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The American Journal of Surgery (2014) 208, 690-694

Surgical Education

A better way to teach knot tying: a randomized


controlled trial comparing the kinesthetic and
traditional methods
Emily Huang, M.D., M.Ed.a,*, Hueylan Chern, M.D., FACSa,
Patricia OSullivan, Ed.D.b, Brian Cook, B.S.c, Erik McDonald, B.S.c,
Barnard Palmer, M.D., M.Ed.d, Terrence Liu, M.D., FACSd,
Edward Kim, M.D., FACSa
a

Department of Surgery, University of California San Francisco, San Francisco, 513 Parnassus Avenue,
S-321, San Francisco, CA 94143-0470, USA; bDepartment of Medicine, University of California San
Francisco, San Francisco, CA, USA; cSchool of Medicine, University of California San Francisco, San
Francisco, CA, USA; dDepartment of Surgery, University of California San Francisco-East Bay,
Oakland, CA, USA

KEYWORDS:
Surgical education;
Knot tying;
Kinesthetic;
Technical;
Skill;
Basic skills

Abstract
BACKGROUND: Knot tying is a fundamental and crucial surgical skill. We developed a kinesthetic
pedagogical approach that increases precision and economy of motion by explicitly teaching suturehandling maneuvers and studied its effects on novice performance.
METHODS: Seventy-four first-year medical students were randomized to learn knot tying via either the
traditional or the novel kinesthetic method. After 1 week of independent practice, students were videotaped
performing 4 tying tasks. Three raters scored deidentified videos using a validated visual analog scale. The
groups were compared using analysis of covariance with practice knots as a covariate and visual analog scale
score (range, 0 to 100) as the dependent variable. Partial eta-square was calculated to indicate effect size.
RESULTS: Overall rater reliability was .92. The kinesthetic group scored significantly higher than
the traditional group for individual tasks and overall, controlling for practice (all P , .004). The kinesthetic overall mean was 64.15 (standard deviation 5 16.72) vs traditional 46.31 (standard deviation 5
16.20; P , .001; effect size 5 .28).
CONCLUSIONS: For novices, emphasizing kinesthetic suture handling substantively improved performance on knot tying. We believe this effect can be extrapolated to more complex surgical skills.
2014 Elsevier Inc. All rights reserved.

There were no relevant financial relationships or any sources of support in the form of grants, equipment, or drugs.
The authors declare no conflicts of interest.
This manuscript is not submitted elsewhere for publication.
Abstract presented at the Northern California Chapter of the ACS Annual Meeting in San Francisco, CA, on June 8, 2013, and won a Best Clinical
Investigation or Education Research Award. Abstract presented at the ACS Annual Clinical Congress in Washington, DC, on October 8, 2013.
* Corresponding author. Tel.: 11-609-936-0827; fax: 11-415-502-1259.
E-mail address: emily.huang2@ucsfmedctr.org
Manuscript received February 25, 2014; revised manuscript April 7, 2014
0002-9610/$ - see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjsurg.2014.05.028

