The Sinistral Surgeon

sinistral adjective | si?nis?tral | ’si-n?s-tr?l, s?-?nis- |

of, relating to, or inclined to the left: as
a: left-handed

Before the musings about left-handed surgeons begins, I have a significant disclosure to make: I am left-handed. This was just confirmed by the 1971 Edinburgh Handedness Inventory [1] which puts me in the worst-possible 10^th decile of the left laterality index. While there is an undeniable conflict-of-interest in having a lefty write an article on left-handed surgeons, the topic is not often discussed, so I aim to rally up the left-handed base while informing  righties about our peculiar ways.

Right lateral bias exists everywhere. From can-openers and spiral notebooks to the location of water fountain handles and the French-word gauche (which not only means “left” but also “awkward, clumsy and socially unrefined”), the list of indignities is long and extends to the surgical profession. Endoscopes like colonoscopes, for instance, are designed to be held with the left-hand on the control head while the right-hand manipulates the scope. Left-to-right turning is more comfortable for the right-hand and thus everything that requires clockwise rotation, like the colonoscope, and/or tightening, from lightbulbs to a pedicle screw, is designed for righties. “Palming” a needle-driver is easy for the right hand but cutting with scissors is hard for the left hand. Left-handed instruments may be a solution to these technical challenges, but I never saw one during training which puts me with the 50% of surveyed left-handed surgeons who had zero contact with these mythological devices in residency [2]. Notwithstanding instruments, rightward bias begins even before starting a case as most surgeons glove right-handed first (an exception: The Mayo Clinic where surgeons glove left-handed first in homage to the left-handed Mayo brothers).

Roughly 10% of medical personnel are estimated to be left-handed in survey-based studies [2, 3]. Some have called this group the “last unorganized minority” [4] and history is replete with famous left-handed individuals (Table 1). 

Not listed in the table are the devil, who is portrayed throughout history as being left-handed, and Bart Simpson, created by left-handed cartoonist Matt Groening. Studies have suggested that left-handed people are more intellectual, musical and artistic [5-7]. These proud attributes, however, are tempered by observations that left-handed people also amputate their fingers more often at work [8] and are more prone to sports injuries [9], motor vehicle accidents [10] and other unintentional injuries [11].

Like most left-handers, I had to make a decision early in surgical training to remain purely left-handed or to become ambidextrous. I took the latter route and adjusted my handedness depending on exposure, position and attending preferences. This meant that I usually opened with my right hand (to avoid clashing instruments with my invariably right-handed attending), sewed in the right-to-left direction (since attendings were used to setting up anastomoses in certain right-handed ways) and tied right-handed. When I had opportunities to sew left-handed, I excelled at (i) confusing the scrub nurse, (ii) confusing the attending and (iii) spinning the customarily right-loaded needle by its tip to properly orient my needle. Relapses of left-handedness during an operation often gave my staff an uncomfortable pause and generated some of my favorite ACGME evaluations: “ambi-confused” and “ambi-awkward.” Memorable cases with old-school surgeons also occurred whereby I was “strongly encouraged” to operate right-handed with the immutable logic that surgery was a right-handed profession. Fortunately, the vast majority of my attendings took up the challenge of teaching a southpaw proper surgical principles despite my attempts at sabotage.

Remarkably few studies have characterized left-handed surgeons but barriers and challenges in training exist. An early study from 1985 found that left-handed surgical residents were more proficient than right-handers on neuropsychological tests for tactile-spatial ability but also more cautious and reactive to stress [12]. In this same study, left-handed residents were rated lower in operative skill compared to their right-handed counterparts. The authors cautioned that these lower ratings more likely reflected the attendings’ level of perceived inconvenience when assisting left-handed residents. A subsequent study conducted in 2004 [2] surveyed 68 left-handed surgeons in Manhattan and Brooklyn on their surgery training experience. The majority of these surgeons reported no mentoring for their left-handedness during their residency. Considerable technical challenges occurred with handling long vascular needle holders, heavy hemostatic clamps, right-handed scissors and the Weitlander retractor. A more recent study in 2010 [13] reviewed 19 studies on the subject of left-handed laterality in surgical training. Eight major issues were identified that left-handed surgeons commonly experienced during training (Table 2).

From reviewing the literature, I do take solace in that no reports and no randomized studies have yet to show inferiority of ambidextrous left-handed surgeons to right-handers with respect to patient outcomes.

Left-handed surgeons exist. Look among the residents. Ask among the staff. They will all need to, or have already, overcome the often overlooked challenges of working in a right-handed world. For left-handed medical students and junior residents, it may be helpful to identify left-handed senior residents/attendings and learn about their experiences overcoming training barriers. For attending surgeons, there may be challenges in teaching left-handed residents, but acknowledging the difference is always a good first-step. Future research will need to identify specific gaps in technical proficiency, if any, and develop strategies to bridge those gaps. Furthermore, I would posit that ambidexterity is a valuable operative skill and perhaps even right-handed surgeons can learn some left-handed ways.

We would love to hear your thoughts and experiences on laterality in surgery (from both left and right-handers – comments welcome below). Otherwise, please mark on your calendar the 23^rd International Left-Handers Day (August 13 2015) which aims to celebrate the all-around awesomeness of left-handed people.

References

1. Oldfield, R.C., The assessment and analysis of handedness: the Edinburgh inventory. Neuropsychologia, 1971. 9(1): p. 97-113.
2. Adusumilli, P.S., et al., Left-handed surgeons: are they left out? Curr Surg, 2004. 61(6): p. 587-91.
3. Henderson, N.J., C.D. Stephens, and D. Gale, Left-handedness in dental undergraduates and orthodontic specialists. Br Dent J, 1996. 181(8): p. 285-8.
4. Rohrich, R.J., Left-handedness in plastic surgery: asset or liability? Plast Reconstr Surg, 2001. 107(3): p. 845-6.
5. Annett, M. and M. Manning, Arithmetic and laterality. Neuropsychologia, 1990. 28(1): p. 61-9.
6. Schachter, S.C. and B.J. Ransil, Handedness distributions in nine professional groups. Percept Mot Skills, 1996. 82(1): p. 51-63.
7. Gotestam, K.O., Lefthandedness among students of architecture and music. Percept Mot Skills, 1990. 70(3 Pt 2): p. 1323-7; discussion 1345-6.
8. Taras, J.S., M.J. Behrman, and G.G. Degnan, Left-hand dominance and hand trauma. J Hand Surg Am, 1995. 20(6): p. 1043-6.
9. Bhairo, N.H., et al., Hand injuries in volleyball. Int J Sports Med, 1992. 13(4): p. 351-4.
10. Coren, S., Left-handedness and accident-related injury risk. Am J Public Health, 1989. 79(8): p. 1040-1.
11. Graham, C.J. and E. Cleveland, Left-Handedness as an Injury Risk Factor in Adolescents. Journal of Adolescent Health, 1995. 16(1): p. 50-52.
12. Schueneman, A.L., J. Pickleman, and R.J. Freeark, Age, gender, lateral dominance, and prediction of operative skill among general surgery residents. Surgery, 1985. 98(3): p. 506-15.
13. Tchantchaleishvili, V. and P.O. Myers, Left-handedness–a handicap for training in surgery? J Surg Educ, 2010. 67(4): p. 233-6.