The chicken dance technique for teaching the instrument tie.

Abstract

Suturing and knot tying are essential skills and a mainstay of medical education, however, there remains a lack of detailed literature on effective methods for teaching new learners.1,2 Over the previous decade of teaching suturing, our team of surgical educators, led by an experienced academic neurosurgeon, has noticed a typical pattern of errors made by new learners, characterized by rigidity and a narrow working area, that result in wasted motions, pulling out the tail of the suture, and loosely tied knots. To combat this, we developed a novel teaching technique using the Chicken Dance that emphasizes visuospatial awareness and the importance of the elbows in knot tying while allowing students to learn the fundamental motions in an unconstricted space. Students are divided into small instructor-led groups, spaced 1 meter apart and positioned perpendicular to the wound. The suture needle is advanced through each end of the wound using a needle driver and forceps, with supination of the wrist, and the suture is pulled leaving a 2–3 cm tail. The needle is removed from the driver, the forceps are palmed, and the long end of the suture is grasped by the non-dominant hand, securing the needle. The Chicken Dance technique is then taught using the following steps. 1. Starting Position: Start by imitating chicken wings—abduct the arm at the shoulder to bring the elbows to 75–90° and flex the elbow to bring the wrists to the sternum while holding the suture with the non-dominant hand behind the needle driver in the dominant hand (Figure 1A). Place the hands approximately 10 cm in front of the chest and at least 10 cm above the wound to maximize the working area. 2. Wing Flapping: With the suture held behind the needle driver, begin the wrapping of the suture around the driver by flapping your “chicken wings”—moving both elbows superiorly from the starting position (Figure 1B-C) and then inferiorly below the starting position (Figure 1C), wrapping the suture around the driver once. Repeat to wrap the suture around the driver a second time (Figure 1D-E), keeping both wrists relatively still and each arm moving in concert so that one arm is not moving more than the other. The flapping motion of the elbows results in the suture wrapping around the needle driver without creating tension on the suture. 3. First Square Knot: Once the suture is wrapped around the needle driver, supinate the dominant hand to prevent the suture from slipping off and grasp the tip of the tail with the driver (Figure 1F). The non-dominant hand is then extended to pull the suture off the driver and create and tighten a knot (Figure 1G). This is performed with minimal movement of the driver to prevent elongation of the tail during tightening. Perpendicular force should then be applied using both hands. 4. Additional Throws: Repeat steps 1–4 with one wrap of the suture around the needle driver, alternating the direction of the wrap with each throw of the knot until the desired number of throws is reached, ensuring a tight square knot (Figure 1B-C, F-G). Cut the suture leaving the desired tail length. As students become more proficient, the working area can be narrowed and these same motions can be translated to the wrists and later the fingers for micro-suturing. By training students from the elbows down, the Chicken Dance Technique helps establish a simple technical foundation from which more advanced skills can be developed. This technique was designed to stimulate situational awareness of oneself and one’s working area as well as the positions of the suture, needle driver, and needle. Flapping of the elbows helps to reduce tension and tunnel vision while demonstrating efficiency of movement and maximizing available workspace.