One Handed Ties

[schussboarder]

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For any attendings/residents out there,
I was talking to a friend about hand ties today and I stated that I could only really do one handed ties w/ actual suture material as I found that the two handed techniques were much more difficult when I was not using the larger ethicon sting set that I learned off of. He stated that most physicians would frown upon not using a two handed tie as a medical student. Is there any truth in this?
Since the one handed tie would still close the tissues is there any time where the two handed tie would have to be done over doing a one handed tie?

Thanks

 

[skiz knot]

For any attendings/residents out there,
I was talking to a friend about hand ties today and I stated that I could only really do one handed ties w/ actual suture material as I found that the two handed techniques were much more difficult when I was not using the larger ethicon sting set that I learned off of. He stated that most physicians would frown upon not using a two handed tie as a medical student. Is there any truth in this?
Since the one handed tie would still close the tissues is there any time where the two handed tie would have to be done over doing a one handed tie?

Thanks

I'm an orthopaedic resident, but I'll throw in my opinion.

I too have heard it is frowned upon for medical students to use a one-handed method of tying. I don't know why.

In my experience, when I'm not doing an instrument tie, a one-handed tie has always sufficed, and is usually more practical, and is not any more difficult than a two-handed tie.

As a medical student this probably won't come up often as you won't likely be asked to tie off any deep bleeders in a wound. You will be lucky to instrument tie a wound closed.

Can anyone out there enlighten us with a situation where a two handed tie is necessary/preferred?

 

[LifetimeDoc]

From my understanding they want to make sure whatever knot we make is going to hold, thus "harder" methods of tying knots is frowned upon. Just my guess gleaned from what I've heard.

 

[ACSurgeon]

I'm an orthopaedic resident, but I'll throw in my opinion.

I too have heard it is frowned upon for medical students to use a one-handed method of tying. I don't know why.

In my experience, when I'm not doing an instrument tie, a one-handed tie has always sufficed, and is usually more practical, and is not any more difficult than a two-handed tie.

As a medical student this probably won't come up often as you won't likely be asked to tie off any deep bleeders in a wound. You will be lucky to instrument tie a wound closed.

Can anyone out there enlighten us with a situation where a two handed tie is necessary/preferred?

For one, it is largely attending preference. However, I think some situations require a two handed tie to get a more secure not and/or cause less trauma to the tissue (tying off vessels during an amputation of a diabetic with ****ty vessels). This is my understanding, but those with more experience can chime in.

 

[GregsAnatomy]

I will pretty much always perform a one-handed tie. Really the only exception is when I close fascia using an interrupted figure-of-eight technique where I'll do a two-handed (usually assisted by the needle driver). Also for some reason, pediatric surgeons always want the residents to do a two-handed tie....

 

[Pir8DeacDoc]

I almost exclusively use one handed or instrument ties. Students will get crap for "Hollywood" tying if they try one handed, so you should probably try to learn the two handed technique.

 

[Guile]

For any attendings/residents out there,
I was talking to a friend about hand ties today and I stated that I could only really do one handed ties w/ actual suture material as I found that the two handed techniques were much more difficult when I was not using the larger ethicon sting set that I learned off of. He stated that most physicians would frown upon not using a two handed tie as a medical student. Is there any truth in this?
Since the one handed tie would still close the tissues is there any time where the two handed tie would have to be done over doing a one handed tie?

Thanks

Learn and master the two-handed tie. One of the keys to doing well on your rotation is keeping your head down and doing what's expected of you. So, to that end, many attendings will give you flak for tying one-handed and will respect you for a good-looking two-handed tie. I've had residents see my two-handed and ask if I knew how to tie one-handed. When I said yes, they said I could tie one-handed now that they had seen my two-handed. Also, the main reason for tying two-handed (in addition to it being old-school) is that they can tell from your hand movements that it's square. It's harder for them to see that it's square when you tie one-handed. If you're getting to tie on something that's staying in the patient, then I would do everything I could to maintain that privilege by making them comfortable with my abilities, and that starts with tying two-handed. I'll probably continue to tie two-handed during internship as well, part of that keeping your head down business.

 

[Winged Scapula]

As others have noted above, the reasons tend to be two:

1) students (and in some programs, interns and junior residents) have to "walk before they run". The one-handed tie is seen as more complicated and a bit "showy" for medical students.

I want to know you know how to do the basics before you start doing the advanced moves.

2) secondly, there IS an increased risk of throwing a slip knot with the one-handed tie. The amount of force is applied more evenly with the two handed knot and therefore, less likely to break than the one-handed and less likely to come untied. Inexperienced tiers, like medical students, will be more likely to fail to maintain equal tension during a one-handed tie, resulting in slippage.

Square knots are also usually more secure than grannies and the fewer knots required to prevent slippage may result in a lower rate of infection.

The one-handed knot does have its place, especially when tying deep ligatures (ie, in a deep hole) or a small narrow hole where both of your hands won't fit into the wound. For my cases, I ligate with clip appliers but I also put one-handed ties (AND clips because I'm paranoid about clips falls off) on major vessels because my incisions tend to be small.

 

[Guile]

For my cases, I ligate with clip appliers but I also put one-handed ties (AND clips because I'm paranoid about clips falls off) on major vessels because my incisions tend to be small.

Man the radiologists must love reading your patients' imaging after a case. They must have a breast full of clips. Why not just ties? And, silk or Vicryl ties?

 

[Winged Scapula]

Man the radiologists must love reading your patients' imaging after a case. They must have a breast full of clips. Why not just ties? And, silk or Vicryl ties?

Well, there aren't many "major" vessels in the breast; even the cancer cases and the pregnant ones are still controllable without clips or ties.

Most breast vessels can be Bovied. I do place clips to demark the lumpectomy cavity for certain Rad Oncs but the majority of clips are in the axilla where I also use them for major lymphatics. I've tried the Harmonic but it takes too long (and the handle is too long so I feel like I'm doing bariatrics or need to stand 10 feet away from the patient).

And why not ties? Because in PP, time is money. Ties take too long (especially if you've got some bleeding and the typical assistant isn't very helpful so I'm trying to suction, find the bleeder AND ligate it. Hard to do a one-handed tie and run the sucker at the same time, all while yelling at the incompetent assist/scrub tech. 😉 ).

 

[Buzz Me]

Because attendings are sick and tired of med students/junior residents who love to tie one-handed but can't throw a proper square knot using the two-handed method.