Knot tying help needed!

[drsender]

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So this is a little embarassing to ask as a third year general surgery resident, but here goes. I have received some flack from more than one attending recently for my knot tying. I have been practicing with free ties and thread at home and there is one technique I have not been able to master that makes my knot tying sloppy.

When using a long free tie in a deep space, I do a one-handed tie toward the ends, with the two ends being similar in length. I then pinch the free end, wrap it around my pinky in order to keep the excess length taught, and bring my index or middle finger down onto the knot. It is this second part I struggle with. I often struggle to take up enough slack to tie it down tight or I look clumsy or even drop the thread when resetting for the next throw.

I have searched extensively for tips on this particular skill, that other surgeons seem to be born with, and I have not come up with anything. I would really appreciate either some advice or maybe a link to a video that describes how to do this. Really anything that makes it look less like I have six thumbs...

Thanks in advance!

 

[Dr.LeoSpaceman]

So this is a little embarassing to ask as a third year general surgery resident, but here goes. I have received some flack from more than one attending recently for my knot tying. I have been practicing with free ties and thread at home and there is one technique I have not been able to master that makes my knot tying sloppy.

When using a long free tie in a deep space, I do a one-handed tie toward the ends, with the two ends being similar in length. I then pinch the free end, wrap it around my pinky in order to keep the excess length taught, and bring my index or middle finger down onto the knot. It is this second part I struggle with. I often struggle to take up enough slack to tie it down tight or I look clumsy or even drop the thread when resetting for the next throw.

I have searched extensively for tips on this particular skill, that other surgeons seem to be born with, and I have not come up with anything. I would really appreciate either some advice or maybe a link to a video that describes how to do this. Really anything that makes it look less like I have six thumbs...

Thanks in advance!

Two things:
1) Unless you are using a double armed suture and will need to run a suture line both ways, there is no reason to keep the strands even. Keeping the free end shorter will help you tie as there is less excess to manage. However there is a sweet spot to this, as if you're too short it's going to be challenging as well.
2) I'm having a bit of a hard time imagining what you mean w/r/t to wrapping the suture, but this doesn't sound right to me. I do what I would call a "double pump". I start the throw normally and as my finger is following the knot down I simultaneously use my other fingers to walk up the free strand and follow the knot down. In practice, it looks like your hand is "jumping" up the strand.

 

[drsender]

Thanks for the reply. I think part of the reason this just became a noticable problem is that the attending I'm currently working with instructs me to keep the ends even, which I generally would not do and makes it more of a problem.

Can you explain what you mean by, " I simultaneously use my other fingers to walk up the free strand"?

 

[DoctwoB]

Urologist here so do a lot of tying in the pelvis. What he means is that when you make your throw, you have a long distance to slide the knot on your post hand. So you will need to move your post hand down your suture “double clutch” it to take the slack out of your post hand as you slide the knot down. This can be mitigated partly by tying your knot as low as possible (at the level of the skin or even below) so there is less distance to slide. Likewise as spaceman mentioned there is no good reason to keep your tails even, and it’s usually easier to tie with a shorter “throw” side and a longer post.

 

[Dr.LeoSpaceman]

I think part of the reason this just became a noticable problem is that the attending I'm currently working with instructs me to keep the ends even, which I generally would not do and makes it more of a problem.

The infernal paradox of residency. Not just learning to do something well. Learning to do something well that is also viewed as "correct" by the person with whom you're working.

 

[OrganRepo]

Is it just the attending that wants you to keep strands even that is complaining about your walk down the strand? If so this might just be a change your technique with this one attending type of deal and tie with a shorter stand in your dominant hand all the other times. I really can't visualize this pinky maneuver your discribing either. From the ready to tie pinch, wrap the rest of your fingers around the strand and get control with your ring/pinky but your hand is really a fist. Now release your pinch and repinch it as far down the strand as your hand is wide so you keep tension. Now open your hand and let the excess suture fall out of your fist, and your back to pinch grip but one hands breadth down the strand. If you need more or less you can walk down again or let the suture slide through your pinch or both. I might be able to make a video for you or something.

 

[dpmd]

I would guess the wrapping it around the pinky is what is making you look awkward. Try just pinching it with your pinky instead.

 

[drsender]

Thanks everyone for your help. I have experimented with different ways of "walking down" the strand that is less awkward. I think just pinching with my pinky and my palm instead of wrapping it around my pinky is what was causing difficulty. I really appreciate all your help!