Fatigue is both the most tremor-producing factor and the constant companion of a busy neurosurgeon. Because of the difficulty in controlling tremor-generating factors, the authors sought to develop a means of manipulating surgical instruments with minimal muscle movement while allowing accurate and repeatable movements in all conditions. The "quiet hand technique" is an isolation technique that creates a stable platform by forming the four fingers into a salute that thenceforth moves as one. Fine movements are supplied by the thumb. For instruments that open and close, the thumb abducts and adducts. For suture placement using a round needle holder, the thumb flexes and extends. Because only the thumb moves, the extent of movement is decreased and therefore momentum and inertia are limited as well. Previously, microsurgeons favored ballistic movements. With the quiet hand technique, however, tension movements are easy. The greater control makes tying 10-0 and 11-0 sutures more predictable. Although the quiet hand technique was developed for use in small-vessel anastomosis, the neurophysiological principles on which it is based apply to movement at all levels and are applicable to working a bipolar coagulator, pickups, a vascular clip holder, or other soft-tissue manipulators.
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