CHAPTER FOUR

ISSUES RELATED WITH LAPAROSCOPIC KNOTTING

AND THE CLASSIFICATION OF KNOTS

‘’A knot….is either exactly right or it is hopelessly wrong’’ ‘’Make only one
change …….and either an entirely different knot is made or no knot at all may
result’’ Ashley

4.0 RATIONALITY OF THE STUDY

The term KNOT has three distinct meaning in common use. It applies to all
complications in strand of a suture or cordage such as kinks, coils etc. Secondly it
includes all bends, hitches, splices and thirdly it applies to a knob tied in a thread
or rope to prevent unreeving and providing a handhold.(Ashley).The term knot is
particularly applied to knobs, loops, fancy and trick knots.

Tissue approximation is a challenging task in laparoscopic surgery. In surgical

practice today, there have been many methods of joining the tissue or sealing a
vessel. Various knot substitutes have been developed like clips, glue, thermal
sealing, embolic sealing etc. However, no acceptable substitutes have been
developed so far.

For tissue approximation, a well-balanced use of knotting and suturing is equally

important to execute a task skillfully. As Cuschieri writes in his book ‘Tissue
approximation in endoscopic surgery’, that aside from gentle handling of tissues,
the approximation must be achieved without compromising the integrity of blood
supply essential to the healing process. If we take the two loose ends of a thread
and glue them together, then we have what mathematicians will agree to call a
knot. However, we are not dealing with a Mathematical knot but knot used for
tissue approximation.

Few comparative studies have evaluated conventional and laparoscopic knots. J

D Amortegui has aptly demonstrated knot security in laparoscopic knot and
compared to conventional knot. One of the most challenging aspects of
laparoscopic surgery is intracorporeal suturing and knot tying. In open surgery,
with a direct vision the knotting and suturing are executed in semiautomatic
faction but because of perceptual and translational problems, endoscopic tissue
approximation can never be conducted with the same ease and fluency as during
open surgery (Z Szabo)

From a practical point of view, the two important types of knots, a Flat knot and
Sliding Knot has been studied extensively for open surgery. According to
Amortegui et al,, more than 80% of the surgeons consciously or unconsciously
make a sliding knot. Most surgeons keep constant tension on one strand to
prevent the first throw from loosening while they make the next throw with the
other hand. This inevitably results in formation of a sliding knot.

Dinsmore in 1995 combined Terra and Berg nomenclature for flat knot and
Trimbos nomenclature for sliding knot and presented with his new nomenclature.
However, A Cuschieri and Z Szabo have refrained from any new classification in
their book and named after the methods of tying. They have broadly stated that
there are two types of knots, utility and ornamental or decorative knots. They
place surgical knots in the category of utility knot. They have put forward a
practical purpose as the main reason to differentiate utility knot from decorative
knots. Amortegui and Restrepo (34) simplified the explanation of the Dinsmore
nomenclature.

.
Various types of knots have been described for the laparoscopic surgeries and
having reporting of the knot stability and knot strength of these knots. It was
surprising to know that while one author recommended a type of knot, they were
few more who strongly condemned it. Various laparoscopic knots described by
many surgeons like Roeder's knot, Tay-side knot, Meltzer’s knot etc. could not
properly fit Dinsmore Nomenclature. Dorsey JH et al demonstrated that the
laparoscopic Roeder knot was significantly weaker than all other laparoscopic and
conventional knots tested. (Dorsey JH, Sharp HT, Chovan JD, Holtz PM.Dept. of
Gynec, Greater Baltimore Medical Centre, Maryland, USA. Laparoscopic knot
strength: a comparison with conventional knots. Obste. Gynecol 1995 Oct; 86(4 Pt
1):536-40)

Therefore, a common classification is required to understand the properties of a

good laparoscopic knot. There is therefore a strong requirement of good
laparoscopic knot, which can be accurately deciphered by Dinsmore classification
not only theoretically but also practically as well. This paper outlines the
modifications of Dinsmore Classification as applied for laparoscopic Surgery. It
also describes a Knot for laparoscopic Surgery which fits the nomenclature.

