Knot Tying SURGICAL SKILLS

The KNOT is the “weakest link” of the suture and therefore must be tied properly

Consequences of Poorly Tied Knot: 1.Vessel Bleeding 2.Fascial Dehiscience 3.Incisional Hernia 4.Superficial Wound Dehiscience

10 COMMANDMENTS: 1.Tie the simplest knot allowable for the suture material. 2. Knots should be as small as possible to avoid excessive tissue reaction.Cut tails short. 3. Avoid Friction between 2 strands when tying ( ‘SAWING”),weakens the material.

10 COMMANDMENTS: 4. Avoid damaging Suture materials by crushing with an instrument. 5. Avoid excessive tension on sutures.Do not try and over compensate for a poor first throw.Practice with finer sutures. 6. Sutures used for tissue approximation should not be tied too tightly = tissue ischemia.

10 COMMANDENTS: 7. After the first throw is placed maintain tension on the end of the strand to avoid loosening and creation of an “AIR KNOT”. 8.Final tension on any throw on a knot should be in a horizontal direction. 9. Change your position in relation to the patient prn to ensure knots go down securely and flat.

10 COMMANDMENTS: 10. Extra throws do not add strength to the properly tied knot.

Square Knot: Square=Loop and Ear exit on same side of the Knot Granny=Loop and Ear exit on opposite sides of the Knot Granny knot inherently weaker

Square Knot: Tails must be pulled in horizontal direction to lay throw flat Next throw direction of hands must be reversed Hand direction not reversed becomes more of a slip knot

Surgeon’s Knot: Double loop 1st throw. Does not improve strength ,but prevents slippage

Tips for Knot Tying: Right Handed surgeons tie with their left hand. Reverse hand directions for each throw to allow knots to lie flat and avoid a series of half hitches. Instrument ties are useful when one or both ends of a suture are short. Surgeon’s knot is useful if the knot is under tension.

Today’s Procedures: Instrument Tie One hand Tie Two Hand Tie Surgeon’s Knot