Surgical Knots: History, Types, Techniques & Videos

From Surgery Encyclopedia


Surgical knots are a way of securely tying sutures over a specific tissue or while ligating blood vessels. Various knotting types and techniques are used in surgical practice and they form an important aspect of basic surgical skillset for a surgeon.

History

Sutures are best made of soft thread, not too hard twisted that it may sit easier on the tissue, nor are too few nor too many of either of them to be put in.                                 Aurelius Cornelius Celsus, 25BC–AD50

Surgical Knots
Surgical Knots

In the first century of our common era, the Greek physician Heraklas wrote a brief essay on how to tie 16 knots and nooses for surgical and orthopedic purposes. It was found that seven of Heraklas' 16 knots and nooses were still applied surgically of late, and that four of these have even been recently rediscovered for such applications. [1] In 1000bc, Indian surgeons were using horsehair, cotton and leather sutures on the other hand, in Roman times, linen and silk and metal clips, called fibulae. At the end of nineteenth century, textile industry provided major advancement, and both silk and catgut became popular as suture Materials. Lister said that catgut soaked in chromic acid (a form of tanning) prevented early dissolution in body fluids and tissue, while Moynihan felt that chromic catgut was ideal as it could be sterilized, was non-irritant to tissues, kept its strength until its work was done and then disappeared. However, catgut is no longer use as it causes an inflammatory cellular reaction with release of protease and may carry the risk of prion transmission if of bovine origin. [2]

Types of Surgical Knots

  1. SQUARE KNOT / REEF KNOT
  2. GRANNY’S KNOT / SLIP KNOT
  3. SURGEON’S KNOT
  4. ONE-HANDED KNOT
  5. TWO-HANDED KNOT
  6. TARUN TECHNIQUE
  7. ABERDEEN’S KNOT / COBBLER’S KNOT

REEF KNOT/SQUARE KNOT

Technique

  1. Hold the Short End between thumb and ring finger with index finger and middle finger straight and keep the right hand in supine position. Hold the Long End between thumb and ring finger with index finder and middle finger straight and keep the left hand in supine position. Make sure to keep short end above and long end below for this technique.
    Square/ Reef Knot
    Square/ Reef Knot [9]
  2. Pull the Long End for tension and bring the short end onto the long end with right hand’s index finger and middle finger and make ‘Figure Of 4’. Here holding the suture junction with left hand is crucial.
  3. Cross the remaining suture of the short end from the loop with the help of right hand’s index and middle finger and the knot to the base of the wound with the help of index figure or thumb. Cross the long end away from you and tighten up the first throw.
  4. Hold the short end with your right hand’s index finger and thumb with sutures lying beneath your pronated right hand’s remaining three fingers and rotate your right hand from inside out at 180 degrees. Bring the long end towards you and put it on you right hand’s remaining three fingers next to short end and make a ‘V’ and hold the suture junction towards you with left hand. Making ‘V’ is important because you can hold suture toward you and space between sutures away from you will give you room for making a loop.
  5. Now pull the long end with your Right hand’s middle finger and hold your short end between middle and ring finger and take the short end from the loop.
  6. Now hold both the ends and cross short end away from you and tighten up the second throw. Voila here is your REEF knot.

Video 1: Reef Knot - Basic Surgical Skills by Prof. Chintamani [3]

Granny Knot

Technique

  1. Hold the Short End between thumb and ring finger with index finger and middle finger straight and keep the right hand in supine position. Hold the Long End between thumb and ring finger with index finder and middle finger straight and keep the left hand in supine position. Make sure to keep short end above and long end below for this technique.
    Granny Knot
    Granny Knot[10]
  2. Pull the Long End for tension and bring the short end onto the long end with right hand’s index finger and middle finger and make ‘Figure Of 4’. Here holding the suture junction with left hand is crucial.
  3. Cross the remaining suture of the short end from the loop with the help of right hand’s index and middle finger and the knot to the base of the wound with the help of index figure or thumb. Cross the long end away from you and tighten up the first throw.
  4. Hold the short end with your right hand’s index finger and thumb with sutures lying beneath your pronated right hand’s remaining three fingers and rotate your right hand from inside out at 180 degrees. Bring the long end towards you and put it on you right hand’s remaining three fingers next to short end and make a ‘V’ and hold the suture junction towards you with left hand. Making ‘V’ is important because you can hold suture toward you and space between sutures away from you will give you room for making a loop.
  5. Again, hold the long end with right hand’s index finger and middle finger and short end with left hand’s index and middle finger.
  6. Keep the short end below the long end
  7. Cross the suture of the short end into the loop from beneath with the help of right hand’s index and middle finger and cross the long end with the help of left hand’s middle and index finger and tighten up the second throw. Here’s your granny knot.

