1. Dismiss Notice
  2. Download free Tapatalk for iPhone or Tapatalk for Android for your phone and follow the SDN forums with push notifications.
    Dismiss Notice

Surgical Knots

Discussion in 'Surgery and Surgical Subspecialties' started by medschoolsoon, Jun 18, 2008.

  1. medschoolsoon

    10+ Year Member

    Joined:
    Apr 8, 2006
    Messages:
    206
    Likes Received:
    0
    Status:
    Resident [Any Field]
    Anyone know a good book/internet site to learn most knots? Youtube only seemed to have a two handed tie. My awesome mentor ;) gave me a few suggestions but a lot of the books don't do a great job if you've never learned them or don't have someone to show you.

    Thanks and much love!
     
  2. Note: SDN Members do not see this ad.

  3. Winged Scapula

    Winged Scapula Cougariffic!
    Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

    Joined:
    Apr 9, 2000
    Messages:
    38,551
    Likes Received:
    26,743
    Status:
    Attending Physician
    Perhaps if you talked to your mentor he/she would probably show you how to tie the knots IRL.
     
  4. medschoolsoon

    10+ Year Member

    Joined:
    Apr 8, 2006
    Messages:
    206
    Likes Received:
    0
    Status:
    Resident [Any Field]

    Just might do that, though there never seems to be a great time. I'm sure I can work something out.
     
  5. -Goose-

    10+ Year Member

    Joined:
    Jul 7, 2005
    Messages:
    1,728
    Likes Received:
    9
    Status:
    Resident [Any Field]
    Call Ethicon or google "free ethicon knot tying board." It's not even close to what you're really going to do, but you can learn some principles. It's free for medical students.
     
  6. Winged Scapula

    Winged Scapula Cougariffic!
    Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

    Joined:
    Apr 9, 2000
    Messages:
    38,551
    Likes Received:
    26,743
    Status:
    Attending Physician
    1-800-ethicon
     
  7. heartsurgeon

    heartsurgeon The Lecompte Manuevre
    2+ Year Member

    Joined:
    Oct 14, 2007
    Messages:
    16
    Likes Received:
    0
    Status:
    Fellow [Any Field]
    You get a royal college of surgeons video which is pretty good for knot tying and other basic surgical skills.There is also a Mayo clinic basic surgical skill video and text.
     
  8. coastal

    coastal Member
    7+ Year Member

    Joined:
    Jul 20, 2003
    Messages:
    133
    Likes Received:
    2
    Status:
    Resident [Any Field]
    Essential Sugical Skills by Sherris and Kern. I got this about a month ago since I'll be starting residency in July and I did 90% of my surgical rotations before last June and haven't been in the OR at all since early December. Step by step diagrams of surgical techniques, knot-tying with a DVD.

    Unfortunately, I can't tell you if it's any good since I haven't been doing a very good job of getting ready for residency...... I still have one week though, I have high hopes :rolleyes:
     
  9. I always found the easiest way to learn is to have an MS-IV or resident teach you. Nothing beats someone walking you through tying, IMHO.
     
  10. SLUser11

    SLUser11 CRS
    10+ Year Member

    Joined:
    Feb 22, 2005
    Messages:
    2,878
    Likes Received:
    762
    Status:
    Attending Physician
    Absolutely. I always took time at the beginning of the students' rotation to show them 2-hand tying and basic suturing skills. Of course, at least at our institution, they almost never utilize anything except the instrument tie. I never really found a good opportunity to have the students knot-tying in the OR.....their role seems to be limited to closing skin.
     
  11. DrDre311

    DrDre311 Makaveli
    2+ Year Member

    Joined:
    Apr 14, 2008
    Messages:
    655
    Likes Received:
    3
    Status:
    Resident [Any Field]
    The OP should take advantage of any of the above-mentioned learning techniques for knot-tying and focus on learning to tie good, square knots. I see a lot of people tie granny knots (poor form!).

    I spent significant time as a student learning to tie one- and two-handed knots with both hands, but now I generally use instrument ties because it's faster, and I can sew with really, really small pieces of suture.
     
  12. nykka3

    nykka3 Senior Member
    7+ Year Member

    Joined:
    Dec 19, 2003
    Messages:
    632
    Likes Received:
    0
    Status:
    Resident [Any Field]
  13. Celiac Plexus

    Celiac Plexus Senior Member
    10+ Year Member

    Joined:
    Oct 9, 2002
    Messages:
    1,128
    Likes Received:
    7
    Status:
    Fellow [Any Field]
    A knot is a knot imho. Square knots are what I throw because that's what was pounded into me. Certainly square knots are useful for closing abdominal fascia, or other high tension closures, but square knots are not essential in every scenario.

