throw.

In particular: the methods for doing this one-handed (without your forceps), why you would want to be able to do this, how to do it, and how to adjust the needle without grabbing it.
(1/ )
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Very often during a case, you'll do a throw of the needle, and a portion of the needle will stick out.

There's enough that you can retrieve it, but not enough that you can just grab the needle again at the intended location (R picture).

This 🧵will go over ways to do that.
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Probably the easiest and most common way to retrieve the needle is with one's forceps.

On the R are DeBakey and Adson forceps. Each of these has hatchings on the ends that help them grab tissue (and also needles).

Avoid grabbing the very tip of the needle or it will bend.
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Read 18 tweets
Jul 18
🧵regarding several ways in which you can inadvertently damage the tissues when approximating them with sutures.

These are particularly important to recognize when the tissue is thin or fragile, because this is when you may not get away with using sloppy technique.

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Our example suture line will require about 6 sutures.
Let's take suture #4. The responsibility of suture #4 is to approximate the tissues within the rectangle without damaging them.

This🧵will show how we might damage the tissues if we aren't careful.
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Put another way, when placing the sutures, the goal is to get the two tissue squares to become approximated without damaging them.

There are at least 4 ways you can damage them. I am R handed, so the R side (where the needle goes in) is especially prone to injury, as we'll see.
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Read 13 tweets
Jul 6
🧵regarding 'the crimp' and other technical pointers having to do with securing surgical drains with suture.

We'll go over my preferred method, other methods like the Roman sandal, some errors people make, and other factoids.
(1/ )



Drains are usually sewn in with Nylon, for the same reason that the skin is often closed with Nylon: it's minimally reactive. Here I'll mostly use silk, since I have that at the moment.

Here I have placed a simple suture and tied the knot, and am ready to fix it to the drain.
When placing a 'drain stitch', usually you first tie a few knots down, keeping the 2 threads equally long so you can wrap them around the drain.

Some surgeons leave the knot a little loose (L picture), and others don't (R picture). Leaving it 'loose' is probably less painful.

Read 15 tweets

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