Afraid of knives

January 25, 2008
Surgical Rounds®, January 2008, Volume 0, Issue 0

Bernard M. Jaffe, Editor-in-Chief

Bernard M. Jaffe, MD

Professor of Surgery

Department of Surgery

Tulane University

School of Medicine

New Orleans, LA

At the time, it seemed an interesting question: Dora, our highly overqualified housekeeper, asked why, after washing the knives, we placed them point-end up to dry in the dish rack beside the kitchen sink. She related several bad experiences, including that of a daughter who had been severely cut, and admitted that she was afraid of knives. I was stunned; I had never considered standing knives point-end down to dry, lest it injure the blade. That interchange inspired me to reminiscence about my surgical experience, and I discovered that I could not remember having been cut by a blade in the operating room. Stuck? Yes, of course, several times. When you assist residents who cannot totally control either the needle or needle holder, getting stuck is inevitable. But, despite making thousands of incisions, I was never victim to a knife injury and consequently never developed Dora's fear of knives.

Surgeons are associated with knives and cutting, even though this constitutes a tiny component of our duties. I take a lot of ribbing from my friends when I carve the turkey on Thanksgiving. My standard response is that while anyone can slice a turkey, I can put it back together again (not that I'd ever want to). Our proprietary knife is the scalpel, and I have long wondered about the derivation of its name. Contrary to popular lore, it is not an instrument used by Apaches to excise the pates of fallen white settlers. The Concise Oxford English Dictionary ascribes the word's origin to the French or Latin scalpellum, diminutive of scalprum (chisel), from scalpera (to scratch).*

When used properly, scalpels can be magical tools. Dr. Eugene M. Bricker, the great St. Louis pelvic and oncology surgeon and my mentor, performed all his dissection with a blade. I was awed by his sharp dissection around the ureter, bile ducts, and hypogastric and portal veins. He was confident and deft, and his moves bordered on artistic. He taught me to do a fair bit of dissecting with the scalpel, but since much of my practice has consisted of reoperative and re-reoperative surgery, I have mostly used the knife to hack through scar tissue, which is like chiseling through concrete.

When I was a resident and young faculty member at Barnes Hospital (now Barnes-Jewish Hospital), an intellectual rift developed between its two major plastic surgeons, Dr. J. Barrett Brown and Dr. Louis Byars. Dr. Brown routinely used the dermatome he had invented (and which still bears his name) to take split-thickness skin grafts. His colleague Dr. Byars took his grafts freehand with the straight edge. When he tired of the forehand motion, he simply switched hands and cut backhand. His grafts were absolutely perfect. Obviously, knives can be used to great advantage, especially in skilled hands.

Knives can also be dangerous in the operating room, however. Dr. Bill Newton, Chief of Surgery at the St. Louis Veterans Administration Hospital, related an experience that sent chills up my spine. Dr. Newton grew frustrated with a timid resident who stroked the skin six to eight times before penetrating the epidermis. He instructed the trainee to push the knife through the skin and draw it downward to make the incision. The resident then pushed the blade in to the hilt and completed the incision by opening all the layers of the abdominal wall in one fell swoop and simultaneously transecting the caudal portion of the liver. Aghast, the attending repaired the huge hepatic injury, and the scheduled operation commenced. And yes, the resident did learn from the experience and became an excellent technical surgeon. As you can imagine, he was no longer afraid of knives.

The use of the scalpel seems to be declining in surgical practice. Many of my colleagues open the skin using the cutting current of the Bovie. I find it aesthetically unpleasant, but they insist that the skin healing and scar formation are identical. Scalpels are now used mainly to make port-site incisions for laparoscopic surgery. Because these incisions are 5 mm, or at most 12 mm, in length, the blade is not used much. There is currently much less use for intracavitary sharp dissection. In minimally invasive surgery, there are some scissors, hooks, and spatulas, but few—if any—blades for internal use. In many cases, tissue is pulled and torn, rather than dissected. Perhaps this will change in time, but I am unconvinced.

Surgery is moving toward progressively less invasive methods. While the robot has yet to make major inroads in general surgery (although it certainly has in urology), research and subsequent progress are inevitable. In the relatively near future, surgeons may find themselves sitting in a comfortable chair outside the operating suite, guiding a robot through a delicate procedure. In this scenario, the surgeon or even the robot may never handle a scalpel. It seems amazing, but the scalpel is in danger of becoming a vestigial accessory, an endangered species. So, too, may be the surgeon's craft of sharp dissection. Should that come to pass, I will surely miss this technique.

If my prediction is realized, the next generation of surgical residents and surgeons will have limited exposure to the scalpel and likely develop little skill in its use. With the current limitations on resident work hours and the real but unfortunate possibility that they will be further shortened, future trainees may come to view knives as nothing more than culinary accoutrements. With less time in the hospital, perhaps they will compensate by spending more time in the kitchen, studying recipes and dissecting meats, poultry, and fish. In that case, the unthinkable could occur, and future surgeons may find themselves afraid of knives.

Reference

The Concise Oxford English Dictionary.

*Soanes C, Stevenson A, eds. 11th ed, revised. New York, NY: Oxford University Press; 2004:1282.