Surgical Knots

[drfeelgood99]

I've taught myself one and two hand ties with various surgery books but have noticed in the OR that none of the attendings or residents follow the way the books demonstrate. Specifically, no one ever crosses their hands with two hand ties or alternates their throws with one hand ties. Are these "non-textbook" ways of tying acceptable?
Also, any advice on how to avoid throwing "air knots", especially with deep and tight structures?

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[Blade28]

Usually, you can tie the first two throws in the same direction - then alternate. That will help you "cinch" the knot down after the first two throws.

It's tough to learn from books - easiest to learn from a surgical resident.

 

[geekgirl]

It's tough to learn from books - easiest to learn from a surgical resident.

this is true. particularly in the realm of the manual.

although kudos for trying, but this is where the books fail. no joke.

 

[toofache32]

I don't know.....I learned off the internet. Seriously:

http://www.bumc.bu.edu/Dept/Content.aspx?DepartmentID=69&PageID=5914

 

[Blade28]

Again, possible, but tough since you don't have that instant feedback - hard to tell if you're doing it correctly.

 

[DW3843]

I don't know.....I learned off the internet. Seriously:

http://www.bumc.bu.edu/Dept/Content.aspx?DepartmentID=69&PageID=5914

very nice.
I just taught myself the 2 handed technique in just a few minutes.

Although I should not practice it too much because I am sure that there is some subtle screw up that I am including that will make an attending think I am a *****.....oh wait, I will probably already look like a ***** to them anyway. nevermind.

 

[mysophobe]

Taught myself when I was a scrub tech and asked a surgeon the next day if he'd let me do it so he could tell me if I was doing it right.

 

[navysurgeon]

i think a sign of a well-trained surgeon is the ability to tie 'square' knots in any scenario. not just throw a bunch of slip nots, but tie a proper square not, which does not slip, and has the highest breaking strength. i think you should seek out a old-school attending and scub with him/her, have them teach you.

ethicon makes an excellent booklet on how to tie sugical knots. that is where i learned.

there is also a great book called the manual of surgical technique, which is outstanding.

keep tying those knots.

xTNS

 

[Pir8DeacDoc]

I've been told (and it makes sense) that once you make your first two throws the rest really don't matter. A nice square knot to start out will prevent slippage. After that granny knots should do just fine. I was given this piece of wisdom by a very well-known PRS guy at Pittsburgh.

 

[BKN]

I've been told (and it makes sense) that once you make your first two throws the rest really don't matter. A nice square knot to start out will prevent slippage. After that granny knots should do just fine. I was given this piece of wisdom by a very well-known PRS guy at Pittsburgh.

If that were the case then the 3 to however many throws are unnecessary. However, it isn't true. Under tension you should do a surgeon's throw to hold it, then the square and then the required number of alternating throws for the suture you're using. The alternating throws and laying them flat are very important. I've had to go back twice when I did it wrong. NOT appreciated by patients.

Learn to do it right and don't get lazy.

 

[Pir8DeacDoc]

I didn't mean to imply that you don't need to make 4 or 5 or whatever number of throws. What I meant was a nice square knot to start things out could then be followed with 3-4 granny knots and all should be well. Also, many plastic surgeons are not big fans of the surgeons knot. I still try and do them the right way but it's interesting how many different ways exist. I guess maybe the plastics guys get a little "lazy" because of how damn many sutures they place on some of their cases. Who knows?

 

[Orange Julius]

Great thread. I'm concentrating on my knots before I start. Can anyone tell me how many knots/techniques I should be comfortable before internship.

I'm guessing:

1. One hand ties: I used to be able to do these but have been long ago "forbidden" to use them. Not for students apparantly.
2. Two hand ties
3. Instrument ties.
4. Interupted, running, subQ
5. mattress, figure of 8


What else should I practice?

 

[deuist]

One thing you could do is to get your campus' Surgery Interest Group to invite a local surgeon or ob/gyn to teach you how to tie knots. A hospital invited the M1s and M2s at my school to a dinner one night where we learned about sutures before heading to the banquet hall.

 

[Blade28]

One of my ortho attendings doesn't like the surgeon's knot to start off with, because he feels it's too thick...hard to cinch down the other throws on top of it. He feels that if you tie properly, you don't need the "crutch" that is the surgeon's knot.

