© ETHICON, 1Dü 01.04, No.

62
primer
A knot-tying
Impressum
A knot-tying
Editor
ETHICON Products Germany primer
Robert-Koch-Straße 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
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

3
 Contents

1 Knots 7

1.1 Square knots, one-hand technique 8–15

1.2 Square knots, two-hand technique 16–23
1.3 Instrument knots 24–27

2 Suture techniques 29

2.1 Subcutaneous sutures 30

2.1.1 Subcutaneous suture using interrupted sutures 31
2.1.2 Subcutaneous suture using a continuous suture 31

2.2 Suture of asymmetrical wounds 32

2.2.1 Joining wound edges of different length 32
2.2.2 Closure of larger wound areas 33

2.3. Skin sutures 34

2.3.1 Vertical mattress suture according to Donati 34
and McMillen
2.3.2 Modified vertical mattress suture according 35
to Allgöwer
2.3.3 Intracutaneous suture according to Chassaignac 36
and Halsted using nonabsorbable suture material
2.3.4 Intracutaneous suture according to Chassaignac 37
and Halsted using absorbable suture material
2.3.5 Skin closure with DERMABOND 39

2.4 Ligature of blood vessels 40–41

4 5
 1. KNOTS

The knots shown on the following pages are those most

commonly used in modern surgery, and the pictures show
them from the surgeon’s angle.

The best way to practise tying initially is with a two-

coloured 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

6 7
 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 there-
fore 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 The right index finger grips the
is unavoidable, either only the left or only the right hand. 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 9
1.1 Square knots
One-hand technique
... and then pulled completely
through the white loop.
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.
10
1.1 Square knots
One-hand technique
The right hand moves its grasp
as shown. The purple end of
the thread is held between the
right thumb and index finger.
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 1.1 Square knots
One-hand technique One-hand technique

The white end of the thread is The purple end is grasped

placed over the purple end by between the right middle and
the left hand. ring finger …

The white end is passed by ... and passed under the white
the right middle finger under end of the thread …
the purple end.

12 13
1.1 Square knots 1.1 Square knots
One-hand technique 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
... and pass it under the white
end.
The purple end of the thread
is grasped by the right hand
and pulled out completely
under the white end.
18
1.2 Square knots
Two-hand technique
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 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 ...
19
1.2 Square knots 1.2 Square knots
Two-hand technique Two-hand technique

... and the left index finger With the right hand, the purple
pushes towards the right under end is pulled out under the
the white end. 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 The left thumb is pulled out
pass the purple end through under the purple and white
under the white end of the ends ...
thread.

20 21
1.2 Square knots 1.2 Square knots
Two-hand technique 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 needle holder now

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

24 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 in-
cluding the lowest point of The sutures are placed through the subcutaneous tissue as shown and
the wound, in order to then tied.
avoid formation of a cavity
after it is tied. Intact fascia
should not be punctured.
2.1.2 Subcutaneous suture using a
continuous suture

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. 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.

30 31

2.2 Suture of asymmetrical wounds
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 sub-
cutaneous and skin
sutures is possible.
Temporary sutures are
removed after closure of
the wound.
32
2.2 Suture of asymmetrical wounds
2.2.2 Closure of larger wound areas
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 Skin sutures 2.3.2 Modified vertical mattress suture

according to Allgöwer
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 subcu-

taneous 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. The Allgöwer 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.

34 35
2.3 Skin sutures 2.3 Skin sutures

2.3.3 Intracutaneous suture according 2.3.4 Intracutaneous suture according

to Chassaignac and Halsted using to Chassaignac and Halsted
nonabsorbable suture material using absorbable suture material

The suture is tied in the sub- Intracutaneous suturing gives

cutaneous area. The stitch is outstanding adaptation.
then taken back as far as the
pole of the wound, so that the
knot is buried.

With good adaptation due to subcutaneous sutures, the intracutaneous The suture is tied with the last
suture gives an outstanding cosmetic result. With non-absorbable sutures, loop and this is cut short. The
both ends of the thread are secured with a suture fixation clip. The fixation last stitch leads from the pole of
clip at the same time acts as an aid when removing the nonabsorbable the wound through the sub-
suture. cutaneous 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.

36 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 water-
proof 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 Correct placement of a
branches has a direct influence on the patency rate and thus on the long- ligature of a vessel branch.
term operative result of coronary and vascular surgery.

Wrong!

Ligature distant from the

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

Ligature too close to the Wrong!

vessel leads to gathering of
the adventitial tissue and
thus to circular narrowing of
the vessel which can lead
to turbulence and vessel
When ligating side branches, correct placement of the ligature is of great occlusion.
importance in order to prevent turbulence and thrombus formation along with
vessel stenosis and occlusion.

40 41
Notes: Notes: