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Knotting in surgical operations

Jul. 04, 2019

Knotting is a very important technique in surgical operations and is one of the most basic operations. It runs through the entire surgical basic operation. Whether the ligation is firm and reliable is related to the correctness of the knotting method. Firm and reliable ligation depends on skilled and correct knotting techniques. The speed and quality of knotting are not only related to the length of the operation, but also affect the quality of the entire operation and the prognosis of the patient, and even the life safety of the patient. A low-quality knot or an incorrect knot may result in unreliable ligation and unreliable ligation, postoperative knot slippage and loosening, bleeding, secondary infection, and digestive fluid leakage. Therefore, it is necessary to master the surgical knotting technique correctly and skillfully.

(One). Type of wire knot:

Commonly used in surgery are square knots, triple knots and surgical knots.

1 1. Square knot: Also known as flat knot, it is made up of two single knots with opposite directions. It is characterized by the overlapping lines of ligatures, firm knots and not easy to loose. It is the most commonly used knot in surgery and is suitable for less. Tissue, or smaller blood vessels as well as various sutures for ligation.

twenty two. Triple knot: Add a single knot on the basis of the square knot. The third knot is opposite to the direction of the second knot, also called the reinforcement knot. It is often used for the more important blood vessels and the ligation of larger tension tissues. In addition, the use of smooth lines such as gut or chemical synthetic lines, in order to prevent loosening, usually requires a triple or multiple knot.

43. Surgical knot: the wire is re-twisted twice when the first single knot is made to increase the friction between the wires. It is not easy to slip or loose when hitting the second knot, so it is relatively strong, but because it takes time, it is only large in ligation. Ligation of blood vessels and tension after suturing. In addition, there is a single knot, that is, only one buckle is used, which is easy to unravel, and is only used for temporary ligation and blocking, and is rarely used in surgery. If the knotting method is wrong, it is easy to cause the following two wrong knots:

Knotting in surgical operations

Knotting in surgical operations


4 1. False knot: also known as the knot, consists of two single knots in the same direction, easy to slip off, should be avoided.

5 2. Slip knot: When the square knot is struck, the second-hand force is uneven when the operator pulls the wire. If it is tight or loose, or only one side of the wire is tightened and the other side is tied, the overlapping knot is wound on a straight line. It is easy to slip off, especially during surgery (Figure 3-38).

(two). Knotting method

1 1. One-handed knotting method: simple and quick, the most commonly used in surgery, left and right hands can be knotted, although the habits of knotting are often different, but the basic movements are consistent. A hand-held line, with the other hand knotted, the main action is 'hold the line, take the line, hook line', completed by the thumb, food, and the middle three fingers (Figure 3-39 40).

twenty two. Two-handed knotting method: In addition to general ligation, it is also used for suture ligation with deep tissue tension. The knotting of hands is more complicated than one-handed knotting, but it is more firm and reliable (Fig. 3-41).

3 3. Pliers knotting method: use vascular clamp or needle clamp to tie knots. This method is suitable for the thread is too short, when there is difficulty in knotting by hand or when the knotting space is small, sometimes to save suture and threading time. The disadvantage is that it is not easy to tighten when there is tension (Figure 3-42).

(three). Knot line

There are two ways to transfer the line during the operation. One is the hand-delivery method, which means that the knotter holds the thread in one hand and clamps the ligature of the ligature around the clamp tissue to the other hand; There is also a line that retains the thread and the line is handed to the other hand for ligation of the superficial part (Figure 3-43). The second method is the instrument delivery method, which uses a vascular clamp to clamp one end of the ligature, and bypasses the vascular clamp head of the clamp tissue. This method is suitable for deep ligation and difficult hand operation (Fig. 3-44). After the line is handed, according to whether the two ends of the ligature line are crossed, the knotting method is adjusted to ensure that the line knot is smooth and avoid twisting the cross.

(four). Knotted notes

1 1. No matter what method is knotted, the winding directions of two adjacent single knots cannot be the same, otherwise they become a false knot and are easy to loose.

twenty two. Evenly force the two hands to ligature. If the one end of the wire is tightened, it is easy to cause slipping and should be avoided.

3 3. The three points of force and the ligation point should be in a straight line, and the force is concentrated at the ligation point. If the three points are connected at a certain angle, when the line is tightened, the line knot is easily pulled off or the line is broken (Figure 3 -45 ).

