1. Knot Tying
SURGICAL SKILLS

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

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

4. 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.

5. 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.

6. 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.

7. 10 COMMANDMENTS:
10. Extra throws do not add strength to the properly tied knot.

8. 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

9. 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

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

11. 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.

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