On the origin and evolution of the Roeder knot and loop--a geometrical review

Security Comparison of Various Surgical Knots Using Nylon Suture

OBJECTIVE

To evaluate the strengths of various surgical knot techniques, including square knot, surgeon's knot, granny knot, and random knot with the same three throws.

METHODS

The authors tested each of the four knot techniques using four different gauges of nylon (polyamide [Ethicon]): 4-0, 5-0, 6-0, and 7-0. Each knot type was tested 20 times per nylon gauge, for a total of 320 knots tested. The authors used a static pull machine to measure elongation at yield and maximal force to break.

RESULTS

A comparison of elongation at yield revealed that the surgeon's knot was superior to the square knot, granny knot, and random knots across all gauges of nylons. Further, a comparison of maximal force to break revealed that the surgeon's knot was superior to the square knot, granny knot, and random knots when using 4-0, 5-0, and 6-0 nylon but not when using 7-0 nylon.

CONCLUSIONS

The surgeon's knot was the strongest, and random knot was the weakest when the authors used nylon 4-0, 5-0, and 6-0. While handling fine suture materials such as 7-0 nylon, knot failure appears to be unrelated to the knot technique used. This study provides not only fundamental guidance for tying surgical knots using nylon, but also a rational basis for an adequately strong knot choice in various fields of surgery.

Evaluation of a pre-tied ligature loop for canine total lung lobectomy

OBJECTIVE

To determine the ability of a pre-tied ligature loop (PLL) to create a seal against physiological airway pressures after total lung lobectomy and report outcomes in dogs requiring lung lobectomy.

STUDY DESIGN

Ex vivo experimental randomized study and clinical case study.

SAMPLE POPULATION

Thirty cadaveric canine lung lobes and 5 client-owned dogs.

METHODS

Thirty canine lung lobes from dogs weighing 22.5-35 kg were randomized to lobectomy with stapler, PLL, or suture ligation. After lobectomy, each bronchial stump was submerged in water, and the mainstem airway pressure was increased to 80 mm Hg. Leakage was compared between techniques. The PLL was subsequently used in 5 dogs (17-25 kg) with neoplastic disease requiring total lung lobectomy.

RESULTS

Two stapled and 4 sutured bronchial stumps leaked at supraphysiological pressures >15 mm Hg. One stapled bronchial stump failed at a physiological airway pressure (5 mm Hg). None of the PLL lobectomies leaked. The incidence of bronchial stump failures did not differ among techniques (P = .15). Lung lobectomy was performed successfully with the PLL in 5 clinical cases with no intraoperative or postoperative complications; median follow-up time was 6 months.

CONCLUSION

Bronchial ligation with the PLL reliably resisted physiological airway pressures and performed comparably to current standard techniques in cadavers. The PLL provided an adequate air and vascular seal in 5 clinical cases undergoing total lung lobectomy.

CLINICAL RELEVANCE

Pre-tied ligature loops provide an alternative method for total lung lobectomy in dogs.

How to facilitate laparoscopic extraperitoneal suture?

To show a simplified technique of extraperitoneal laparoscopic suture. Step-by-step explanation of the technique using an educative video and pictures. This technique of extraperitoneal laparoscopic suture is highlighted through two laparoscopic procedures: a sacrocolpopexy (mesh fixation) for a pelvic organ prolapse and an ovariopexy after hysterectomy without adnexectomy (fibromatous uterus). This method avoids the need for repetitive use of the knot-pusher in performing extraperitoneal knots. Time saved in the operating room and limited gestures can theoretically contribute to decrease cost and improve safety. Although our intimate conviction goes in this direction, further studies are needed to better evaluate this procedure. Rehabilitating a process historically used during laparotomic procedures, this technique avoids iterative intra-abdominal gestures and expedites the knot-tying steps.

YS knot: A new technique for a tension-controlled slip knot using a trocar

The Yoon Soon (YS) knot is a laparoscopic extracorporeal slip knot that is easy to learn and apply. Our new technique, which uses the trocar as a knot pusher, is simpler, faster, and has more tension than conventional knot methods. The YS knot will help surgeons save operative time and perform tension-controlled knot-tying during laparoscopic surgery.

Initial Experience with Thoracoscopic Esophageal Atresia and Tracheoesophageal Fistula Repair: Lessons Learned and Technical Considerations to Achieve Success

The minimally invasive surgical (MIS) repair of esophageal atresia/tracheoesophageal fistula (EA/ TEF) is challenging and requires advanced endoscopic skills. The purpose of this study was to provide insight in successfully introducing the MIS repair based on the initial cases performed by a single pediatric surgeon and review of the experience of others. A retrospective review of all MIS TEF repairs performed by a single surgeon was conducted. Data gathered included patient demographics, technical details of repair including operative time, short- and long-term postoperative morbidity, length of stay, and follow-up. Eight cases (seven Type C, one Type D) were selected for MIS repair based on the judgment of the surgeon with consideration of adequate patient size, stability, type of associated anomalies, and expected length of esophageal gap. Operative time was an average of 207 minutes and there was one conversion to open for successful repair. There were no leaks and only one patient required a single anastomotic dilation at 19 months of age. There were two postoperative pneumothoraces of which one required bronchoscopic laser fistula ablation. Length of stay was an average of 16 days and length of follow-up is a median of 219 days. MIS repair of EA/TEF can be done successfully but requires careful patient selection, advanced MIS skills and meticulous attention to operative technique.

Technical progress in single-incision laparoscopic cholecystectomy in our initial experience

Single-incision laparoscopic cholecystectomy (SILC) has rapidly spread throughout the world because of its low invasiveness and because it is a scarless procedure. Various surgical methods of performing SILC are present in each institute; however, it is necessary to develop a standardized procedure that we can perform safely, such as the conventional 4-port laparoscopic cholecystectomy (LC). The SILC experiment in our institute was started by use of the commercial SILS Port and changed from a 3-port method via an umbilicus to a 2-port method to improve some problems. Although none of the conversions to conventional 4-port LC and also none of the complications such as bile duct injury occurred in each method, the 2-port method functioned best and was also economical. However, it is most important to adopt strict criteria and select the patients suitable for SILC to demonstrate SILC safety same as 4-port LC.

Heraklas on knots: sixteen surgical nooses and knots from the first century A.D

In the first century of our common era, the Greek physician Heraklas wrote a brief essay on how to tie 16 knots and nooses for surgical and orthopedic purposes. His work is reintroduced and discussed here because its place in the origin and evolution of surgery needs to be properly acknowledged and recorded in the current medical literature. To do so, Raeder's definitive Greek edition of the oldest extant manuscripts of Heraklas' essay was studied along with the various illustrated interpretations of his text published over the last six centuries. Moreover, the contemporary literature was searched for current applications of Heraklas' knots by use of a database of surgical knots. It was found that seven of Heraklas' 16 knots and nooses were still applied surgically of late, and that four of these have even been recently rediscovered for such applications. Therefore, it is concluded that Hellenistic, Roman, and Byzantine medicine had a rich knowledge and high standards. Contemporary surgical techniques may be found to be truly ancient if we search deep enough, far enough, and long enough.