Many factors may influence the formation of a knot. The US pharmacopeia has
defined the length and size of the suture material, the knot pull strength, the
needle attachment force. It is often said that ‘Chirality’ has an important role
in the formation of a knot. But, what is Chirality? The root of the word
‘Chiral’ is the Greek word cheir meaning ‘hand’ and handedness is what
’Chirality’ is about. The word is more used with Mathematical knot theory
principles. No study has so far been done to link surgical knot with mathematical
knot theory and the moves described by Reidemeister a German mathematician
during the Nazi time, who demonstrated in Konigsberg in 1933, a mathematical
knot theory. Reidemeister , stated that all the projections of a knot or link by the
sequence of three moves which he called ‘Reidemeister Moves’ .

The knot then can be formed by following movements of the suture.

The purpose of present study was to apply and compare Reidmeister moves to
understand the formation of a knot.

Research Question

A modification of Dinsmore nomenclature will not out of place if the same could
be applied to laparoscopic knotting. This will resolve many issues like knot safety
in laparoscopic surgery and uniformity of benchmarking of the knots. Still there
are two important questions remain to be answered.

1. What makes one Knot stronger than others do for the same size and type of
the suture material?
 2. What makes in any one type of knot, a difference in strength of various
knot samples when tested on Tensinometer

NULL HYPTHESIS N0: All laparoscopic sliding knots have the same configuration
and there is no difference between various knots

HYPOTHESIS N1: All the laparoscopic sliding knots can be deciphered according to
Modification of Dinsmore Classification

NULL HYPOTHESIS N1: The breakpoint for all sliding knot is same and does not
depend upon any variable and any change is due to chance alone

4.1 METHOD

4.1.1 KNOT TESTING APPARATUS

a) In our first experiment, a LR5K Lloyd Tensinometer was used to measure knot
breaking strength. Here the loop method was employed in which the loop is
placed over two hooks leaving the knot in the middle of them. The distraction
rate was 50 mm per minute. The load applied was 20k. The knot breaking force
was plotted on a graph. A total of 3 samples of various types of knots were
tested. The knot breaking force was calculated in Newton (N). The same
experiment was repeated by testing the knots again on Tensinometer

b) In the second experiment, the knot testing apparatus was set up using an
Instron Tensinometer (model 4464, Instron Ltd., UK). Knots were tested between
the two steel clamps of the Tensinometer and the signal from it was fed to a
signal processing unit which provided a filter to remove the high frequency noise.
The modified signal was recorded by Digital method in a computer recording
system using DOS program. A data analysis program was used to remove zero
offsets, synchronize each record using a trigger system, derive force data and
calculate the knot breaking force. The knot breaking force was calculated in
pounds force. Convert software was used to convert Pound force into Newton
(N). The distraction rate was 50 mm per minute. Three samples were tested for
each type of the knot and the computer automatically calculated the mean,
standard deviation, minimum and maximum force required. The knot breaking
force was plotted on a graph

1. The security of knot was tested by Tensinometer and knot-sliding capacity

was observed. When the suture’s maximum tensile strength is reached, it
may break or the knot may slip. The knot strength was determined when
either the knot broke or slipped more than 2 mm
2. During the construction of each of the knot, the step of only turning or
winding of the thread around either axial strand or loop was omitted and
the subsequent knot was constructed as if it were in normal way. This now
showed the knot in basic configuration of Dinsmore The knot strength was
observed.
3. For constructing a slipknot, a combination of two slip knots were used to
construct a new knot around the same axial strand and the ease of slipping
and loop holding capacity was observed.
4. The loop holding capacity or the knot breaking capacity was observed
for
Each throw in = and X each throw in // and # mod e after the required
second throw
5. After the slipknot was slid into the place and tightened, the two ends
were cut and the last hitch was converted into flat knot by pulling both
ends in opposite direction. By this simple step, increase in knot holding
capacity was observed.

Since the variable for the strength of the suture material was the size and
type of the suture material, we, tested the knot with vicryl (Ethicon) as 1-0 and 2-
0 and chromic catgut 1-0 and 2-0 as suture material and keeping the configuration
of knot constant. We used a loop sliding knot with a configuration of 2SxSxS.This
was typical number of throws for each suture. Suture of larger size of more than 1
was not considered because of increased inherent strength of the material
requiring larger force .Similarly suture with the size less than 3-0 were also not
considered because of the delicate nature of the suture material.

