ETHICON, 1D 01.04, No.

62

A knot-tying
primer

Impressum
Editor
ETHICON Products Germany
Robert-Koch-Strae 1
22851 Norderstedt
Consultant
Priv.-Doz. Dr. med. Friedrich-Christian Riess
Cardiac Surgery
Albertinen-Krankenhaus Hamburg
Concept & Design
RIESSmedien, Norderstedt
Communication for medicine,
science and technology
Photographs and art design
Andreas Riess

A knot-tying
primer

Foreword
With this new revised edition of our Knot-tying primer,
Ethicon would like to give those studying and commencing
their career in medicine instructions to assist them in
learning the most important knots and suturing techniques
of modern surgical practice.
We have limited ourselves quite deliberately to those
techniques which are helpful for those at the start of their
career to master. Further techniques, which the surgeon
learns in the course of his professional practice, are not the
subject of this publication.
We hope that our information brochure is of use to you and
wish you every success in your professional practice.
Norderstedt, April 2003

Contents

Knots

1.1
1.2
1.3

Square knots, one-hand technique

Square knots, two-hand technique
Instrument knots

Suture techniques

29

2.1
2.1.1
2.1.2

Subcutaneous sutures
Subcutaneous suture using interrupted sutures
Subcutaneous suture using a continuous suture

30
31
31

2.2
2.2.1
2.2.2

Suture of asymmetrical wounds

Joining wound edges of different length
Closure of larger wound areas

32
32
33

2.3.
2.3.1

34
34

2.3.5

Skin sutures
Vertical mattress suture according to Donati
and McMillen
Modified vertical mattress suture according
to Allgwer
Intracutaneous suture according to Chassaignac
and Halsted using nonabsorbable suture material
Intracutaneous suture according to Chassaignac
and Halsted using absorbable suture material
Skin closure with DERMABOND

2.4

Ligature of blood vessels

2.3.2
2.3.3
2.3.4

7
815
1623
2427

35
36
37
39
4041

1. KNOTS
The knots shown on the following pages are those most
commonly used in modern surgery, and the pictures show
them from the surgeons angle.
The best way to practise tying initially is with a twocoloured string, at first always holding the coloured end in
the right hand. Later practice blind and then with surgical
gloves and surgical suture materials in different sizes. That
way you can get a feeling of how many throws in opposing
directions are needed with each suture material in order to
obtain a secure knot

1.1 Square knots

One-hand technique

1.1 Square knots

One-hand technique
Experience has shown that the square knot is one of the best and is therefore generally recommended. Whenever possible, it is tied with both hands
in order to achieve with a few throws in genuinely opposite directions a
knot that does not slip. In certain situations, however, use of only one hand
is unavoidable, either only the left or only the right hand.

The right index finger grips the

white end and pulls it through
under the purple end.

By turning the right hand

inwards and extending the
right index finger, the purple
end is pushed through the
white loop ...

The purple end of the thread is held between the thumb and middle finger
of the right hand, while the raised and extended index finger of the right
hand acts as a bridge. The white end of the thread is held between the
thumb and index finger of the left hand.
8

1.1 Square knots

One-hand technique

1.1 Square knots

One-hand technique

10

... and then pulled completely

through the white loop.

The right hand moves its grasp

as shown. The purple end of
the thread is held between the
right thumb and index finger.

The first stage of this knot is

completed by pulling both
ends of the thread vertically.
The right hand points towards
the surgeon and the left hand
away from the surgeon.

The right hand grasping the

purple end of the thread is
turned so that the palm of the
hand is showing towards the
surgeon.

11

1.1 Square knots

One-hand technique

1.1 Square knots

One-hand technique

12

The white end of the thread is

placed over the purple end by
the left hand.

The purple end is grasped

between the right middle and
ring finger

The white end is passed by

the right middle finger under
the purple end.

... and passed under the white

end of the thread

13

1.1 Square knots

One-hand technique

1.1 Square knots

One-hand technique

Square knot, overview of one-hand technique

... and pulled through fully.

The knot is completed by

pulling both ends of the thread
vertically. The left hand points
towards the surgeon and the
right hand away from the
surgeon.