Personally, I feel it's helpful when using monofilament like Prolene.

 

[mysophobe]

I just like it. It lets me sleep at night when my teddy bear is in the wash.

 

[Plastikos]

I didn't mean to imply that you don't need to make 4 or 5 or whatever number of throws. What I meant was a nice square knot to start things out could then be followed with 3-4 granny knots and all should be well. Also, many plastic surgeons are not big fans of the surgeons knot. I still try and do them the right way but it's interesting how many different ways exist. I guess maybe the plastics guys get a little "lazy" because of how damn many sutures they place on some of their cases. Who knows?

It depends on what your suturing and what your using. Monofilaments tend to slip easier and thus we are always told to throw 5+ on when using prolene, etc...For plastics, it has to do with many factors. First, there isnt supposed to be any tension to speak of and the sutures should just approximate edges, therefore a brutal knot isnt "necessary". Also, there is the multi-level closure with most tension and bigger knots below, and the sheer number of sutures to help. I would think its just experience and not laziness. In other situations it probably wouldnt be used.

 

[mysophobe]

Word. I was told to always use 5+ on monofilaments, including a surgeon's knot. Other stuff we use 3-5, but we still use a surgeon's knot. Everyone uses that here for just about everything.

 

[supercut]

There are, unfortunately, a lot of surgery residents who don't tie proper square knots. I had to learn this the hard way...when one of our attendings who will actually teach interns saw my knots and told me they weren't square. I was shocked, cuz I spent a lot of time learning and thought I was doing fine (and the residents who watched me didn't correct me). This attending complained that even some of the chiefs weren't tying square knots..(so you can imagine if there are some chiefs that aren't tying square knots, then there are also probably some attendings who aren't.) What I learned from this is that even the subtle things like which direction you move your hand to cinch the knot down can make it square or not.

I like the idea of getting an old time surgeon to show you, if you can find one. The Ethicon knot tying manual is good, and available on their web site. It is good to practice using a larger string that is two colors, so you can make sure things are square. If you don't have access to a knot tying board, you can use shoelaces and use a sharpie to color half of it. I found this visual indespensible when I was correcting my technique.

 

[Pianoboe01]

Great thread. I'm concentrating on my knots before I start. Can anyone tell me how many knots/techniques I should be comfortable before internship.

I'm guessing:

1. One hand ties: I used to be able to do these but have been long ago "forbidden" to use them. Not for students apparantly.
2. Two hand ties
3. Instrument ties.
4. Interupted, running, subQ
5. mattress, figure of 8


What else should I practice?

Why would students be "forbidden" to do the one-hand tie?

Also, when people say x number of throws, does one throw = one square knot or half of a square knot?

 

[toofache32]

Why would students be "forbidden" to do the one-hand tie?

Also, when people say x number of throws, does one throw = one square knot or half of a square knot?

One throw = one half of a square not.

I think the one-hand is easier than the two- hand. I never figured out how these were named, because the "one-handed" tie still requires 2 hands.

 

[Blade28]

One throw = one half of a square not.

I think the one-hand is easier than the two- hand. I never figured out how these were named, because the "one-handed" tie still requires 2 hands.

Well, technically, if the attending holds one end of the suture, you can do a one-handed tie with the other end. You can't do that (without the attending helping) in a two-handed tie.

 

[Orange Julius]

I think the one-hand is easier than the two- hand. I never figured out how these were named, because the "one-handed" tie still requires 2 hands.

One hand tie = one hand active, one hand passive

Two hand tie = two hands active

 

[Orange Julius]

Why would students be "forbidden" to do the one-hand tie?

Beats the hell out of me. It's apparantly a rule around here, especially amongst the old timers. I had guessed that was the same everywhere. Maybe it isn't.

 

[toofache32]

One hand tie = one hand active, one hand passive...

....equals two hands total.

My original comment was sort of tongue-in-cheek.

 

[Orange Julius]

....equals two hands total.

My original comment was sort of tongue-in-cheek.

Just explaining the nomenclature to you. The passive hand isn't counted. Concievably you could just anchor the passive strand or have someone else hold it for you. Then you could tie the knot with one hand.