Each of the knots was tied around a red India rubber catheter of 4 mm diameter.
The catheter with knot was mounted on one hook of a LR5K Lloyd Tensinometer.
The second end of the suture was on second arm of the Tensinometer. A steady
pull was applied until the suture broke. Since the study was to understand the
knot breaking point, the force applied to the suture was variable and till the
suture broke. The distraction rate was 50 mm per minute. The load applied
initially was 20k.The knot breaking point was noted on the suture material. The
broken knots were mounted on glass slide and examined under low power
microscope (10 x magnifications) to know the exact point of breakage. The
junction where the standing part of the suture enters the Nub is marked X. The
point on the stem just above the Nub was marked Y whereas, the point on the
Nub just below the junction was marked Z .The knot under steady tension will
break at X, Y or Z A total of 10 knots were tied for each size of the suture material
by the same surgeon who is highly experienced in advanced laparoscopic surgery
and knotting, suturing and has trained several surgeons..

(b) In second experiment the animate tissue of porcine frozen small intestine
were taken and after thawing, the loop knots were tied around the intestine in
‘Pelvi-trainer’ .The intestine was taken as an experimental tissue to prevent
suture cutting through a thinner tissue. The knots were pushed home by a pusher
rod (plastic) or dissecting forceps (Maryland forceps by Jarit). A steady pull on the
stem of the suture was applied at the same time pushing the knot by either
pusher rod or the half closed jaws of dissector until the knot was tightened in
place at first instance and the force of pull and push continued until the knot
broke. The knots were examined first by naked eye and then under microscope to
determine the point of breakage.

The results were tabulated to show frequency distribution of breakage point. The
data collected was analyzed using Non-parametric Chi-square test
 4.1.2 Knot tying

Various types of sliding knots were tied. The order of choosing various types of
laparoscopic knots was at random. Each of the knot described as a standard knot
was first tied and three samples of each were tested. Since, we wanted to test
the nomenclature; only one type of suture 2-0 vicryl (Ethicon) was used. Each of
the primary selected knots was modified by making one turn less and testing the
three samples of resultant knot. Thus, Roeder knot was first tested followed by
modified knot with one turn less (only 2 turns).The third modified Roeder knot
was having only one turn. The effect of each turn on knot breaking force was
observed. Similarly, the experiment was repeated with Meltzer, Tay-side knots.
Each of the modified knots having one turns less than the preceding. The effect
of simple turns around either loop or axis was observed in terms of knot breaking
force. In another set of knots, simple sliding knots with Dinsmore classification
were tested and the effect of additional throw or change in axial strand was
observed.

In the third experiment, the slip knot was modified arbitrarily by randomly putting
two turns or throws or making a Roeder’s knot to which two more throws of
sliding knot was added and again knot breaking strength was observed.

For making a knot, a second throw is required. The second throw can be on an
axial arm as in a square knot or on a complete loop (bowline knot). The second
throw however, can be a half throw if it is taken on one arm of loop instead of the
complete loop and the half throws are taken either on an axial arm of the loop or
looping arm of the loop.

4.1.3 SUGGESTED MODIFICATIONS IN NOMENCLATURE

Few of the terms used in describing these are defined.

(a) Nub: The Nub of a knot is the knotted portion. The nub does not include the
standing part or the tail. (b) Nip: The Nip of a knot is the place within the knot
where pressure provides friction. As used by Warner, it means, "the place where a
particular crossing first makes the knot secure"(c) Stem: The stem (shown
between the dotted lines), is the place where the standing part enters the nub.
The curve in the stem distributes the load unevenly, causing the knotted rope to
fail at Point X (d) Point X: Point X is the location just outside the knot where the
stem connects directly to the standing part. This is the place that a knot usually
breaks when it is overloaded.

(e) Collar The collar is the segment of suture that the stem passes through or over
as it enters the knot. The configuration of the collar helps to create and maintain
the characteristics of the stem and the lead. f) Hitch: It is the curving or arcing
part of the knot (g) Loop: It is the portion of the knot which acts as a lasso to
‘snare’ or ‘catch’ the tissue. There are two arms of the loop,

Formation of a knot involves

1 Throw

2 Half Hitch

3 Twists

4 Turn/wrap

5 Axis Arm or Standing Part

6 Looping Arm and Loop

1 Throw: This is any knot’s step or a layer. For the formation of a surgical or
square knot, two or more throws or knot steps are required. For example, a
square knot is formed by two throws, each throw having one turn. The first throw
always involves both the ends of a suture. The subsequent second throw
however, may be on axial arm or a loop arm

2 Half throws or a half hitch.

The difference in formation between half throw and half hitch is the way the
second end is turned after formation of a knot step.