14

15

1.2 Square knots

Two-hand technique

1.2 Square knots

Two-hand technique

Simplest and best knot, if circumstances permit.

Left index finger and thumb

move to the left and pass
under the white end of the
thread.

Left index finger and thumb

grasp the purple end ...

The white end of the thread is placed over the extended index finger of the
left hand, which acts as a bridge. The thread is held with the left hand. The
purple end of the thread which is held in the right hand, is passed between
thumb and index finger of the left hand.

16

17

1.2 Square knots

Two-hand technique

1.2 Square knots

Two-hand technique

... and pass it under the white

end.

The first stage of this knot is

completed by pulling both
ends of the thread vertically.
The left hand points towards
the surgeon and the right hand
away from the surgeon.

The purple end of the thread

is grasped by the right hand
and pulled out completely
under the white end.

The white end of the thread is

held by the left hand, with the
white end passed around the
extended thumb.
The left index finger grasps the
purple end ...

18

19

1.2 Square knots

Two-hand technique

1.2 Square knots

Two-hand technique

... and the left index finger

pushes towards the right under
the white end.

With the right hand, the purple

end is pulled out under the
white end.

The purple end is placed by

the right hand between left
index finger and thumb, which
grasp it.

Left index finger and thumb

pass the purple end through
under the white end of the
thread.

20

The left thumb is pulled out

under the purple and white
ends ...

21

1.2 Square knots

Two-hand technique

1.2 Square knots

Two-hand technique

Overview of square knot, two-hand technique

... and the knot is completed by pulling both ends of the thread vertically.
The left hand points away from the surgeon and the right hand towards the
surgeon.

22

23

1.3 Instrument knots

1.3 Instrument knots

A knot tied with the aid of instruments is appropriate in cases where one or
both ends of the thread are short or, for instance, to save on suture material
in the case of interrupted sutures. It is important to ensure that sharp edges
are avoided, especially in the jaws of the instrument employed, as they lead
to damage to the surface structure of the thread.

The needle holder grasps the

short purple end and pulls it
through the two white loops
towards the surgeon.

The first half of the knot is

completed by pulling the
needle holder towards the
surgeon and the white end of
the thread away from the
surgeon.

The short purple end of the thread is free, while the long white end is held
between index finger and thumb of the left hand. The first two loops are
made by placing the thread around the needle holder.

24

The needle holder now

releases the purple end of
the thread.

25

1.3 Instrument knots

1.3 Instrument knots

Overview of instrument knots

A further loop is placed with

the white end of the thread
around the needle holder,
which approaches from above,
and then the purple end is
grasped with the needle holder.

The knot is completed by

pulling the purple end away
from the surgeon and the white
end of the thread towards the
surgeon. The white end can
also be held by an instrument
instead of the left hand at
every stage.

26

27

2. SUTURE
TECHNIQUES
The most important suture techniques for closing
subcutaneous tissue and skin are described below.

28

29

2.1 Subcutaneous sutures

2.1 Subcutaneous sutures

2.1.1

Subcutaneous suture using interrupted

sutures

Subcutaneous sutures are used to join the subcutaneous tissue. Absorbable

suture materials (e.g. VICRYL, VICRYL RAPID or MONOCRYL) are usually
employed for these sutures.

The subcutaneous suture

is placed as shown including the lowest point of
the wound, in order to
avoid formation of a cavity
after it is tied. Intact fascia
should not be punctured.

The suture is tied loosely.

The subcutaneous sutures
should be tightened only
enough to prevent the
formation of cavities in the
subcutaneous fat and on
the other hand to avoid
disorders of perfusion.

30

The sutures are placed through the subcutaneous tissue as shown and
then tied.

2.1.2 Subcutaneous suture using a

continuous suture

With the continuous subcutaneous suture, the path of the thread

through the tissue is identical with the subcutaneous suture using
interrupted sutures. The continuous subcutaneous suture is the faster
method compared to the interrupted suture technique.
31

2.2 Suture of asymmetrical wounds

2.2 Suture of asymmetrical wounds

2.2.2 Closure of larger wound areas

In surgical practice, wounds with margins of different length or wounds with

defects of skin substance require special wound closure techniques.