 

[Smoke This]

Beats the hell out of me. It's apparantly a rule around here, especially amongst the old timers. I had guessed that was the same everywhere. Maybe it isn't.

It's an unwritten rule at my school too. The joke is that students can't do one-handed ties because they might show up some of the attendings.

 

[DrRobert]

It's an unwritten rule at my school too. The joke is that students can't do one-handed ties because they might show up some of the attendings.

Show up the attending surgeons at WashU? really?

 

[navysurgeon]

the 'one handed' tie is used in two scenarios

1. tie a knot into a 'hole', whatever 'hole' you might be placing a knot into...deep in the pelvis or sub hepatic space.

2. with a needle driver in one hand, throwing the knot in the other

i think a good surgeon should be able to tie left and right handed as well.

xTNS

 

[Winged Scapula]

It's an unwritten rule at my school too. The joke is that students can't do one-handed ties because they might show up some of the attendings.

Same here...heck, even interns aren't allowed to tie one handed knots. I had to teach myself all over again!

 

[mysophobe]

I hope it's not an unwritten rule everywhere, because I do them all the time.

 

[Pianoboe01]

Changing the subject a bit, but I got some expired suture from the hospital to practice knot tying and suturing, but it has a needle on both ends. When would you use this?

 

[LaCirujana]

Changing the subject a bit, but I got some expired suture from the hospital to practice knot tying and suturing, but it has a needle on both ends. When would you use this?

Whenever you're sewing an anastomosis that requires a patent lumen, such as in vascular surgery. Essentially, you use one needle to sew the back wall and around the corner, and then use other needle to sew the front wall, tying the two ends together when the anastomosis is complete.

 

[tRmedic21]

Whenever you're sewing an anastomosis that requires a patent lumen, such as in vascular surgery. Essentially, you use one needle to sew the back wall and around the corner, and then use other needle to sew the front wall, tying the two ends together when the anastomosis is complete.

Ok, this is getting kinda scary, am I the ONLY MS4 prospective GS applicant who's never tied a suture? Never been taught, never had the opportunity, etc.? Am I going to be asked on the interview trail to do this? I heard about the soap carving, but that was rare experiences in plastics from what I heard.

 

[Plastikos]

Ok, this is getting kinda scary, am I the ONLY MS4 prospective GS applicant who's never tied a suture? Never been taught, never had the opportunity, etc.? Am I going to be asked on the interview trail to do this? I heard about the soap carving, but that was rare experiences in plastics from what I heard.

They didnt teach you during your surgery rotation? Seems like an essential part of any core gsurg curriculum. Teach yourself the basics, its not quite as hard as its made out to be (to teach yourself), there were some links on a thread about suturing. Or maybe you can find a classmate who knows how and have them teach you.

 

[tRmedic21]

They didnt teach you during your surgery rotation? Seems like an essential part of any core gsurg curriculum. Teach yourself the basics, its not quite as hard as its made out to be (to teach yourself), there were some links on a thread about suturing. Or maybe you can find a classmate who knows how and have them teach you.

We weren't taught any suturing at all in my GS core. I was in Ireland for all my cores, and even the SHOs there were scraping for chances to close. When we scrubbed in (rarely), we basically were just human retractors.

 

[mysophobe]

Whenever you're sewing an anastomosis that requires a patent lumen, such as in vascular surgery. Essentially, you use one needle to sew the back wall and around the corner, and then use other needle to sew the front wall, tying the two ends together when the anastomosis is complete.

Another time they have two needles is those big retention sutures, the big nylons. Now they make them with one needle and a big lead thing on the other end, which makes it a hell of a lot easier and quicker, but some places probably still use the double-ended nylon.

 

[SLUser11]

We weren't taught any suturing at all in my GS core. I was in Ireland for all my cores, and even the SHOs there were scraping for chances to close. When we scrubbed in (rarely), we basically were just human retractors.

That's too bad, but it doesn't mean you shouldn't have tried to teach yourself....alot of medical education won't be spoonfed.

Although you won't be asked to demonstrate surgical technique at many (if any) interviews, that doesn't mean that you shouldn't know how. Get started now....I'm sure our fellow SDNers have some websites or something that they can post.