4 4. For each single knot, the knot should be straightened and then tightened. If the twist of the knot is not smooth, the direction of the tail should be exchanged to make it smooth.

5 5. When ligating, the second-hand use force is slow and even when tightening the knot. The strength of the two hands should not be too far, especially when the knot is deep, the one finger of the deep operation presses the other side of the line and slowly tightens, otherwise it is easy to pull the line. Broken or knot slip (Figure 3-46).

6 6. When playing the second knot, the action should be fast and light, and should not be pulled excessively to prevent the first knot from loosening; if the tissue tension is large, the assistant can use the shackle or the forceps after tightening the first knot. Clamp the knot to prevent loosening, and then relax and remove when the second knot is tightened.

(1) Regardless of the method used to tie the knot, the direction of the first and second knots cannot be the same. If the direction of the knot is wrong, even a very square knot may also become a slip knot, or the secant may cause the line to break. . A single knot in the same direction is also prone to form a false knot. To make a knot, the two knots must be reversed. At the beginning of the first knot, the sutures are in a parallel state. After the ligation, the hands are crossed in the opposite direction to tighten the suture, and in the second knot, the hands are not crossed, as shown in (Fig. 2-10); if the first knot is started before the ligation The line is in a crossed state. After the ligation, the hands do not cross, the suture is tightened, and the second knot is tied and the hands are crossed again. Of course, in the actual knotting process, the direction of knotting may have a smaller range of directional changes due to the requirements of the surgical field and the operating site. However, this change should be in the range of less than 90 °; if the size is 90 ° or close to 180 °, it will cause the slip or secant to break the line. 

(2) Evenly in the process of knotting, the force of both hands must be uniform, which is crucial for the quality and safety of the knot. Otherwise, it may lead to two possibilities: slipping; pulling on the ligated tissue, which can cause tearing, tearing, etc. (Figure 2-13).

(3) When tightening the knot line, three points (that is, the force point and the ligation point of the two hands) are required to be in a straight line, and the opposite directions of the two hands are equal, and each knot should be flattened and then tightened. If it is not flat, you can exchange the position at the end of the line. Avoid making it an acute angle. Otherwise, it will be broken when it is slightly forced. It cannot be pulled up at an angle. Otherwise, the ligation point will be torn or the knot will be loose. Three points are in line (Figure 2-14).

4) When ligation, the distance between the two hands should not be too far off the line, especially when deep knotting, it is best to use a finger to press the line close, slowly tighten, and use force slowly and evenly. Excessive force or sudden

With force, it is easy to break the wire or slip it off. 

(5) When playing the second knot, pay attention to the first knot not to relax. If necessary, use a hemostat to press the first knot. When the second knot is tightened, remove the hemostat, or The first knot is finished

After that, the hands can pull the ligature line slightly and not release. 

(6) Knotting should be carried out under direct vision. In order to grasp the tightness of ligation according to the specific ligation site and the ligation tissue, the surgeon or other operators can understand the exact situation of knotting and ligation. Even if the ligation of some deeper parts, it should be exposed to direct vision as much as possible. But sometimes the deep knots are not clear, it is necessary to tie the knot with the feeling of the hand, but this requires quite a good foundation.

(7) The tissue on the skin is ligated as little as possible, and the anterior end of the vascular clamp is used to clamp the fracture of the blood vessel. It is best to clamp the broken end perpendicularly to the direction of the blood vessel, and the clamping tissue should be less. Do not make a large clamp. Due to massive ligation, tissue necrosis will be excessive, and systemic and local reactions will be large after surgery (Fig. 2-15). The ligature head that is buried in the tissue is cut as short as possible without causing looseness. Silk thread and cotton thread generally leave 1~2mm, but if it is ligation of larger blood vessels, the retaining thread should be slightly longer; the gut retains 3~4mm; the stainless steel wire retains 5~6mm, and the "wire" should be twisted and buried into the tissue.

In the middle; the thread of the ligature after suturing the skin is left 1 cm to remove the thread.

(8) When knotting, choose a suitable line with good quality and thickness. Drain the line with salt water before ligation, because the line can increase the friction between the lines and increase the tension. The main line is fragile.


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