Some surgeons choose to use slip knots or granny knots intentionally in certain circumstances, but you should make this decision intentionally based on the amount of tension across the knot and the relative importance of knot security. Square knots fail by breakage due to limitations in the strength of the suture, while granny knots are more likely to fail due to slippage or unravelling. Square knots are inherently more secure than granny knots (or sliding knots). At this point you should practice while wearing gloves, tying in a narrow cavity, and/or tying under increased tension. Once you have reached automaticity you should be able to reliably tie a square knot without slippage and without looking at your hands. When practicing knot-tying, it is helpful to start by using rope or string, and then work towards larger sutures and eventually smaller sutures. ![]() Remember that tissue will likely continue to swell after the wound is closed. The goal of knot tying is “approximation not strangulation.” In other words, the knot should be tightly enough such that the knot will not slip and that tissue is brought together snugly, but not so tight that the tissue is rendered ischemic which can lead to wound breakdown. It is also much easier to tie a square knot using two hands, which increases knot security. While many trainees gravitate to the one-handed tie due to increased speed, the two-handed tie allows much better control of tension across the knot. The two-handed tie is the fundamental skill of all of general surgery.
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