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 Bleeding2.Fascial Dehiscience3.Incisional Hernia4.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