    If you think about it, why in the world is a square knot essential for closing skin? Most of the attendings in my program don't even use suture for skin... they use staples. And why should a square knot be essential for closing skin which should be under zero tension anyway? A "granny" knot will work just as well for skin or other zero tension closures. I've even started selectively using dermabond in the ED to close some small, clean, lacs...

    Dre, I'm not trying to pick a knot fight here, but the "square knot mafia" mentality never made sense to me. Now, being ambidextrous does make sense, and I encourage all trainees to get equally comfortable with tieing with either hand.
     
  14. SocialistMD

    SocialistMD Resident Objectivist
    15+ Year Member

    Joined:
    Jan 29, 2001
    Messages:
    2,913
    Likes Received:
    13
    Status:
    Fellow [Any Field]
    I learned how from my Cub Scout Handbook back in 3rd grade. I think it is still less than $10 ;).

    Studies have actually shown that loop (slip) knots have greater tensile strength under tension than do square knots. Furthermore, it has been shown that anchoring a running stitch by starting with half-hitches and ending with a square knot is safer and more secure.

    As for skin closure, many of our plastic and breast surgeons don't tie in the suture at all; they place a subq stitch without tieing either end (to approximate the skin), dermabond over the top and then pull out the suture (or cut it at the edge of the skin and leave it) when the dermabond is dry.
     
    #13 SocialistMD, Jun 21, 2008
    Last edited: Jun 21, 2008
  15. Some of our attendings like that as well, when closing laparoscopic incisions. That way you can use one piece of 4-0 Monocryl to close all 3-4 incisions, without the need to stop and use scissors to cut anything. Just connect all the incisions, Dermabond, then snip!
     
  16. Winged Scapula

    Winged Scapula Cougariffic!
    Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

    Joined:
    Apr 9, 2000
    Messages:
    38,551
    Likes Received:
    26,743
    Status:
    Attending Physician
    That's how I do it...have to be all about efficiency now.
     
  17. Agreed. :thumbup:
     
  18. SocialistMD

    SocialistMD Resident Objectivist
    15+ Year Member

    Joined:
    Jan 29, 2001
    Messages:
    2,913
    Likes Received:
    13
    Status:
    Fellow [Any Field]
    Blade, how many of your thousands of posts are simply the above? ;)
     
  19. :laugh: Not THAT many, promise! :)
     
  20. DrDre311

    DrDre311 Makaveli
    2+ Year Member

    Joined:
    Apr 14, 2008
    Messages:
    655
    Likes Received:
    3
    Status:
    Resident [Any Field]
    I suppose I'm guilty of that as well. I make a point of throwing square knots because that's what's been drilled into me since I started sewing. As far as skin closure goes, it depends on what situation you're describing. For a small skin closure, by the time you get to the skin, it should be zero-tension. In most cases I favor a running subcuticular stitch over stapling, because the subcuticular stitch allows for closer approximation of wound edges, leading to a smaller scar. The real strength of closure derives from approximation of the superficial fascial system as described by Lockwood et al. However, when you're doing something like an a-plasty on a big person, the case can be long enough to allow for significant primary contraction and no matter how good your subcutaneous/SFS closure is, the dermis on the apposed wound edges always wants to pull away from itself, which can lead to exposed dermis without good subcuticular closure. That is, the size of the incision combined with the size of the patient dictates that there will be some tension on the skin closure.

    No knot fight necessary, even though I've been forced to join the Square Knot Mafia. Ambidexterity is also good.

    I read that study. I hadn't seen it before, and it's pretty interesting. However, there are a few problems with it: first, the study is based on only 5 knots with 5 throws each tied, all tied by the same person; second, the knots were tied in a "dry" fashion (i.e. not in a real operative situation); and third, the sutures all had their loops divided and forcibly distracted at 180 degrees (again, not realistic) at half a centimeter per minute with a preload of 1 kN (~100 kgf!). If I saw one of my sutures being stretched 50 mm in one minute, I would become mildly distressed. Finally, the study also concludes that larger suture has a lower tensile strength, which seems slightly counterintuitive.

