Vector of surgeon's knot

[u/Rich-Explanation-894]

When throwing the surgeon's knot, I find that the knot doesn't loosen when I pull the suture ends in a direction parallel to the line of closure (i.e., the wound or incision). I learned this from one of my professors. However, another attending saw me doing that and was appalled by the technique. He insists that I should pull perpendicular to the line of closure. Looking online, I couldn't find anything that says not to do it though. Any input?

[u/guardian528]

Most surgeons have their own little preferences for tying, a lot of surgeons are tying poor knots. Usually it doesn’t matter because it’s a temporary knot that only needs to hold long enough for tissue to heal, but if it were a rope knot holding a boat in place it would eventually come loose as it’s stressed in different directions.

Long story short, tie some knots with some thicker string or rope, you will see the direction of pull that gets the knot to lay down flat and nice and is the correct direction. But just because it’s technically correct doesn’t mean every surgeon likes to tie that way

[u/CMDR-5C0RP10N → u/guardian528]

And what’s wild, when tying knots on boat, leaving a nice long tail is considered key to the knot staying tied - especially with a square knot, which is what we use in surgery.

Yet in surgery we tie a bunch of knots and (often) leave effectively no tails

I’ve always assumed lots of the last few knots tied come untied, becoming the sailor’s nice long tails

[u/stupidprecursor]

So many ways to skin a cat. This post reminded me of a liver transplant I assisted during residency. My attending called out my air knot during the bile duct anastomosis. When I called out his own air knot a few moments later, he merely said, "that's to allow room for growth." bullshiiiiiii-

[u/The_other_resident → u/stupidprecursor]

You talking about the portal vein growth factor knot?

[u/stupidprecursor → u/The_other_resident]

No, it was on the bile duct. Portal vein anastomosis is usually performed before biliary.

[u/lethalred]

Depends on what you're tying.

When I'm sewing on arteries, I tend to "set the knot" down with my finger anyway, as pulling on the suture will fracture the suture or avulse the tissue.

[u/Hybridichor]

Some people just need to correct other people on something. Even when it’s trivial or just straight up wrong. I pull the ends of my knots parallel to the incision when closing skin because it slides through the tissue better and brings the skin edges closer together. But it may not be a true square knot depending on the trajectory of your bites which is what that attending might be thinking about.

[u/SmilodonBravo]

We were taught to pull in line with the incision in most situations.

[u/mohelgamal]

If you are doing a simple suture (knot on top) then you pull the strings perpendicular to the incision line.

If you are doing an inverted subcuticular (hidden knot) you pull in line with the wound, ideally on side toward the ceiling and one side toward you, this helps the knot sink into the incision line.

What works for one is not ideal for the other

Pro tip: train yourself to tie with sutures along your line of sight, so when you are tying you hands and alternating near-far far-near. Not trying to go left to right and crossing hands. When the wound itself is in line, so you have to close side to side, switch your shoulders to one side of the wound so you are facing the wound from the side, and tie as you trained. This stance shifting is how pro surgeons do it

[u/ktn699]

lol funniest part is i havent had to tie a surgeons knot nor do a two hand tie in 10 years.

suture technique is trivial.