Half knot is tied with two ends around an object in an over or under throw fashion

Half hitch is tied with one end of suture which is passed around an object and
secured to its own standing part.

It can be around either the loop or Standing Part of the suture. If around the loop,
it can be formed on entire loop or descending arm of the loop or even ascending
arm The good example is laparoscopic Roader knot or Meltzer’s knot.

3 Turn/Wraps: This is the number of wraps in given knot. The wrap can be
around standing part. This is aptly shown in Tay-side knot where, after formation
of loop with a half knot or first knot step, the suture is wrapped around the
standing part. Alternatively, the wrap can be around the loop as is depicted in
Roeder’s knot and its modifications. Every loop knot therefore has a standing part
and a loop and knot formed in the middle.
 Loop

Axis Arm Looping Arm

One Half Throw or hitch One Half Throw or hitch

Two Half Throws Two Half Throws

Wrapping (Turning)

Can be around

Loop Standing Part (Axis)

In same In opposite In same In Opposite

Direction direction

(of half knot) (of half hitch)

Of Preceding Throw direction of Preceding throw

Twist: Only a loop can be twisted to give a figure of 8 appearances. The twist can
be in clockwise or counterclockwise direction. The axial thread twist has no much
bearing.

4 When the suture is simply wrapped around a loop, we assigned the symbol WL
(W for wraps and L for around the loop and when it was wound around the
Standing Part (axial strand), we gave the symbol WA (W for wraps or turns and A
for axial strand or Standing Part).The symbol A over S or SP was chosen for
Standing part which is considered as Axial strand to avoid confusion when S is
assigned by Dinsmore to describe the second throw same as preceding one.

5 When the suture is wound around the loop, it can be (a) around complete loop
(WL) or around descending arm of loop (WDL) or the looping arm or ascending
arm of the loop (WAL)

6 The numbers 1 or 2 or 3 or 4 presents the number of turns. Thus it can be 3WL

when the suture was wound or turned simply 3 times around the loop or 2WA
when it was wound 2 times around the axial strand or standing part

7 Again the relation of simple turns to preceding throw can be shown by sign =
when the turns started in the same direction of preceding throw and when the
turns were wound round from the opposite direction of preceding throw, sign X
was assigned

8 Assign T for twist of the loop. If the twist was with descending arm over
ascending arm then TDL was assigned and twist having loop arm below axis arm,
TAL was assigned

9 Half throws or hitches. We assigned ½ H for half throws. If half throws were on
standing or axis arm of the loop then ½ HA and if it were on loop arm then ½ HL
was assigned. While taking the half throws, if the throw is from above then its
relation was shown by = sign and if it were from below then X was put. If a throw
is around whole loop or both the strands of loop then it is a single throw.
10 The // sign was assigned when there was a change in axial strength, if the next
throw turns in same direction as preceding one. The # sign was used when the
axial strand changes and the next throw is in the opposite direction of the
preceding one

With this new configuration, every type of sliding knots in laparoscopic surgery
can be configured and a prediction be made about knot security depending upon
a knot configuration

Thus for a Roeder knot for laparoscopic surgery, the modified configuration will
be S= 3(WL) =½HL. Note that in terms of Dinsmore classification it is really a
1½knot with configuration of S=½ HL and obviously not a strong one. This explains
why it is a weak knot. A Meltzer’s knot can be now configured as 2S=3(WL) = (½
HL X ½ HL).Even though the Meltzer is stronger than the Roeder’s as seen from
various literature and even configuration (as it has 2S=, like a surgeon’s knot),
again the question is whether two ½ HL will make one S in knot strength?

This new nomenclature deciphers the conventional and laparoscopic sliding knot
easily.

Different commonly used knots with the new nomenclature are given .In this way
all the knots can be deciphered easily.

Since the study was for the configuration of knots, we have used 2-0 vicryl for
knot holding capacity

4.1.4 SUGGESTED BJ KNOT

Extracorporeal BJ Loop Knot:

1)The loop knot is formed by taking free end of suture e.g. 1-0 vicryl and forming
a double throw with right over left suture and thereby making a loop.