    Basically, the study conditions are not realistic, and the authors themselves acknowledge that they do not assess for knot slippage--only tensile failure of the material--and I've always been taught that a slipknot does just that, it slips. My guess is that the authors obtained the results that they did because their testing apparatus exposed the suture to artificially increased angles, which enhances the point of weakness (i.e. suture kinking) created by any knot, and extremely high tensile forces. A better way to test this question would be to reduce the angles to something closer to a real-life scenario, to have many different knot-tyers tying a much larger number of knots, to assess for knot slippage as a measure of knot failure, and to test more than three kinds of suture.

    Every surgeon likes to do something different. Some people like to run a subcuticular Monocryl/Prolene/whatever with the ends left free and reinforce it with Dermabond or Steri-Strips, others like to anchor the subcuticular closure with a knot. Depends on who's operating. I personally favor Prolene with the ends left free and Steri-Strips.
     
    #19 DrDre311, Jun 21, 2008
    Last edited: Jun 21, 2008
  21. thedrjojo

    Physician 10+ Year Member

    Joined:
    Jun 20, 2008
    Messages:
    23,823
    Likes Received:
    15,930
    Status:
    Fellow [Any Field]
    I had a related question that someone out there might know... I've gotten down the 1 handed knot (the best thing I got out of my 3 week Neurosurgery rotation to start my 3rd year) but in the process never practiced or saw a 2 handed knot (the NS residents flat out said they don't even remember how to tie one) so my question is, having knowledge of a 1 handed square knot, is learning the 2 handed knot necessary or is there no indications that have a 2 handed knot is better than a 1 handed (I know the NS people said a 1 handed was required for some of there things because it allowed you to maintain tension with the stationary hand). Any input?
     
  22. Winged Scapula

    Winged Scapula Cougariffic!
    Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

    Joined:
    Apr 9, 2000
    Messages:
    38,551
    Likes Received:
    26,743
    Status:
    Attending Physician
    I would say it was very program dependent.

    I learned the one handed as a medical student and started using it exclusively until I got to intern year. I trained in a program where junior residents were not allowed to tie a one handed knot; so several of the interns and myself sat around trying to remember the two handed. Then I got so good with the two handed that it was hard to switch back. The one handed is very useful in small places (like the brain) or deep cavities (like in the abdomen).

    Therefore, not knowing what situation you may find yourself in knowing both is a good idea. I know of no good reason to prefer one to the other except as I've outlined (room and program preference).
     
  23. SLUser11

    SLUser11 CRS
    10+ Year Member

    Joined:
    Feb 22, 2005
    Messages:
    2,878
    Likes Received:
    762
    Status:
    Attending Physician

    I like using the prolene/steristrip combo, but I have to admit there are only a handful of people outside of plastics that use it here in Wichita. There are some incisions, such as peri-areolar, where I feel like the running subcuticular looks like crap. For those, I like to do interrupted dermal stitches and steri-strips, although I end up placing the dermal stitches superficial enough that they're almost interrupted subcuticulars......

    Honestly, as an intern I spent a lot of time on my closures, but now I usually let the med students do them, and you have to allow them a certain amount of lattitude since they're just learning.....



    I feel like the 2-handed tying comes into play from time to time, and it needs to be in your arsenal. When I'm throwing a surgeon's knot, I'll use two hands because I find it easier than the 1-handed technique.
     
  24. Med students should ALWAYS learn the two-handed tie before the one-handed one. Helps you learn the basics of a square knot.
     
  25. roja

    7+ Year Member

    Joined:
    Oct 20, 2003
    Messages:
    6,040
    Likes Received:
    19
    Status:
    Attending Physician
    Ditto.


    Knot tying and suturing is best learned by doing. I generally take interns/med students and have them start 'suturing' a sheet for me. I give tips on how to hold needle drivers, etc (assuming that all my ms4's have learned first the two handed and then the one handed).

    Then I like to throw them for a loop and have the try their hands at vertical and horizontal mattresses.

    Learning by doing is really the only good way to learn to tie. Then practice.
     
  26. coastal

    coastal Member
    7+ Year Member

    Joined:
    Jul 20, 2003
    Messages:
    133
    Likes Received:
    2
    Status:
    Resident [Any Field]
    yuck....started practicing today. T-minus 8 days and let me tell you there's some work to do to get back to my baseline.....

    Plug into the ipod and sew sew sew.
     
  27. seansss

    seansss ATX
    7+ Year Member

    Joined:
    Mar 9, 2008
    Messages:
    71
    Likes Received:
    0
    Status:
    Pre-Medical
    My uncle, a GS, taught me how to do one handed knots. And for a week while he did consults in his office I tied knots into pillows :)....By the end of the week I thought I was pretty good, then we went back into the OR and saw him closing, he won......
     

Share This Page