569077
research-article2015
SRIXXX10.1177/1553350615569077Surgical InnovationYeşiloğlu et al
Letter to the Editor
An Easy Method to Secure Knots in Tissues Under Tension: Sliding the Knots by Pulling the Long Rope
Surgical Innovation 2015, Vol. 22(4) 444–445 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1553350615569077 sri.sagepub.com
Nebil Yeşiloğlu, MD1, Tahsin Görgülü, MD2, Hakan Şirinoğlu, MD1, and Gürsel Turgut, MD3 Dear Sir, Primary repair of tissues that are under tension is usually achieved by another assistant to hold the first knot, called surgeons’ knot, in position by using another needle holder or approximation of wound edges by the assistant. However, holding the knot with an instrument may deform the suture material, making it breakable during the knot tying process. The authors used a simple method based on sliding the knots like beads deep to the base of suturation (available as Video 1). The first stage of the technique is to make a loose double loop called “surgeons’ knot,” which is followed by second and third single loops that are also not tightened. The second stage includes sliding of the knots deep to the base by pulling the long side of the rope that is at the left hand for right sided surgeons while the short end of the rope is fixed by the needle holder without any tension. Therefore, the right hand only fixes the short rope in position not to escape from the loop. Enough tensile force on the long rope will push the knots deep to the base. At the third stage right after the slide of the knots, the tension of the short rope is increased by the needle holder in order to tighten the suture. Although this method is mainly used for the primary closure of tissues under tension by the authors, it is also useful especially in deep cavity soft tissue suturation such as cleft palate surgery and nasal septal suturation. Approximation of both ends of the nerves and vessels, which are slightly under tension, may be accomplished by the same maneuver if there is no need for nerve or vessel graft or suture approximation does not affect the functional results of nerve repair or blood flow in the anastomosed vessel. Several techniques have been reported to secure the loosened knots without the help of an assistant. Some of them are based on the knots that are used for nonmedical purposes like Aberdeen knot, which has been shown to be stronger than surgeons’ knot.1,2 Also, Davis and Tisdale reviewed 3 methods to secure the knots and suggested a novel fourth method called “tension transfer stich,” which is based on a constant tension on both ends of the rope, which should stabilize the first knot in its position and
transfers the tension from one rope to the other during the tying procedure.3 However, in our method, stabilizing the first knot in its position is not necessary and the method is especially used for tightening the loosened first knots. At the beginning all the 3 knots are loose and they are all slid and stabilized at the base of the suturation by pulling the long rope first and tightened by pulling the short rope at the end. Another method that may be used to secure the knot is making 3 loops when tying the surgeons’ knot rather than 2 knots and then tying the single knots.4 The authors of this study also used this method effectively in many cases but tying one more loop increases the mass of the knot and it seems that it does not fit the second and third knots well especially when braided sutures are used. As it provides a reliable adaptation of the knot to the base of suturation, our method may help surgeons work without assistance during the knot-tying process in tissues under tension. Author Contributions Nebil Yeşiloğlu: Study design, description of the technique, article writing Tahsin Görgülü: Article writing, review of the syntax Hakan Şirinoğlu: Video editing, review of artwork Gürsel Turgut: Critical review of the text, article writing
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
1
Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey 2 Bülent Ecevit University School of Medicine, Zonguldak, Turkey 3 İstanbul Cerrahi Hospital, Istanbul, Turkey Corresponding Author: Nebil Yeşiloğlu, Department of Plastic Reconstructive and Aesthetic Surgery, Dr. Lütfi Kırdar Kartal Training and Research Hospital, Acıbadem Mh, Gömeç Sk, Sabancı-1 Sitesi 8/16, Kadıköy, İstanbul 34718, Turkey. Email: [email protected]
Downloaded from sri.sagepub.com at DEAKIN UNIV LIBRARY on November 12, 2015
445
Yeşiloğlu et al Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Lovett PB, Flaxman A, Stürmann KM, Bijur P. The insecure airway: a comparison of knots and commercial devices for securing endotracheal tubes. BMC Emerg Med. 2006;6:7.
2. Stott PM, Ripley LG, Lavelle MA. The ultimate Aberdeen knot. Ann R Coll Surg Engl. 2007;89:713-717. 3. Davis DA, Tisdale GG. 1, 2, 3, 4: four techniques to secure buried knots. Dermatol Surg. 2002;28:588-589. 4. Rothfuss M, Schilling M, Breuninger H. Early excision of congenital melanocytic nevi under tumescent anesthesia and skin expansion by intracutaneous double butterfly sutures. J Dtsch Dermatol Ges. 2009;7:427-433.