2) A second throw is over the stem or standing part of the suture unlike Roeder
where the suture is wound round on the loop .The throw is right under the left
suture. A similar third and 4th throw can betaken in reversing position .The knot
can be described by modified Dinsmore classification as 2SxSxSxS. The knot can
also be formed according to the nomenclature of 2S=S=S=S when the knotting
arms are not reversed. Excess of the free end is snipped off keeping 1 cm tail.

3) The loop is then grasped with a Maryland forceps by holding at the fundus of
the loop and the assembly is introduced through appropriate trocar and reducer
system.

4) After ensnaring the free structure like appendix, and maneuvering it through
the loop, the Maryland forceps now holds the suture just above the knot gently.
The loop is shortened by pushing the knot down with Maryland and at the same
time pulling the long end.

5) After ascertaining the exact place where the knot is to be put, the Maryland is
pushed and at the same time long end is pulled to tighten the knot.

6) The knot is finally made more secure by grasping the free tail end of suture and
both the ends of the knot are pulled in opposite direction thereby converting
sliding knot to a flat knot.

7) Extracorporeal BJ in line Knot: This knot is taken by introducing one end of

suture round the duct or vessel to be ligated. Care is taken that there is no sawing
effect on the structure while retrieving through the same port. A knot is formed
outside the abdomen in a way described above and tightened with the Maryland
forceps as described above.

4.2 Analysis and Result

1 Knotting Data and Statistical Analysis was done in following categories.

1 Frequency distribution
2 The tabulation shoes means, variance and SD for various types of knots and
standard Errors of means. Confidence Interval Degree of Freedom and

One tailed or two tailed test of significance

3 Co-efficient of variation is also calculated for lose and tight knots as well as
for force of various knots

4 Measurement of relationship is calculated for

5 Graphs were constructed for various data presentation

6 Z test was calculated for significance of difference between means of force

of classical and Dinsmore configuration.

7 ANOVA or F test calculated for significance of difference of means.

8 Regression Analyses

Experiment 1 Table 1

No Conventional Projected Modified Load at % Strain at Force in

laparoscopic Classification Peak Autobreak N
Knot
(Kg

1 Tay-side std 3.425 20.78 33.58

2 Tay-side (3 3.424 18.02 33.56

turns

3 Tay-side (2 3.134 16.88 30.73

turns)
4 Roeder (std) 3.275 15.77 32.11

5 Roeder (2 3.502 21.63 34.34

turns)

6 Roeder (1 3.495 16.80 34.27

turn)

Experiment 2 Table 2 Projected Classification and Calculated force for various knots

No Conven Projected Modified Load at Peak Std Deviation Force in N

tional Classification
laparos (Kg)-Mean
copic
Knot

1. Roeder(S S= 3(TL) =1/2 HL. 6.519 0.350 63

td)

2. Roeder(2 S= 2(TL) =1/2 HL. 6.628 0.193 64.99

turns)

3. Roeder(1 S= 1(TL) =1/2 HL. 5.894 0.249 57.8

turn)

4. Meltzer 2S=3(TL) = (½ HL X ½ 7.217 1.083 70.77

HL)

5. Modified S=2(TL) = (½ HL X ½ 6.590 0.266 64.62

Meltzer HL)

6. Smith ½ HA=TL=1/2 HL//S 6.683 0.336 65.53

&Nephe
w

7. Tay- S=(4TA)=(½HLX½HL) 6.526 0.278 64.01

 side(std)

8. Tay- S=(3TA)=(½HLX½HL) 7.749 0.427 76

side(3
turns)

9. Tay-side S=(2TA)=(½HLX½HL) 7.008 0.494 68.72

(2 turns)

10. Tay-side S=(1TA)=(½HLX½HL) 7.104 0.157 69.66

(1 turn)