E. Huang et al.

A better way to teach knot tying

Surgical knot tying is almost always the first technical


skill a surgical learner is requested to perform in the
operating room. Learners approach this moment with
excitement and trepidation, as the moment when they
transition from being observers of surgery to being
participants. For the learner (and the patient), this is also
a high-stakes event: Demonstration of competence (or
failure) both reflects on the learners capacities and affects
future participation opportunities in the operating room,
whereas the performance of the knot-tying act affects, in
however small a measure, the patients actual surgical
outcome. Optimally, preparing learners to perform basic
surgical skills such as knot tying in vivo is thus an
important goal of any basic surgical education program.1
To address this goal, programs have made significant
efforts to incorporate more basic surgical skills training into
undergraduate medical education and early residency
training,2 as well as to standardize curricular materials and
instructional pedagogies.3 Physical resource and time limitations in the form of duty-hours restrictions have also
compelled considerable changes in graduate medical education over the last decade, necessitating development of ways
to efficiently train surgical learners.4 Against the backdrop of
this complex environment, the humble surgical knot provides
a perfect focus for beginning to understand and improve the
ways in which we think about teaching surgery.
Surgical knots must be of high quality to securely bind
structures. A less obvious principle, particularly to novices,
is that knots are simply the products of a process that
must be executed with great precision and finesse. If a
surgeon avulses a blood vessel in the process of ligating it
by erratically pulling on the sutures, he has entirely
defeated the purpose of the knot. Surgical educational
materials have always emphasized the steps of the process,
showing pictures of the spatial configuration of the hands
and suture ends as a knot is formed, as well as the product,
usually highlighting the final appearance of a square knot.5
How to form these spatial configurations in an atraumatic manner is a matter of kinesthetics: finely attuned
awareness of sensory input and control of motor output
that is akin to body positioning and balance in sports.
Expert surgeons intuitively perform suture-handling maneuvers to tie knots fluidly, but novices cannot learn these
maneuvers without explicit instruction. An analysis of
novice knot-tying errors by Rogers et al6 provides vivid
illustration of this fact. They identified 4 common beginner
errors (frequency):
1.
2.
3.
4.

Too much motion in right hand (38%),


Failure to maintain consistent tension (17%),
Hands too close to knot (13%), and
Failure to cross hands (7%).

Most of these errors stem from a single root cause:


failure to obtain and then maintain a comfortable working
distance from the knot. For example, novices often hold the
suture ends too loosely and slide up on them, causing their

691
relative lengths to change. The tail end of the suture
becomes too short to easily loop into knots, which results in
fumbling, uneven tension, and the use of extra fingers to
form the loop (the 2 most frequent errors, as observed by
Rogers et al6). By teaching some key suture-handling maneuvers (gathering, sliding, and locking) and emphasizing
kinesthetic awareness, we address these root causes of error
and teach trainees to establish and maintain an ideal,
balanced position from which it is easy to tie knots
smoothly without excessive or erratic lifting, fumbling,
and dropping of suture.
The kinesthetic curriculum7 incorporates a clear and
concise practical glossary to improve communication between instructors and students and builds up on basic
suture-handling (pretying) maneuvers to show learners
not only how to tie a knot but also how to manipulate the suture to lay it down precisely. The teaching manual and
accompanying video provide step-by-step instructions with
specific attention to the relevant details of setup, technique,
and recovery. Because the method aligns with principles of
cognition for deliberate practice in the acquisition of technical skills,810 we postulated that emphasizing kinesthetic
suture handling would improve performance on knot tying,
even over a very short instructional time. Furthermore, we
believe that focusing on teaching kinesthetics in surgery
can help trainees improve technical performance even on
more advanced surgical skills. Therefore, we undertook
this study to compare novice learners instructed using traditional versus kinesthetic methods.

Methods
We recruited first-year medical students from the
University of California, San Francisco (UCSF) School of
Medicine to participate in this randomized controlled study
as part of a basic surgical skills elective. The study was
performed under an institutional review boardexempted
protocol. None of the students had any prior experience in
knot tying or other surgical skills. The individual students
were randomly assigned to 1 of the 2 groups: learning to tie
surgical knots via the traditional or kinesthetic
methods before beginning the elective.
All students attended a 2-hour knot-tying teaching session
in the Surgical Skills Center with expert faculty instructors
who had previously been identified as strong teachers. The
traditional method group was taught by faculty who had
never previously been exposed to the kinesthetic method to
avoid any potential bias, and followed teaching principles
from the American College of Surgeons Surgical Skills
Curriculum for Residents.5 The kinesthetic method group
was taught by faculty familiar with the kinesthetic method,
and followed kinesthetic teaching principles.7 Both groups
received the same amount of face-to-face instructional
time, and the average instructor to student ratio was 1:6. After the initial instructional session, students were provided
with links to instructional YouTube videos to promote

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The American Journal of Surgery, Vol 208, No 4, October 2014

Figure 1

Knot-tying tasks. Clockwise from top left: tying at surface, tying at depth, atraumatic tie, and square knot.

deliberate practice at home.11,12 Students in the traditional


method group were directed to a video using the traditional
method, whereas students in the kinesthetic method group
were directed to the video A Kinesthetic Curriculum for
Teaching Knot Tying by UCSF Surgical Skills Center.13
All students were given a package of 2-0 silk sutures for
home practice and required to save and submit at least 8 cm
of practice knots at the second session 2 weeks later, to
control for variable practice. During the second session in
the skills laboratory, students were given approximately
10 minutes to warm up and then videotaped while performing 4 tasks designed to simulate real situations in the
operating room (Fig. 1).
(1) Tying at surface: students tied 6 throws onto a Penrose drain attached to a tying board; students were allowed to throw hitches or square knots.
(2) Tying at depth: students tied 6 throws onto a hook inside a cup, designed to simulate tying in a hole in
the operating room.
(3) Atraumatic tying: students tied 6 throws onto a rubber
band looped around a regular metal spoon, with the
goal of not moving the spoon at all.
(4) Square knot: students tied 6 throws onto a Penrose
drain attached to a tying board; knots had to lie
down square.
During the assessment session, trained observers recorded knot quality (ie, the knot securely binds the tied
structure, all throws are laid down securely with no air
knots) as adequate or not adequate.
All videos were deidentified and then scored by 3 UCSF
surgical faculty raters using a visual analog scale for global
rating. Raters were blinded to the randomization, and

furthermore, none of the raters were aware of the content


of the kinesthetic curriculum to prevent bias based on any
observable characteristic maneuvers. The raters were asked
to provide a global score (0 to 100 points by placing a
marker along the visual analog scale) considering both
overall performance (poor to excellent) and their likelihood
of allowing this student to tie knots in their operating room
(unlikely to likely).
Data from the kinesthetic and traditional method groups
were analyzed in 2 ways. First, the 2 groups were compared
using t tests for each task. Second, the 2 groups were
compared using an analysis of covariance, with submitted
practice knot length as a covariate to control for practice,
and the averaged score (0 to 100) for the 3 raters as the
dependent variable. Partial eta-square was calculated to
indicate overall effect size (ES). For each task, we
compared the 2 groups using a t test and calculated the
ES using the Cohen d.14 We also compared knot quality between the 2 groups using the chi-square statistic.

Results
Seventy-four students agreed to participate and 70
completed the full study (37 in the traditional method
group and 33 in the kinesthetic method group). Using 3
raters, we had a reliable measure with an interclass
correlation coefficient of .92. Practice, as indicated by
length of knots tied, was not significantly different between
the traditional and kinesthetic method groups (31.4 cm;
SD 5 14.4 vs 28.6 cm, SD 5 12.6; P 5 .55).
The kinesthetic method group scored significantly
higher than the traditional method group on each individual

E. Huang et al.

A better way to teach knot tying

Figure 2 Postintervention performance on individual knot-tying


tasks: kinesthetic and traditional method groups.

task (Fig. 2). All P values were less than .004 and ESs,
calculated using the Cohen d were between .32 and .52
(moderate). Overall, when controlling for practice, the
kinesthetic method was more effective than the traditional
when averaging across all tasks (P , .001; Fig. 3). Overall
ES, calculated using eta-square and adjusted for practice,
was .28 (small-moderate).
Knot quality, as assessed by trained observers, was not
significantly different between the 2 groups except in the task
of tying at depth, where the kinesthetic method group
performed significantly better (79% vs 54% of students tying
adequate knots; P 5 .03). Knot quality was acceptable overall.

Comment
Novices learning to tie surgical knots via the kinesthetic method performed significantly better than their
peers. This effect was seen despite the very limited
instructional time (2 hours) and practice time (2 weeks).
We found the greatest difference between the 2 groups in
the task of tying at depth, a common scenario encountered
in the operating room. The apparatus used to simulate this
situation (a hook inside a cup) was only 1 inch deep, very

Figure 3 Mean postintervention performance across 4 knottying tasks: kinesthetic and traditional method groups.

