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Related Experiment Video

Updated: Jan 19, 2026

Application of Straight-needle, Three-tailed, Knot-free, Peritoneal Sutures in Laparoscopic Transabdominal Preperitoneal Hernia Repair
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Which Knots Are Recommended in Laparoscopic Surgery and How to Avoid Insecure Knots.

Armando Romeo1, Luiz Flavio Fernandes2, Graciele Vidoto Cervantes3

  • 1Departments of Gynecology and Obstetrics (Dr. Romeo), University of Torino, Torino, Italy; Project Leader REC Research Educational Centre Department of Gynecology and Obstetrics University of Torino (Dr. Romeo), Torino, Italy.

Journal of Minimally Invasive Gynecology
|September 24, 2019
PubMed
Summary

Secure surgical knots by starting with an H3 knot, tying with force, and using bimanual suturing to prevent accidental transformation into insecure half-hitch knots. Additional half-hitches can improve stability when needed.

Keywords:
Knot securityKnot tyingKnotsSurgerySuturing

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Area of Science:

  • Surgical techniques
  • Knot security
  • Laparoscopic surgery

Background:

  • The security of identical knot sequences in surgical suturing can be variable.
  • Understanding factors influencing knot security is crucial for preventing surgical complications.

Purpose of the Study:

  • To investigate the variability in security of identical knot sequences.
  • To identify methods for avoiding occasionally insecure knots during laparoscopic suturing.

Main Methods:

  • A factorial design assessed factors affecting half knot (H) and half-hitch (S) knot combinations.
  • Tying forces and risk factors for H-to-S knot transformation were evaluated.
  • Security of transformed knots and their modification with additional half hitches were assessed in vitro.

Main Results:

  • Tying knots with greater force significantly increased security for both half knots and half hitches.
  • Inexperience, short sutures, and monomanual knot tying increased the risk of transforming half knots into insecure half-hitches.
  • Inadvertently created S2S1 and S2S2 knots are generally dangerous, though the symmetric S2S2 is stable. Additional half hitches improved stability for most unstable knots.

Conclusions:

  • To minimize the risk of accidental H-to-S knot transformation, surgeons should initiate with an H3 knot, apply sufficient tying force, use adequate suture length, and employ bimanual suturing.
  • Preferential use of H3H2 knots or five half hitches (SSSbSbSb) is recommended.
  • When in doubt, securing knot combinations with at least two blocking half hitches is advised.