Surgical and Knot Tying Tips
TIP #1: HOW TO PREPARE FOR SURGERY (PRE-OP CONSIDERATIONS)
- History and physical examination.
- Pre-operative blood work.
- Ensure patient hydration with peri-operative fluid therapy.
- Pre-emptive analgesia.
- Patient stabilization (hydration, electrolytes, shock therapy, nutrition, etc.).
- Determine surgical and anesthetic risks.
- Avoid hypothermia.
- Ensure client communication and commitment to medical recommendation.
TIP #2: SUTURE PATTERNS – SUTURE KNOTS – BURYING THE KNOT
The basic principle entailed in burying a knot is that the knot must be placed at a location within the tissues that ensures availability of a sufficient amount of superficial tissue to cover the knot.
- Pass the suture through the deepest tissue layer within the wound before beginning suture placement within subcutaneous tissues.
- Then pass the suture from the deep subcutaneous tissue to the subcuticular tissue on the same side of the wound.
- Next, pass the suture from the subcuticular tissue to the deep subcutaneous tissue on the opposing side of the wound.
- Tie the free end of the suture to the loop formed by the placement of the suture through the deepest aspect of the wound.
TIP #3: HEALING TIMEFRAMES AND PARTICULARS
- Atraumatic surgical technique should be the surgeon's constant goal.
- When closing a skin incision, the surgeon must always consider techniques to minimize tension, dead space, and self-trauma by the patient.
- Incisions placed parallel to normal tension lines result in less gaping and therefore a more narrow scar.
- Don’t use too much suture, or suture that is larger than necessary.
TIP #4: POST-OP (CHECK LIST / CONSIDERATIONS)
- Remember – infection delays wound healing.
- Body temperature.
- Overall patient condition.
- Ventilation, heart rate, respiratory rate, etc.
TIP #5: PRE AND POSTOPERATIVE PAIN MANAGEMENT
- Preemptive analgesia ideal to prevent hyperalgesia.
- Pain that is uncontrolled and unresolved is not good medicine.
- Benefits of pain control:
- Patient more comfortable
- Better immune function, healing
- Pet more involved with family
- Better appetite, attitude, behavior
- Safety (staff, handlers, owner)
- Improved client relationships
- Quality of Life
KNOT TYING TIPS
TOP TEN PRINCIPLES OF KNOT TYING
- Choose the simplest knot for the suture material.
- The knot should be as small as possible. Use appropriate small gauge suture. Cut suture ends short.
- Avoid friction or “sawing” as you tighten the throws. Suture should be tightened by pulling in opposite directions with uniform rate and tension.
- DO NOT crush or crimp suture with surgical instruments. Grasp the free end of the strand only during an instrument tie.
- Avoid excessive tension which may cut tissue.
- Do not tie sutures used for tissue approximation too tightly causing tissue strangulation.
- Maintain traction on one end of the strand after the first loop is tied to avoid loosening of the throw. Tie to eliminate slippage.
- Make the final throw as close to horizontal as possible.
- Do not hesitate to change position in relation to the patient to place a knot securely and flat.
- Extra throws do not add to the strength of a properly tied knot, only to its bulk.
- Recommended for most surgery.
- Allows for economical use of suture.
- Knots can be tied with short ends.
- Do not crush suture with instruments!
- Grasp suture only on end that will be discarded.
BURYING THE FINAL KNOT
Mastering the technique for burying the end knot is the greatest challenge of the Buried Continuous Subcuticular (BCS) pattern.
- After the BCS pattern is completed, the needle is advanced 2-3 mm to the opposite side. A vertical bite is placed from the mid-dermis down to subcutaneous tissue. The needle is then inserted on the opposite side, vertically aiming up from the subcutaneous tissue, exiting at the mid-dermis within 2-3 mm of the commissure. A 2 cm loop of suture is created between the 2 vertical bites.
- A third vertical bite is taken parallel to the first, initiating in the mid-dermis, but exiting deeper in the subcutaneous layer. The needle is brought up between the exposed loop and final suture crossing the incision.
- After tension is applied to the exposed loop to tighten the horizontal sutures and appose the wound margins, the free suture end is tied to the exposed loop with 4-5 throws to complete the knot and close the wound.
- The loop is trimmed 2-3 mm above the knot. The needle is then inserted close to the knot, aimed to exit the dermis at least 1cm lateral to the incision. As tension is applied to the suture, the knot is pulled deeper into the tissue, below the dermis. Finally, under tension, the free end of suture is trimmed flush with the skin.
BCS pattern is recommended for skin closure in elective surgery for veterinary patients, and MONOCRYL* suture is an excellent choice for this suture pattern.