11. Blood (3TL)=1/2HA 7.338 0.632 71.96

12. Blood S=(3TL)=1/2 HA 6.940 0.675 68.05

modifie

13. Tennesse (1TL)=1/2 HL//S 7.336 0.404 71.94

14. BJ Knot 2SxSxS 6.953 0.528 68.18

15. Modified S(2ST)=S=S=S 6.787 0.329 66.55

1

16. Sx2StxSxSxS 7.234 0.241 70.94

2

17. S=2LTx(S)=S=S=S 7.568 0.120 74..21

3

18. S//2S#S#S#S 7.792 0.052 76.41

4

19. Sx TLxS#S#S#S 7.367 0.493 72.24

5

20. S//2LT//S//S//S 6.906 0.782 67.72

6

21. S//LT1#S#S#S 7.414 0.231 72.70

7

22. Sx2LTx(S)xSxSxS 7.705 0.90 75.56

8

23. S//2ST//S//S//S 7.397 0.196 72.53

 9

24. 10 Sx2Tx1xLxS#S#S 7.759 0.320 76.08

Table 3 Effect of Loose and Tight turn on Strength of a Knot

No Load at % Strain Loose or Force in N

Peak(Kg) at Tght
Autobreak winding

1. 3.360 20.76 Loose 32.95

2. 2.988 17.22 Tight 29.30

3. 3.463 17.46 Loose 33.96 ANOVA: Between Groups

4. 3.200 18.06 Tight 31.38 Design

Source SS df
5. 3.697 16.36 Loose 36.25
MS F P
6. 3.431 16.03 Tight 33.64
Knot 20.54 1
7. 3.490 14.80 Loose 34.22 20.54 6.2 0.0320

8. 3.093 14.06 Tight 30.33 Error 32.89 10

3.29
9. 3.698 17.97 Loose 36.26

10. 3.548 13.40 Tight 34.79

PAIRWISE COMPARISONS
11. 3.346 17.05 loose 32.81 [Q=TukeyHSD: *=p<0.05
**=p<0.01]
12. 3.193 14.82 Tight 31.31
AvB t(10)=2.50 p< 0.0315
13.
Q=0.0000
DESCRIPTIVE DETAILS

Knot Loose tight

A B

Mean 34.41 31.79

StDev 1.53 2.06

SE 0.63 0.84

Var 2.35 4.23

CI95% 1.65 1.65

N 6 6

Skew 0.443 0.500

zSkew 0.443 0.500

The table value of F ratio at 0.05 level of significance is 4.28. Since our value obtained is 6.2 which is
much more than that,we conclude that the looseness or tight winding of knot does affect the force

78
75

72
69

66
Y

63

60
57

54
51
1.2 2.4 3.6 4.8 6 7.2 8.4 9.6 10.8 12
Compare of Dinsmore and conventional force of knot

78
75

72
69

66
Y

63

60
57

54
51
Dinsmor

Convent

Univariate Analysis

0 Dinsmore Conventional

N 11 13

Min 66.55 57.8

Max 76.41 76

Sum 793.12 877.05

Mean 72.1018 67.4654

Std. error 1.03618 1.32526

Variance 11.8104 22.832

Stand. dev 3.43662 4.77829

Median 72.53 68.05

Skewness -0.275948 -0.160621

Kurtosis-1.49122 -0.691556

Geom. mean 72.0265 67.3071

F and T Test

SAMPLES

Dinsmor Convent

N: 11 N: 13

Mean: 72.102 Mean: 67.465

Var.: 11.81 Var.: 22.832

TESTS

F: 1.9332 p(eq): 0.30473

t: 2.6808 p(eq): 0.013653

Welch t 2.7561 p(eq): 0.011675

Permutation t test: p(eq): 0.0152

The table value of F ratio at .05 level of significance is 2.9130. Since our calculated value is 1.9332,much
less than the table value, we conclude that force of conventional knotting does not significantly differ
than the knot formed by Dinsmore classification
P=0.0140

Conventional Dindmore

N 13 11

Means 67.46 72.102

SD 4.78 3,436

Actual difference between Means=4.64

SE of the difference =2.82

4.64

Z= ----------- =1.64

2.82

Again hre, to reject a Null hypothesis, we need a Z vlue of 1.96. Since our computed value is lower than
yhat , we retain Null Hypothesis and conclude that there is no much difference in force between theknot
tied by conventional means and by modifiedDinsmore classification