Downloaded from sri.sagepub.com at DEAKIN UNIV LIBRARY on November 12, 2015
research-article2015
SRIXXX10.1177/1553350615569077Surgical InnovationYeşiloğlu et al
Letter to the Editor
An Easy Method to Secure Knots in Tissues Under Tension: Sliding the Knots by Pulling the Long Rope
Surgical Innovation 2015, Vol. 22(4) 444–445 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1553350615569077 sri.sagepub.com
Nebil Yeşiloğlu, MD1, Tahsin Görgülü, MD2, Hakan Şirinoğlu, MD1, and Gürsel Turgut, MD3 Dear Sir, Primary repair of tissues that are under tension is usually achieved by another assistant to hold the first knot, called surgeons’ knot, in position by using another needle holder or approximation of wound edges by the assistant. However, holding the knot with an instrument may deform the suture material, making it breakable during the knot tying process. The authors used a simple method based on sliding the knots like beads deep to the base of suturation (available as Video 1). The first stage of the technique is to make a loose double loop called “surgeons’ knot,” which is followed by second and third single loops that are also not tightened. The second stage includes sliding of the knots deep to the base by pulling the long side of the rope that is at the left hand for right sided surgeons while the short end of the rope is fixed by the needle holder without any tension. Therefore, the right hand only fixes the short rope in position not to escape from the loop. Enough tensile force on the long rope will push the knots deep to the base. At the third stage right after the slide of the knots, the tension of the short rope is increased by the needle holder in order to tighten the suture. Although this method is mainly used for the primary closure of tissues under tension by the authors, it is also useful especially in deep cavity soft tissue suturation such as cleft palate surgery and nasal septal suturation. Approximation of both ends of the nerves and vessels, which are slightly under tension, may be accomplished by the same maneuver if there is no need for nerve or vessel graft or suture approximation does not affect the functional results of nerve repair or blood flow in the anastomosed vessel. Several techniques have been reported to secure the loosened knots without the help of an assistant. Some of them are based on the knots that are used for nonmedical purposes like Aberdeen knot, which has been shown to be stronger than surgeons’ knot.1,2 Also, Davis and Tisdale reviewed 3 methods to secure the knots and suggested a novel fourth method called “tension transfer stich,” which is based on a constant tension on both ends of the rope, which should stabilize the first knot in its position and
transfers the tension from one rope to the other during the tying procedure.3 However, in our method, stabilizing the first knot in its position is not necessary and the method is especially used for tightening the loosened first knots. At the beginning all the 3 knots are loose and they are all slid and stabilized at the base of the suturation by pulling the long rope first and tightened by pulling the short rope at the end. Another method that may be used to secure the knot is making 3 loops when tying the surgeons’ knot rather than 2 knots and then tying the single knots.4 The authors of this study also used this method effectively in many cases but tying one more loop increases the mass of the knot and it seems that it does not fit the second and third knots well especially when braided sutures are used. As it provides a reliable adaptation of the knot to the base of suturation, our method may help surgeons work without assistance during the knot-tying process in tissues under tension. Author Contributions Nebil Yeşiloğlu: Study design, description of the technique, article writing Tahsin Görgülü: Article writing, review of the syntax Hakan Şirinoğlu: Video editing, review of artwork Gürsel Turgut: Critical review of the text, article writing
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
1
Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey 2 Bülent Ecevit University School of Medicine, Zonguldak, Turkey 3 İstanbul Cerrahi Hospital, Istanbul, Turkey Corresponding Author: Nebil Yeşiloğlu, Department of Plastic Reconstructive and Aesthetic Surgery, Dr. Lütfi Kırdar Kartal Training and Research Hospital, Acıbadem Mh, Gömeç Sk, Sabancı-1 Sitesi 8/16, Kadıköy, İstanbul 34718, Turkey. Email: [email protected]
Downloaded from sri.sagepub.com at DEAKIN UNIV LIBRARY on November 12, 2015
445
Yeşiloğlu et al Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Lovett PB, Flaxman A, Stürmann KM, Bijur P. The insecure airway: a comparison of knots and commercial devices for securing endotracheal tubes. BMC Emerg Med. 2006;6:7.
2. Stott PM, Ripley LG, Lavelle MA. The ultimate Aberdeen knot. Ann R Coll Surg Engl. 2007;89:713-717. 3. Davis DA, Tisdale GG. 1, 2, 3, 4: four techniques to secure buried knots. Dermatol Surg. 2002;28:588-589. 4. Rothfuss M, Schilling M, Breuninger H. Early excision of congenital melanocytic nevi under tumescent anesthesia and skin expansion by intracutaneous double butterfly sutures. J Dtsch Dermatol Ges. 2009;7:427-433.
Downloaded from sri.sagepub.com at DEAKIN UNIV LIBRARY on November 12, 2015