 

[mysophobe]

Ethicon Wound Closure Manual

 

[Pianoboe01]

Here are some videos

 

[drpectin]

Here are some videos

Thanx Pianoboe, that is an excellent resource.

 

[Blade28]

Ok, this is getting kinda scary, am I the ONLY MS4 prospective GS applicant who's never tied a suture? Never been taught, never had the opportunity, etc.? Am I going to be asked on the interview trail to do this? I heard about the soap carving, but that was rare experiences in plastics from what I heard.

Wow, that's crazy! Just practice at home, I guess.

 

[WaZoBia]

well, you've still got some time before the start of residency, you can learn now then practice every chance you get. you can also try suturing some pig skin together, some people also practice on banana "skins" (peelings), this might help you develop some confidence. you don't need to be an expert when you start, just decent, and it won't take you too long to get decent.

hang in there

 

[tRmedic21]

well, you've still got some time before the start of residency, you can learn now then practice every chance you get. you can also try suturing some pig skin together, some people also practice on banana "skins" (peelings), this might help you develop some confidence. you don't need to be an expert when you start, just decent, and it won't take you too long to get decent.

hang in there

Oh I do plan on working on it, I just wasn't aware I was supposed to already know and be doing these things. After all, the people in Ireland who were PGY3 or more weren't even closing all that often in the OR over there, so I really wasn't aware it was a student 'skill' in the US, that's all. I am sure it's not a technically demanding skill, just needs a little practice.

 

[WaZoBia]

Oh I do plan on working on it, I just wasn't aware I was supposed to already know and be doing these things. After all, the people in Ireland who were PGY3 or more weren't even closing all that often in the OR over there, so I really wasn't aware it was a student 'skill' in the US, that's all. I am sure it's not a technically demanding skill, just needs a little practice.

yeah, i heard that about irish training, i think the thought behind it is that you'll eventually learn the skills you need during training.

all the best.

 

[Plastikos]

Oh I do plan on working on it, I just wasn't aware I was supposed to already know and be doing these things. After all, the people in Ireland who were PGY3 or more weren't even closing all that often in the OR over there, so I really wasn't aware it was a student 'skill' in the US, that's all. I am sure it's not a technically demanding skill, just needs a little practice.

Its probably school dependent, the experience is very different depending on where you go and how active the interest groups are. At USC, we have a skills center and the surgery group we had got us suturing and basics taught in the first year, lap instruments and stuff second year, and even surgeries on pigs and residency readiness electives in years three and four.

 

[tRmedic21]

Well, I actually finally got some instruction yesterday in my Family Practice rotation. We had a Derm workshop and got to practice excision of lesions and subsequent suturing on pigs' feet. I plan to find some supplies and begin learning more knots and such. I learned to do some deep closures and then simple square knots to close the skin.

I loved it! Best part of FP so far.

 

[The Squid]

A resident taught me how to tie knots, but they look significantly different than the knots I tie based on the manuals. The way the resident taught me, there's sort of a backbone going down the row of knots and all of the knots are on the same side, very uniform. The way I do it from the manuals, it sort of looks like a braid (not exactly, but alternating and the knots aren't all on one side). Do either of those sound like square knots? Thanks

 

[Orange Julius]

Most manuals suck because they don't provide illustrations for all the steps involved. This doen't make that mistake. It's simple, comprehensive and easy to follow. Enjoy.

http://www.amazon.com/gp/product/1889326011/103-0110614-9283879?v=glance&n=283155

 

[mysophobe]

The way you're describing the resident do it is the way I do it usually. I haven't had any problems or had anyone yell at me, so that's what I do. The way it actually looks depends on the alternation of the throws. If you alternate everytime, it'll look like a braid. Everyone here does two of the same throw and then alternates, followed by a few grannys, so it looks more like what your resident does.

 

[asdfaa]

Everyone here does two of the same throw and then alternates, followed by a few grannys, so it looks more like what your resident does.

Two of the same throw IS a granny knot, right? That's so you can cinch it down nice and snug and avoid tying an air-knot. But why would you go back to tying granny's AFTER switching to alternates?? I din't think granny knots cotributed anything to the strength of the knot. Is that just cutting corners or is there a reason for it?