Most common cause of a bulky instrument tie knot?

[migm]

Hi guys,

Was suturing someone up yesterday who had just a bajillion cuts from broken glass. I noticed that my knots were a lot bigger than the residents when we were using instrument ties (4-0 and 6-0 gut). What's the best way/most common cause for a bulkier looking square knot? First throw was a surgeon's knot then I was doing between 3 and 4 total knots. His thought was that my levels were off but I'm not sure this is what was causing a bulky knot to appear.

Thanks,
m

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[cpants]

You don't need to use a surgeon's knot closing skin with gut. That probably is adding some bulk. Otherwise make sure your knots are squared and you are tying them tight.

 

[SocialistMD]

You are stacking the throws instead of laying them flat on top of one another. It is possible to tie a knot on top of another throw, leading to bulkiness (and a less secure closure).

 

[migm]

You are stacking the throws instead of laying them flat on top of one another. It is possible to tie a knot on top of another throw, leading to bulkiness (and a less secure closure).

This sounds like what I'm doing. How do I fix it? Making sure the throw is flat before tightening it down?

 

[illixir]

You should be able to see it turn flat as it comes down based on how you pull the sutures. I alternate pulling them in opposite directions and make sure there is tension on both ends as it comes down.

 

[Buzz Me]

Surgeon's knot at the beginning only if you're using monofilament. Braided suture won't slip. Otherwise, you're doubling the size of the initial knot without any appreciable benefit.

 

[igap]

It's generally unnecessary to ever throw a "surgeon's knot". If you are about to throw an air knot, just cinch the short end of your suture and this will slide the knot down.

As for bulkiness, agree with other posters' that you should simply square each knot.

 

[dude1344]

It's generally unnecessary to ever throw a "surgeon's knot". If you are about to throw an air knot, just cinch the short end of your suture and this will slide the knot down.

As for bulkiness, agree with other posters' that you should simply square each knot.

Is there some source that can elaborate on this? Is this surgeon preference or are there actually hard and fast rules. I'm a rising MS4 that's still a bit confused about when to use the "surgeon's knot."

 

[SocialistMD]

This sounds like what I'm doing. How do I fix it? Making sure the throw is flat before tightening it down?

Keep better tension on one end.

 

[cpants]

Is there some source that can elaborate on this? Is this surgeon preference or are there actually hard and fast rules. I'm a rising MS4 that's still a bit confused about when to use the "surgeon's knot."

A surgeon's knot gives your first throw a little more insurance when you using a suture material prone to slippage (ie. large size monofilaments) to approximate tissue that is under tension. The surgeon's knot makes it less likely to slip before your second throw causing an 'air knot'. That is basically the only situation it should be used. Otherwise you are just adding bulk for no benefit. Gut is basically braided suture, and you should probably never put a surgeon's knot in it.

 

[migm]

thanks all, helpful posts.

 

[dpmd]

A surgeon's knot gives your first throw a little more insurance when you using a suture material prone to slippage (ie. large size monofilaments) to approximate tissue that is under tension. The surgeon's knot makes it less likely to slip before your second throw causing an 'air knot'. That is basically the only situation it should be used. Otherwise you are just adding bulk for no benefit. Gut is basically braided suture, and you should probably never put a surgeon's knot in it.

So if you have your deep layer closed well, you don't need a surgeon's knot (since there is no tension-leading to better looking scar). I can't remember the last time I used a surgeon's knot. Even if I am closing something under tension, I just do a county slide if doing instrument ties, or throw a granny and slide it tight with the second throw if hand tying. Not sure if I can adequately describe the county slide, but basically involves allowing the thing to loosen with the first throw, then on the second throw keeping a little loop of the long side in your finger as you pull the short side (this tightens the first knot), then you release the long side while keeping tension on the short. Viola! Tight, square knot.

 

[45408]

When you say "throw a granny and slide it tight with the second throw," do you mean two half-hitches? Because that's how I do a slip knot.

 

[dpmd]

When you say "throw a granny and slide it tight with the second throw," do you mean two half-hitches? Because that's how I do a slip knot.

Yeah, I just wasn't sure it is actually called a slip knot.

 

[45408]

Yeah, I just wasn't sure it is actually called a slip knot.

There are lots of ways to make slip knots, and that's just one of them. I don't know of any other ways to do one using the throws that surgeons use.