Data of Knots on Lloyds Tensinometer

No Knot Observed Values Mean Force in N

force
in Lb
1. Roeder(std 6.3 6.8 6.9 7.7 6.92 30.78

2. Roeder (2 turn 3.1 4.4 3.75 16.68

3. Roeder (1 turn 3.4 5.2 5.8 5.93 26.37

4. Roeder 4.9 4.9 4.9 21.79

(modified

5. Meltzer(std) 5.7 5.7 5.3 5.56 24.73

6. Meltzer(1 turn) 3.9 3.2 3.55 15.79

7. Blood Knot 3.4 3.4 2.2 3 13.34

8. Blood 1.8 3.6 7.9 4.43 19.70

knot(modifid

9. Blood knot(2 2 4.5 7.5 4.66 20.72

turns

10. Blood Knot (1 1.9 2.7 3.1 2.56 11.38

turn)

11. Tayside(std) 3.4 2.8 4.3 3.5 15.56

12. Tayside (3 turns 2.7 3.4 2.8 2.96 13.16

13. Tayside(2 turns 3.3 5.2 2.7 3.73 16.59

14. Tay-side(1 turn 4.1 1.4 1.8 2.43 10.8

15. Tennesse(std) 3 8.5 6.3 5.9 26.24

16. Tennesse(modifi 2.5 2.4 1.7 2.2 9.78

e)

17. Smith and 1.5 2.3 3.3 2.36 10.49

Nephew
 18. Seoul medical 2 3.4 5.4 3.6 16.01
Centre

19. 2SxSxS 4.1 3.9 4 17.79

20. SxS=(2TA)=SxS 8.5 5.8 5.2 6.5 28.91

21. SxS=(2TA)=S//S 2.4 2.6 2.8 2.6 11.56

22. SLxSLxSLxSA 1.6 4.3 4.5 5.3 3.92 17.43

18
16
14
12
10
8
6
4
2
0

Results of BJ KNOT

The mean knot strengths +/- standard deviation (SD), measured in Newton. A two-way way analysis of
variance was performed to uncover differences in mean knot strength. Turkey multiple-comparisons
multiple
test was performed to determine the variability in strength of different knot geometries. The Roeder’s
knot breaking strength was measured
measure to be 29.4N ± 1.5N

For the Tay-side knot, S=(4TA)=(½HLX½HL)it

S=(4TA)=(½HLX½HL)it showed the knot breaking strength to be 31.6N

Simplified BJ Knot.2SxS having change in the axial Strand had more knot breaking strength (35 Newton±
1.3N) It was found that a configuration of having turns around the axial strand(TA) had more
knot breaking strength (34.5N± 2.6N ).
Graph 1

Graph2

4.3 DISCUSSION

A) With respect to open surgery, Dinsmore in 1995 combined Terra and Berg
nomenclature for flat knot and Trimbos nomenclature for sliding knot and
presented with his new nomenclature. Amortegui and Restrepo (34) simplified
the explanation of the Dinsmore nomenclature.

For flat knot, Dinsmore classification assigns number for each interlocking
throw. For a single throw, it will be 1 and for double it will be 2 and so on. If the
throws are in the same direction as that of preceding one, the relation between
two interlocking throw is shown as = and if the second throw is in opposite
direction to the preceding one ,their relationship is shown as X .Hence for a
Surgeons’ knot with first double throw is 2 and the succeeding throw in opposite
direction is 1 and their relationship is shown as 2X1. Thus depending upon the
single or double throws , their directions and total number of throws ,we can
have 2X1X1 or 2=1=1.

Sliding knots, more useful in laparoscopic surgery were divided into two
subcategories. Simple sliding knot and complex sliding knot. In Simple sliding
knot, one axial strand is constant and under tension and the second suture is
thrown in an interlock around it. For a sliding knot, symbol S is used. If each
subsequent throw is in opposite direction then the relationship between each
throw is shown by X and if the second throw is in same direction as that of first,
relation is shown by = sign . Hence the simple configuration is S=S=S=S or SXSXSXS
or SXS=SXS and so on. For a Complex Sliding knot, there is a change in axial strand.
Now if the second throw is in same direction as the first one after the change of
axial strand then their relation is shown by // and if it is in opposite direction after
the change of the axial strand, it is shown by # sign. Thus a knot can be SXS//SXS
or S=S#S=S#SXS.