Video 2: Granny Knot[11]

Surgeon's Knot

Technique

  1. Hold the Short End between thumb and ring finger with index finger and middle finger straight and keep the right hand in supine position. Hold the Long End between thumb and ring finger with index finder and middle finger straight and keep the left hand in supine position. Make sure to keep short end above and long end below for this technique.
    Surgeon's Knot
    Surgeon's Knot[12]
  2. Pull the Long End for tension and bring the short end onto the long end with right hand’s index finger and middle finger and make ‘Figure Of 4’. Here holding the suture junction with left hand is crucial.
  3. Cross the remaining suture of the short end from the loop TWICE with the help of right hand’s index and middle finger and the knot to the base of the wound with the help of index figure or thumb. Cross the long end away from you and tighten up the first 2 throws.
  4. Hold the short end with your right hand’s index finger and thumb with sutures lying beneath your pronated right hand’s remaining three fingers and rotate your right hand from inside out at 180 degrees. Bring the long end towards you and put it on you right hand’s remaining three fingers next to short end and make a ‘V’ and hold the suture junction towards you with left hand. Making ‘V’ is important because you can hold suture toward you and space between sutures away from you will give you room for making a loop.
  5. Now pull the long end with your Right hand’s middle finger and hold your short end between middle and ring finger and take the short end from the loop.
  6. Now hold both the ends and cross short end away from you and tighten up the second throw. Voila here is your Surgeon’s knot.

Video 3: Surgeon's Knot by Prof. Chintamani [4]

Two-Handed Reef/ Square Knot

Technique

  1. Hold Long End with left Hand’s index finger suture winding from outside to inside and keep it tight and steady with rest fingers. Keep long end above and short end below.
  2. Hold Short End and wind it around Left Hand’s index finger from inside to outside where long end is kept and hold the loop between left hand’s index finger and thumb.
  3. Move the pinched index finger and thumb to the opposite side of the loop, grab the free short end suture and move back to from the loop. Hold free short end with your right hand and cross it away from you while tightening throw from your index finger or thumb.
  4. Hold the long end with right hand and slid the right thumb from outside of the stretched suture and hold the suture over your thumb’s dorsal surface. Put the short end with right index finger and thumb over left thumb next to long end and pinch the index finger and thumb to hold the both ends in the loop.
  5. Move the Left-hand index finger and thumb pinch from outside to inside and grab the free short end, move it back outside the loop. Hold the short end with right hand, move the throw with index finger towards base and tighten up the knot.
Two Handed Reef Knot
Two Handed Reef Knot [13]
Two Handed Reef Knot
Two Handed Reef Knot

Video 4: How to Tie Surgical Knots: One-Handed, Two-Handed Suture Tying, Instrument Ties (1/4)[5]

One-Handed Reef/ Square Knot

Technique

  1. Hold long end above and short end below.
  2. Hold the short end with your right hand’s index finger and thumb with sutures lying beneath your pronated right hand’s remaining three fingers and rotate your right hand from inside out at 180 degrees. Bring the long end towards you and put it on you right hand’s remaining three fingers next to short end and make a ‘V’ and hold the suture junction towards you with left hand. Making ‘V’ is important because you can hold suture toward you and space between sutures away from you will give you room for making a loop. Now pull the long end with your Right hand’s middle finger and hold your short end between middle and ring finger and take the short end from the loop.
  3. Now hold both the ends and cross short end away from you and tighten up the first throw
  4. Hold Short End and wind it around right hand’s index finger from outside to inside and put the long end winding inside to outside over right hand’s index finger next to short end.
  5. Now take the free short end from the loop with the help of left index finger. Move the knot to the base with the help of left index finger and tighten up the knot.

Video 5: How to Tie Surgical Knots: One-Handed, Two-Handed Suture Tying, Instrument Ties [2/4] [6]

Tarun Technique

Technique

  1. Hold the long end above and short end below.
  2. Hold the short end with your right hand’s index finger and thumb with sutures lying beneath your pronated right hand’s remaining three fingers and rotate your right hand from inside out at 180 degrees. Bring the long end towards you and put it on you right hand’s remaining three fingers next to short end. Now pull the long end with your Right hand’s middle finger on the top and pull the short end with Left index figure at the same time.
  3. Now pull the both strand short end away and long end towards you and tighten up the 2 throws.

