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There are eight important rules that surgeons should follow when tying and securing knots. Before you learn the techniques involved in creating surgical knots, let us review each of the overarching principles required to create a good quality surgical knot.
The primary objective in knot tying is to ensure knot security with the least number of throws. The square knot is almost exclusively used in surgery since it is the simplest and most secure knot.
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RULE #1
When creating a knot, always select the appropriate suture gauge to ensure that the knot will be as small as possible. Knots made using smaller-sized material are generally more secure and their knot ears cause less mechanical irritation to surrounding tissues. Additionally, if smaller knots are compressed down between the wound edges, these knots do not separate tissue edges as much as bulkier knots.
RULE #2
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Attempt to tighten throws by pulling in opposite directions in a horizontal plane while slowly pushing down toward the tissue plane with similar rate and tension.
RULE #3
While tying a knot, do not crush or kink the suture with surgical instruments or your hands, because this will compromise the strength of the suture. Instead, grasp the suture with needle holders only on the portion that will be cut and discarded.
Portion of suture
to be discarded.
RULE #4
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RULE #5
For sutures intended for tissue approximation, avoid creating excessive intrinsic suture tension. Minimizing suture tension will help to reduce tissue cutting, tissue ischemia, and resultant postoperative pain.
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RULE #6
The knot ears shown above are of appropriate length (approx. 3 mm)
Avoid cutting knot ears too short, particularly with suture material that has known knot security issues. If ears are left too long, however, irritation from the suture ends can create unwanted tissue inflammation.
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When tying a knot, try not to cross your hands or arms, since doing so will obstruct your line of vision. Instead, adjust your body position whenever necessary to facilitate tying toward and away from your body.
RULE #7
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RULE #8
It is important to ALWAYS setup for your knot tying the same way each and every time you attempt a manual or instrument tie. Repetition and consistency allows the surgeon to develop a “muscle memory” of the physical motions necessary to create a knot correctly.
RULE #1
RULE #2
RULE #3
RULE #4
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RULE #5
RULE #6
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RULE #7
RULE #8