Course Welcome
Welcome to the Core Surgical Skills: Knot Tying with Instruments and Hands. Learning to tie secure surgical knots is a critical skill for any veterinarian who performs surgery. Most wound repairs rely on sutures or a row of stitches, known as a suture line, to hold separated tissue together until healing occurs. If sutures fail before the healing process is underway, this can cause significant wound complications, such as dehiscence or even complete failure of the surgical repair. Failure of a knot on a suture that is used to occlude a blood vessel, called a ligature, could result in a life-threatening hemorrhage. Consequently, the surgeon must develop considerable expertise in tying knots in sutures or ligatures using either instrument-tie or manual/hand-tie techniques. Knotting decreases the strength and stiffness of nearly all suture materials, yet knots are necessary to secure a suture. In other words, the knot is the weakest part of a stitch or suture line. Therefore, to be sure wounds are closed securely, it is critical that suture knots are created uniformly and reliably.
Learning surgical knot tying is challenging, and it requires extensive practice in order to become proficient. Once the technique is learned successfully and you become proficient, the process of knot tying becomes innate and does not require concentration to complete correctly. It is very important to practice the same method of knot tying every time so that your hands and fingers become trained in one technique, and this "memory" permits you to know when a knot tie is performed incorrectly because it "feels" wrong. As you watch surgeons knot tie, it appears as if they are not paying attention to the mechanics of the knotting sequence. However, the surgeon knows when the tie is wrong because the tie "behaves" differently, and that signals the surgeon to either replace the suture or tie additional correct knots on top of the questionable one.
Arguably, suturing is often the most time consuming part of a surgical procedure. An efficient knot-tying technique is important to reduce the procedure time, but this should not be your primary goal when first learning knotting methods. Once your knot technique becomes innate, the next steps are to work on efficient management of the suture ends and practice quickly controlling and transitioning your throws with your fingers or instruments.
This module begins with common terminology used to teach knot tying, and is followed by a description of the basic principles of knot tying and the mechanisms of knot security. Next, step-by-step descriptions of basic knot techniques are demonstrated through a series of instructional videos. This module covers basic knots, which are those knots surgeons should know for most surgical procedures. Finally, we explain some practical considerations related to the application of knot-tying techniques in surgery.
It is important to understand that the primary goal of knot tying is to create a secure knot. You will notice that surgeons have developed individual variations in their knot-tying techniques, yet they still produce a consistent square knot. It is beyond the scope of this core skill module to cover literally a dozen or more different method variations for creating a square knot. The knot mechanics shown in this module are those that the authors have found easiest to teach novice surgeons, but they might not entirely match your individual instructor's preferred technique. It is important to consult with your surgery instructors regarding their preferred techniques. Other knot-tying technique resources are also listed at the end of this module, which might help supplement your understanding and mastery of the concepts and techniques presented in this module.
