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Advanced Open Surgical Skills »  ATOSS Tasks »  Task 6: Push-push-pull (deep)

Task 6: Continuous Suturing At Depth: Push-Push-Pull

Instructional Video


Task Overview


Summary: This task requires 10 continuous sutures at depth using push-push-pull reloading technique.

Equipment: One fine needle holder, one fine forceps, one 5-0 or 6-0 Prolene suture on a C1 cut to 15cm.


Task set-up: Position fabric at the base of the model (lowest platform level) as follows:



Task steps:

  1. Load needle into fine needle holder.
  2. Complete 10 continuous sutures at depth using push-push-pull reloading technique.

Task rules: Take single bites, entering and exiting at blue dots on either side of the slit. Use forceps to stabilize the tissue. Reload needle while still in tissue then atraumatically remove. Lock the needle driver after the needle is completely removed from tissue, then rotate the needle holder in preparation for the next bite.


Tips & tricks:

  • Load your needle at a 100-150 degree angle.
  • Unlock needle holder before entering tissue; do not lock until needle is fully removed from tissue.
  • Use forceps to stabilize tissue at needle entry and exit.
  • Do not handle the needle tip with forceps (this will cause damage and blunting).
  • Follow the curve of the needle when removing it from tissue, do not torque.
  • For push-push-pull, introduce the needle into the tissue far enough to expose at least 50% of the needle, so that the final loading of the needle with the needle holder will be in the appropriate segment of the needle.

Cutoff time: Maximum time for task completion is 260 seconds. During formal assessment, time will start when the needle makes contact with the tissue for the 1st time and end when the needle is removed from tissue for the last (10th) time. If the task is not completed within the allotted time, you will be asked to stop.


Scoring: A score will be assigned for each micro-skill. Score assignments are based on the following:









Unable to complete task

Completed task w/ major errors

Completed task w/ minor errors

Proficient, no errors, some awkward moves

Expert, no errors, smooth and efficient


Score (1-5)

1. Loading the needle with correct angle


2. Releasing the needle in atraumatic fashion


3. Pushing the needle through the tissue in atraumatic fashion


4. Reloading the needle in the correct orientation for the next stitch


5. Following the curve of the needle


6. Overall Rating


Total (Sum of Scores for All Micro-Skill) [Max = 30]


Scoring Formula: see Task & Scoring Overview or score calculator (access via Google doc or download excel file)

Expert Score: 50

Example Video


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