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similar to depths trainees might encounter in basic
procedures such as an inguinal hernia repair. The kinesthetic method group performed comparatively better on
this task, both on global assessment of videotaped performance and assessment of knot quality. We postulate that
this is because tying at depth is a skill that requires
increased dexterity in handling the additional length of
suture, precisely the skill component that the kinesthetic
method emphasizes.
The kinesthetic group also performed better on tying
square knots despite having less instructional time specifically devoted to teaching square knots. During the teaching session, the kinesthetic group initially focused on
suture manipulation and practiced tying half-hitch knots.
Only after demonstration of rudimentary proficiency with
the half-hitch knot was the square knot introduced near the
end of the session. In contrast, the traditional groups
primary learning goal from the beginning was to tie square
knots. That the kinesthetic group performed better on
square knots further supports the argument that careful
suture manipulation and creation of an optimal working
distance are the fundamental underpinnings of all knot
tying.
The key elements of the kinesthetic curriculumdgathering, sliding, and lockingdare not novel. In fact, most of us,
if not all, use these very maneuvers when we tie knots in the
operating room. What is novel and effective about the
kinesthetic method, as demonstrated in this study, is that for
the first time, we present the learner with a complete and
accurate description of how surgeons tie knots.
According to the Fitts and Posner theory on skill
acquisition, during the cognitive (beginning) stage of
learning, the novice needs to understand how to perform
the task. Without this solid foundational understanding,
learners may spend more time in the associative (second)
stage, and through many hours of practice, trial, and error,
they may eventually reach the autonomous (final) stage.10
In the case of knot tying, most trainees will pick up
the skills of suture handling over months or years with
continued practice and exposure. However, given the current external pressures faced by surgical education, this
type of inefficiency in teaching is no longer an affordable
luxury if our trainees are to maximize their participation
and learning in the operating room.
A potential point of concern may be the emphasis placed
on teaching the half-hitch knot, also known as a slip knot.
Effective instruction in every technical discipline from
sports to music follows a logical progression from simple to
complex tasks. The half hitch is a simple knot that requires
one to alternate only the orientation of the loop with each
knot. This allows learners to hone their skills of suture
manipulation and rotation of the wrist to form knots. The
square knot has an added layer of complexity because it
requires one to orient the sutures in a specific sequence and
to pull them in equal and opposite directions. As the results
of our study show, learners who follow a progression from
half-hitch knot to square knot fare better than those who

694
start with the more difficult square knot, which often leads
to cognitive overload.
One could also make the contention that the gathering
maneuver is important for tying at depth, a more advanced skill,
and that its omission from introductory traditional knot-tying
curriculum is appropriate. However gathering is necessary
for much more than just tying at depth, it is also essential for
controlling relative suture lengths and creating optimal working
distances. We should also distinguish tying in a truly deep
space, such as the pelvis, from tying in a shallow cavity. The
latter is a skill required even for novices. Our apparatus for
tying at depth replicated typical depths seen in basic procedures. Even at a depth of an inch, gathering was necessary.
The last obvious limitation of this study is the short
duration of instruction and limited assessment of learners.
Long-term retention of skills and degree of transfer into the
actual operating room are unproven. The full impact of the
kinesthetic method as part of a longitudinal curriculum
remains to be demonstrated. However, we believe that the
effect seen here would likely be enhanced by deliberate
practice over a longer period of time.
In the context of the bigger picture of surgical education,
our experience with teaching surgical knot tying has prompted
us to focus on the details of how we teach and to be aware of
the unconscious competence that characterizes the expert
blind spot.15 Although many tasks may simply require repetitive practice and exposure, there may be opportunities for significant improvement in the quality of instruction through a
more careful analysis of the key steps and guiding principles.

Acknowledgment
The authors would like to acknowledge and thank Wendy
Fong, Operations Manager at the UCSF Surgical Skills
Center, for her technical assistance in conducting this study.

The American Journal of Surgery, Vol 208, No 4, October 2014

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