TEHNIK IKATAN BEDAH
Tehnik ikatan Bedah = KNOT TYING
Video Ikatan Bedah – knot tying (6 Minutes)
Knot tying and suturing are basic surgical skills that need to be learned and practiced so they become virtually automatic.
In this lesson, we’ll learn how to tie knots and suture using medical instruments. During the lesson, you’ll need several items:
- A foot or two of thin rope
- Some suturing material with a curved needle
- A surgical needle holder or similar instrument
- Surgical forceps or pickups with teeth
- Scissors for cutting sutures
- Something to tie onto
- Something to suture together…Foam rubber works well for practice.
A ligature is a thread that is tightened around an object, such as a blood vessel, and is secured in place by tying the loose ends in a knot.
For example, during surgery, a bleeding point might be identified and grasped with a hemostat. Then the surgical assistant elevates the hemostat so that the surgeon can see it’s tip. The assistant does this in a way that the assistant’s hand covers the ring of the hemostat to prevent the ligature from becoming entangled. The surgeon passes a ligature around the hemostat and encircles the clamped tissue. After placing a first throw with the ligature, the surgeon snugs down the ligature around the enclosed tissue. After the surgeon completes the knot with a second and sometimes third throw, the assistant releases the hemostat. Depending on the tissue, the surgeon may indicate to the assistant to release the tissue sooner than the final throw.
The reason this technique works is that the knot is tied in such a way that it won’t relax or come loose. The best way to accomplish this is with a square knot. The square knot locks on itself so that with increasing tension, the knot gets tighter.
There are a number of good ways to tie square knots. We’ll show one technique here, and you can later learn some of the other techniques if you wish.
The granny knot, in contrast to the square knot. loosens when tension is applied. While there might be an occasional use for a granny knot in medicine, most surgical knots should be tied as square knots.
I want you to start off using thick rope to learn the knots. Later, when you’ve got the basic techniques down, we’ll advance to actual ligatures.
The square knot is tied using two different motions or throws. We’ll consider each throw separately.
- Begin with the long end of the suture in your left hand and the short end in your right hand. If the short end is too short, you will have difficulty in tying it. If it is too long, it will flop around and get in the way of your tying.
- Use your left index finger to push the left thread over the right thread, creating an opening between them.
- Swing your left thumb up through the opening you have created.
- Lay the right end of the thread over your left thumb and pinch it between your thumb and index finger.
- Use your left index finger and thumb to push the thread down through the opening, bringing it out the other side, where your right hand can grab it.
- Use your two index fingers to tighten the knot. In this picture, the hands are crossed to allow the threads to lay down flat. It is preferable for the knot to lay down flat as it is stronger.
- Tighten the knot using your index fingers. Some material is very strong and won’t break no matter how much tension you apply. Other material is more fragile and will snap if you apply too much tension. With experience handling different suture materials of different thicknesses, you will learn how much tension to apply.
Now watch the whole first throw a few times and then practice it on your own.
If you just used first throws all the time, all of your knots would end up as granny knots.
You need to learn the second throw, which will lock your knot in place.
- Use the thumb of your left hand to push the left thread under the right, opening a space between them.
- Pinch your left index finger and left thumb together. Rotate your left index finger through the space you just created.
- Use your right hand to bring the right thread to your left pinched thumb and index finger. Grasp the thread between them.
- Rotate the left thumb/index finger back through the opening, bringing the right thread through the opening.
- Re-grab the right thread with your right hand.
- Pull the loose ends, laying the second throw down squarely on the first.
- Tighten the ends to complete the knot.
Watch the whole second throw a few times, then practice tying this second throw.
When you have mastered the second throw, try alternating first, then second, then first, then second throws. In this way, you will create a series of square knots that will be very strong.
As you are laying down your throws, they should go down flat and not curled back on themselves. This may require you to briefly cross your hands before snugging down the throw. Alternatively, you can cross the thread before you start tying it. Either way, the throws need to go down flat or you won’t get the square knot you are seeking.
When tightening your throws, apply the tension in line with the orientation of the thread. If you tighten at an oblique angle, you may tear the tissue and your knots generally won’t be as snug. Usually, the orientation of the thread is perpendicular to the line of the incision. This means that usually, you will exert your tension on the ends of the threads perpendicular to the line of the incision.
When tightening your throws, exert your force equally in both directions and level with the knot. In other words, don’t pull up on the knot when you snug down your knots. If you pull up while tying, you may tear the tissue.
Practice now tying knots so you are applying even tension at the level of the knot, perpendicular to the line of the incision.
One important, useful variation on the square knot is called the Surgeon’s knot. With the surgeon’s knot, rather than completing the first throw, you double back after half the throw is done and make a second half throw, before moving on to the second throw.
The purpose of a surgeon’s knot is to apply a better grip to the first throw so that it won’t loosen while you are putting in your second throw. While it does this very effectively, surgeon’s knots are used sparingly during surgery because they break more easily, they add extra bulk to the knot, and usually aren’t necessary. Sometimes they are.
Watch this surgeon’s knot a few times, and then practice on your own.
Now that you have a working knowledge of tying square knots and surgeon’s knots with the thick rope, I’ll want you to switch to tying your knots using thread.
But first, a few words about suturing