However, various laparoscopic knots described by many surgeons like Roeder's

knot, Tay-side knot, Meltzer’s knot etc. could not be properly shown according to
the nomenclature. Some variations in the knot like wrapping around a strand or
taking a half hitch were not properly understood.

The modifications in the nomenclature have been proposed as potentially

valuable parameters in deciphering and understanding the qualities of the knots
in laparoscopic surgery.

b) SUGGESTED BJ KNOT

The comparison of the result of simplified BJ laparoscopic knot with Roeder’s

and Tayside knots and when they were reduced to Dinsmore configuration and
found that the BJ knot is a true knot in a sense but can not be said for Roeder’s or
Tayside. It was easy to form and learn and didn’t require pusher rod. This was
possible when all the sliding knots were properly deciphered to modified
configuration before tying to understand the knot security. The normal Roeder’s
knot breaking strength was measured to be 29.4N ± 1.5N. For the Tay-side knot,
S=(4TA)=(½HLX½HL)it showed the knot breaking strength to be 31.6N

Average simplified BJ Knot with a configuration of 2SxS with turns around the
axial strand (TA) had more knot breaking strength (34.5N± 2.6N) than the
Roeder’s knot. When there was a change in the axial Strand, it had even more
knot breaking strength (35 Newton±1.3N). These measurements are useful in
proposing the valuable parameter in knot making ease and the strength of BJ knot
over other knots like Roeder’s or Tay-side knot.
c) KNOT BREAKING POINT

Many experiments have been done to determine the relative strengths of

different knots, and these show that the break in a knotted rope almost invariably
occurs at the point just outside the 'entrance' to the knot (3) When a force is
applied while sliding the knot down to the standing part of the suture either by tip
of the dissector or pusher rod, full load comes to bear on the stem or standing
part of the suture just outside the knot. When the fully-loaded standing part
enters the knot and crosses another segment of suture, some of its load is
converted to pressure and friction, and the load on it is reduced. This reduction of
load takes place at all crossings and points of contact between surfaces in the
knot. Hence the full force falls only on the standing part entering the knot.

A braided suture is basically a string of entwined fibers whereas the

monofilament suture can be seen as a string of packed molecules which will resist
or support a force or pull. When a suture is straight as seen in standing part of any
knot, the load or force is transmitted along the length of the suture. Since it is in
straight line, the tensile force is evenly distributed along all the fibers or
molecules of the standing part. Therefore at any given cross section of the
standing part of the suture, all the fibers or molecules will carry the same load. At
the top of any knot, the bight or turn or collar of the suture, will make the stem to
curve or deviate from its straight path at an angle to the main line of longitudinal
forces in the knot. While a straight-line segment of suture distributes the load
equally on the fibers, a curved-line segment of the stem stretches the outside
fibers and compresses the inner ones, redistributing the load unequally. The
fibers on the inside of the curve have less force, while the fibers on the outside of
the curve have more loads. This uneven distribution of the force in the stem
caused by deviation or curve causes weakness of the suture at the point X .The
outside fibers carry more force or load than the inner fibers and are at a greater
stress. These outer fibers under the excessive load will stretch till they break and
the inner fibers unable to bear the additional force or load will break soon after.
Observation of knots breaking outside the knotted portion shows that even a
gentle curve at Point X reduces their strength sufficiently to cause them to break
at that point. Every crossing of the suture reduces equal and even load
distribution on the bends. Thus every curve will cause a weak point in the knot
but it is at the stem only, a sharp transition for the force is present making it a
weakest point to break. Therefore, complexity of knot with numerous and
repeated hitches and turns do not increase the knot’s strength.

What makes a particular knot stronger or weaker as compared to other? It

is the sharpness or gentleness of the curve in the stem. The sharper is the curve,
the weaker a knot becomes in strength because of sudden transition of the
distribution of a force. By turning the suture just below this curve to create a
collar for increasing the KHC or stability as is done in Roeder’s knot will create
rigidity at that point & maintain the sharpness at the stem causing weakness at
point X. A knot's strength depends largely on the radius of the first bend as the
loaded end of the rope enters the knot at stem. A very tight bend will result in a
weaker knot than one with a more gradual bend. (1,2)

This is in broad agreement while testing knot strength for the same type of
knot with the same batch of suture material varied in their strength curves. When
the first bend was sharply wound with fewer radiuses tended to have less
strength than when a gentler first bend was taken.