Video 6: How to Tie Surgical Knots: One-Handed, Two-Handed Suture Tying, Instrument Ties [4/4] [7]

Aberdeen Knot/ Cobbler's Knot

Technique

Aberdeen Knot
Aberdeen Knot[14]
  1. At the finishing end of the subcuticular suturing take the bite with needle from opposite side horizontally to the skin and take out the needle part from the finishing end.
  2. Make a loop between last bite and make sure the loop is not twisted. Hold the loop between right index finger and thumb.
  3. Now hold the suture end with needle tight and pull that suture end with the help of middle finger. Now leave the suture from right index finger and thumb and pull the free suture and with right ring finger as the same time and make another loop. Do not leave the suture from left hand.
  4. Repeat these steps and make minimum 6 throws but ideally 10 throws are preferable.
  5. At the end pull through needle ended suture from the loop and tighten it up.
  6. Now take a bite from needle from inside and get the needle out from the skin so that whole 6-10 throw burry inside and become upside down.
  7. Cut the remaining suture just from the skin and here is your Aberdeen knot.

Video 7: SUTURE Tutorial: Subcuticular Continuous Suture with Aberdeen Knot - HD Demo! [8]

Authors

Dr Shreyans Patel
Dr Shreyans Patel

Dr. Shreyans Patel

General Surgery Resident at Santosh Medical College and Hospital, Ghaziabad

  • Studied M.B.B.S at GMERS Medical College, Valsad from Veer Narmad South Gujarat University
  • Former internship at GMERS Medical College, Valsad
  • Former Orthopedic Junior Resident at Valsad Civil Hospital
  • Carried out PSBH project entitled “Occupational hazards and perception of safety measures among construction workers- A cross sectional study.”

Dr. Mansi Dahiya

Dr Mansi Dahiya
Dr Mansi Dahiya

General Surgery Resident at Santosh Medical College and Hospital, Ghaziabad

  • Studied M.B.B.S at Santosh Medical college, Ghaziabad
  • Former internship at santosh Hospital, Ghaziabad
  • Former Obstetrics and Gynaecology Junior Resident at Jag Pravesh Chandra Hospital



References

[1]          J. Hage, "Heraklas on Knots: Sixteen Surgical Nooses and Knots from the First Century A.D.," World Journal Of Surgery.

[2]          N. Williams, P. R. O'Connell and A. McCaskie, Bailey & Love's Short Practice of Surgery, 27th Edition : the Collector's edition, 2018.

[3]          S. b. P. Chintamani, "youtube.com," [Online]. Available: https://www.youtube.com/watch?v=R3QztUpW_9w&list=PLZJap2TJGZND09HLtuwxfR75moMVkJhup&index=4.

[4]          S. b. P. Chintamani, "youtube.com," [Online]. Available: https://www.youtube.com/watch?v=I1Uht-Gyyqc&list=PLZJap2TJGZND09HLtuwxfR75moMVkJhup&index=1.

[5]          M. S. Insiders, "youtube.com," [Online]. Available: https://youtu.be/AKhDa5fcGgI.

[6]          M. S. Insider, "youtube.com," [Online]. Available: https://youtu.be/pDUX64waHQg.

[7]          M. S. Insider, "Youtube.com," [Online]. Available: https://youtu.be/cpxWpH7xbBU.

[8]          MiniMedLessons, "youtube.com," [Online]. Available: https://youtu.be/M3vISruyFkI.

[9]          “How To Tie A Square Knot - Make A Reef Knot Clipart - Full Size Clipart (#1038663) - PinClipart.” https://www.pinclipart.com/maxpin/TohTii/ (accessed Mar. 19, 2022).

[10]        “Type of Nautical or Marine Node Granny Knot for Rope with a Loop. Stock Vector - Illustration of granny, curve: 147086668.” https://www.dreamstime.com/type-nautical-marine-node-granny-knot-rope-loop-isolated-vector-sea-illustration-white-background-image147086668 (accessed Mar. 20, 2022).

[11]        “(32) Surgical Knots: Granny’s Knot - YouTube.” https://www.youtube.com/watch?v=CnBdM9B8eao (accessed Mar. 20, 2022).

[12]        “Creating a Leak-Proof Ligature with Confidence, Part 1: Overview of Ligation & Surgical Binding Knots - Today’s Veterinary Practice.” https://todaysveterinarypractice.com/creating-a-leak-proof-ligature-with-confidence-part-1-overview-of-ligation-surgical-binding-knots/ (accessed Mar. 19, 2022).

[13]        “(20) Dr. Johnny Stewart. MD , FRCSC / RMC, CAF on Twitter: ‘“Technique for tying two-handed square knot!!” #SoMe4IQLatAm #SoMe4Surgery https://t.co/y0mPqwKjmt’ / Twitter.” https://twitter.com/DrJonnys/status/1285693293515411457/photo/1 (accessed Mar. 19, 2022).

[14]        O. Schaaf, M. Glyde, and R. E. Day, “A secure Aberdeen knot: In vitro assessment of knot security in plasma and fat,” J. Small Anim. Pract., vol. 50, no. 8, pp. 415–421, Aug. 2009, doi: 10.1111/j.1748-5827.2009.00771.x.