2.2.1 Joining wound edges of different length

With wound edges of

different length, it is helpful
to divide the overall length
into several smaller
sections by one or more
temporary sutures.
This can be done with
interrupted mattress
sutures, for instance.

After tying the temporary

suture, tension-free
closure by means of subcutaneous and skin
sutures is possible.
Temporary sutures are
removed after closure of
the wound.

32

When there is a skin

defect, a mattress suture
that picks up only the
subcutaneous parts of
the lappets can shift
the wound edges so that
tension-free wound
closure can take place.

After tying the mattress

suture, the subcutaneous
and skin closure takes
place. The mattress suture
used for adaptation can
be left, as it is of advantage
for the perfusion of the
skin lappets that only the
subcutaneous tissue is
punctured.

33

2.3 Skin sutures

2.3.2 Modified vertical mattress suture

according to Allgwer

2.3 Skin sutures

The importance attached by the patient to the cosmetic result after an
operative procedure must not be underestimated. Besides a step-free
approximation of the wound edges through appropriate subcutaneous
sutures, the technique for skin closure has a crucial influence on the
cosmetic result. The needle should pass vertically through the skin, as
resistance is least so that the needle characteristics can be exploited
optimally.

2.3.1 Vertical mattress suture according to

Donati and McMillen

When the subcutaneous fat layer is

thin, both skin and
subcutaneous tissue
are closed as shown.
The suture should
be placed in such a
way that a cavity is
avoided. With good
adaptation, a very
good cosmetic result
is obtained.

34

The Allgwer mattress suture differs from the Donati and McMillen mattress
suture only in the fact that the thread does not penetrate the surface of the
skin on the contralateral side.

35

2.3 Skin sutures

2.3 Skin sutures

2.3.3 Intracutaneous suture according

to Chassaignac and Halsted using
nonabsorbable suture material

With good adaptation due to subcutaneous sutures, the intracutaneous

suture gives an outstanding cosmetic result. With non-absorbable sutures,
both ends of the thread are secured with a suture fixation clip. The fixation
clip at the same time acts as an aid when removing the nonabsorbable
suture.

36

2.3.4 Intracutaneous suture according

to Chassaignac and Halsted
using absorbable suture material

The suture is tied in the subcutaneous area. The stitch is

then taken back as far as the
pole of the wound, so that the
knot is buried.

Intracutaneous suturing gives

outstanding adaptation.

The suture is tied with the last

loop and this is cut short. The
last stitch leads from the pole of
the wound through the subcutaneous tissue back to the
surface of the skin.

By tautening the end of the

thread, the knot is buried in the
wound pole. Finally, the suture
is cut at skin level.

37

2.3 Skin sutures

2.3.5 Skin closure with DERMABOND

For skin closure there are now modern adhesives available (2-Octyl
Cyanoacrylate). With good adaptation an outstanding cosmetic result can
be obtained. The stress of surgical wound care can be greatly reduced by
this method, especially in children.

DERMABOND

Exact adaptation of the skin surface by manual approximation of both

wound edges between the thumb and index finger is important for a good
result. The adhesive is applied in several layers and forms a stable waterproof wound closure.

38

39

2.4 Ligature of blood vessels

2.4 Ligature of blood vessels

To ligate a side branch of a blood vessel securely, the ligature is secured by
taking the surface of the adventitia on both sides of the origin of the vessel,
so that the ligature is prevented from slipping off. For example, when
ligating the branches of the great saphenous vein, which is used as bypass
material in coronary and vascular surgery, the correct ligature of the
branches has a direct influence on the patency rate and thus on the longterm operative result of coronary and vascular surgery.

Correct placement of a
ligature of a vessel branch.

Wrong!

Ligature distant from the

vessel leads to turbulence
and thrombus formation in the
residual stump.

When ligating side branches, correct placement of the ligature is of great

importance in order to prevent turbulence and thrombus formation along with
vessel stenosis and occlusion.

40

Ligature too close to the

vessel leads to gathering of
the adventitial tissue and
thus to circular narrowing of
the vessel which can lead
to turbulence and vessel
occlusion.

Wrong!

41

Notes:

Notes: