{"id":465,"date":"2015-03-01T13:45:11","date_gmt":"2015-03-01T13:45:11","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=465"},"modified":"2022-02-16T16:17:27","modified_gmt":"2022-02-16T16:17:27","slug":"surgical-skills-creating-a-leak-proof-ligature-with-confidence-part-2-step-by-step-approach-to-surgical-binding-knots","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/soft-tissue-surgery\/surgical-skills-creating-a-leak-proof-ligature-with-confidence-part-2-step-by-step-approach-to-surgical-binding-knots\/","title":{"rendered":"Creating a Leak-Proof Ligature with Confidence, Part 2: Step-by-Step Approach to Surgical Binding Knots"},"content":{"rendered":"<div class=\"page\" title=\"Page 1\">\n<div class=\"section\">\n<div class=\"section\">\n<div class=\"layoutArea\">\n<div class=\"column\">\n<p>Certain binding knots are highly useful in achieving consistently secure ligations. Very little information is available in the human and veterinary literature describing indications and contraindications for use of binding knots for ligation, and we could find no published, well-illustrated instructions on how to tie these knots. There is also considerable confusion regarding the descriptions on tying, and correct names for, these knots.<sup>1<\/sup><\/p>\n<p>In this article series, Part 1\u2014<a href=\"https:\/\/todaysveterinarypractice.com\/creating-a-leak-proof-ligature-with-confidence-part-1-overview-of-ligation-surgical-binding-knots\/\" target=\"_blank\" rel=\"noopener noreferrer\"><strong>Overview of Ligation &amp; Surgical Binding Knots<\/strong> <\/a>(January\/February 2015 issue)\u2014 discussed suture selection and security and types of binding knots. This article provides step-by-step instructions on how to create the following knots:<\/p>\n<ul>\n<li>Double reverse half hitch (DRHH)<\/li>\n<li>Miller\u2019s knot<\/li>\n<li>Strangle knot: A new (to the surgery realm), highly effective, and easy-to-tie binding knot.<\/li>\n<\/ul>\n<h2>Qualities of Binding Knots<\/h2>\n<p>Ideal qualities of the first throw of a binding knot include the ability to:<\/p>\n<ul>\n<li>Cinch down tightly and completely without prematurely locking, allowing the surgeon to \u201cfeel\u201d when the knot does not cinch down any further during tensioning, which signals when the first throw is tightly applied<\/li>\n<li>Resist loosening once placed, allowing time for additional throws to be performed for a permanent secure knot.<sup>1,2<\/sup><\/li>\n<\/ul>\n<p>Binding knots commonly employed in veterinary surgery can be classified by how many passes areplaced around the pedicle:<\/p>\n<ul>\n<li><strong>1-pass binding knot:<\/strong> Chosen by some surgeons as it is easier to apply, requiring only 1 pass of the suture around the pedicle or vessel (eg, DRHH).<\/li>\n<li><strong>2-pass binding knot:<\/strong> Takes more effort to pass twice around the pedicle; however, first throw very effectively resists loosening (eg, miller\u2019s knot and strangle knot).<sup>3,4<\/sup><\/li>\n<\/ul>\n<p>Binding knots can be applied with either <strong>hand ties<\/strong> or <strong>instrument ties<\/strong>.We describe only hand ties in this article because, in general, complete tightening of each throw is less consistent with instrument ties\u2014as the surgeon receives less tactile feedback\u2014compared with hand ties.<sup>1<\/sup><\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"page\" title=\"Page 6\">\n<div class=\"section\">\n<div class=\"layoutArea\">\n<div class=\"column\">\n<blockquote><p><strong>KEY POINT:<\/strong> It is important to note that the binding knots described are considered the\u00a0first throw; they are made permanently secure by adding 4 square throws stacked on top of the binding knot.<\/p><\/blockquote>\n<p>Indications and specific comments about each type of knot are provided in the <strong>Table<\/strong>.<\/p>\n<table border=\"1\" width=\"580\" cellspacing=\"0\" cellpadding=\"5\">\n<tbody class=\"arial\">\n<tr>\n<td colspan=\"3\" valign=\"top\">TABLE.<br \/>\n<strong>Hand-Tied Suture Knot Indications &amp; Comments<\/strong><\/td>\n<\/tr>\n<tr>\n<td class=\"NAVCMint2\" valign=\"top\" bgcolor=\"#ffffff\"><strong>KNOTS<\/strong><\/td>\n<td class=\"NAVCMint2\" valign=\"top\" bgcolor=\"#ffffff\"><strong>INDICATIONS<\/strong><\/td>\n<td class=\"NAVCMint2\" valign=\"top\" bgcolor=\"#ffffff\"><strong>COMMENTS<\/strong><\/td>\n<\/tr>\n<tr>\n<td class=\"NAVCMint2\" colspan=\"3\" valign=\"top\" bgcolor=\"#7fcecd\"><strong>Double Reverse Half Hitch<\/strong><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\">\n<ul>\n<li>To <strong>incrementally tighten and draw together 2 structures under moderate to high tension<\/strong>, such as tying stifle imbrication sutures or, in arytenoid lateralization for canine laryngeal paralysis, to pull the arytenoid cartilage toward the cricoid with a suture to open the glottis<\/li>\n<li>To <strong>tie a knot deep within a body cavity<\/strong>, since the knot only needs 1 pass around or through a structure rather than 2 passes<\/li>\n<li>To <strong>create a knot outside the cavity first<\/strong>, where it is easy to manipulate the strands; the loosely formed knot is then slipped down to the deep structure or pedicle before being tightened and set<\/li>\n<li>To <strong>bring together rigid adjacent ribs during closure of a lateral thoracotomy approach<\/strong>; knot of choice for many surgeons because it holds the ribs tightly together until the knot is eventually secured with additional square throws<\/li>\n<\/ul>\n<\/td>\n<td valign=\"top\" bgcolor=\"#cccaca\">\n<ul>\n<li>This 1-pass binding knot may prematurely <em>bind<\/em> before being fully tightened; close attention to knot formation and strand tension is paramount for successful use; this is especially true when using this knot on multifilament suture material<\/li>\n<li>Formed exactly like a standard square knot, except the surgeon <em>purposefully<\/em> pulls up on the fixed strand while creating the 2 throws with manipulation of the free strand; this converts it from a square knot to a DRHH<sup>3<\/sup><\/li>\n<li>Double throws or hitches are slid down the more tensely held fixed strand before the knot is fully tightened<\/li>\n<li>The free end should NOT be tensioned until the hitches are pushed down to the desired intrinsic suture tension (the tension developed on the tissue encircled within the suture loop)<\/li>\n<li><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td class=\"NAVCMint2\" colspan=\"3\" valign=\"top\" bgcolor=\"#7fcecd\"><strong>Miller&#8217;s Knot<\/strong><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\">\n<ul>\n<li>The most traditionally taught 2-pass binding knot<sup>3<\/sup><\/li>\n<li>To <strong>tie off vessels or pedicles<\/strong>; works well on large pedicles, such as ovarian pedicles or uterine body during ovariohysterectomy<\/li>\n<\/ul>\n<\/td>\n<td valign=\"top\" bgcolor=\"#cccaca\">\n<ul>\n<li>Does NOT <em>bind<\/em> prematurely, providing confidence that the knot has been tensioned correctly to obstruct blood flow through the pedicle<\/li>\n<li>The knot strands have many surfaces in contact to increase friction and greater surface area of compression from the multiple suture passes encircling the pedicle<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td class=\"NAVCMint2\" colspan=\"3\" valign=\"top\" bgcolor=\"#7fcecd\"><strong>Strangle Knot<\/strong><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\">\n<ul>\n<li>Can be used in lieu of a miller&#8217;s knot; a variation of a 2-pass binding knot<\/li>\n<\/ul>\n<\/td>\n<td valign=\"top\" bgcolor=\"#cccaca\">\n<ul>\n<li>Preferable in our opinion because, similar to the miller&#8217;s knot, it stays tight even when its ends are manipulated but tends to be easier to tie and master<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div class=\"orange-box\">\n<h3>Hand and Strand Setup<\/h3>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-1-Standard-Horizontal-Bar-marked-copy2.jpg\"><img fetchpriority=\"high\" decoding=\"async\" class=\"size-full wp-image-4373 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-1-Standard-Horizontal-Bar-marked-copy2.jpg\" alt=\"Figure 1 Standard Horizontal Bar marked copy\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-1-Standard-Horizontal-Bar-marked-copy2.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-1-Standard-Horizontal-Bar-marked-copy2-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/a><\/p>\n<p>A standard hand and strand setup (<strong>Figure<\/strong> shown for right-handed surgeons) is used for each of the knots described in this article:<\/p>\n<ol>\n<li>Position the knot tying board with tubing horizontal, or perpendicular to your line of vision.<\/li>\n<li>Loop a 14- to 16- inch, unfixed or free, strand behind and underneath the tubing, held toward your body with your right hand.<\/li>\n<li>Grasp the fixed strand\u2014the strand that will have a needle or instrument attached (in image, this is white strand with knot on end)\u2014with the left hand and hold it in a \u201cgun\u201d shape: palm facing toward you; index finger extended; fixed strand held with left middle, ring, and little fingers; and left thumb held in neutral position.<\/li>\n<li>Drape and hold the fixed strand over the\u00a0left palm, facing your body.<\/li>\n<\/ol>\n<p>Depending on the surgeon\u2019s preference, this technique can be performed with either the fingers of the left hand or right hand forming the knot. Most right-handed surgeons choose the left hand manipulation technique in which the fingers of the right hand only deliver and tension the free strand while the left hand does the actual tying; however, if unsure, view the images in a mirror to see how the technique works holding the fi xed strand in your right hand, transferring the suture with your left.<\/p>\n<\/div>\n<h2>Step-by-Step<\/h2>\n<h2>Double Reverse Half Hitch (Hand Tie Technique)<\/h2>\n<\/div>\n<\/div>\n<div class=\"layoutArea\">\n<div class=\"column\">\n<p>STEP 1. Begin with the standard hand and strand setup (<strong>Figure<\/strong>): On top of your extended left index finger, cross the free strand in your right hand over the fixed strand in your left hand by moving the right hand away from your body at an angle to the left.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/FIgure-3A-Step-1-top-left-DRHH-First-Cross-Final1.jpg\"><img decoding=\"async\" class=\"size-full wp-image-4374 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/FIgure-3A-Step-1-top-left-DRHH-First-Cross-Final1.jpg\" alt=\"FIgure 3A Step 1 top left DRHH First Cross Final\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/FIgure-3A-Step-1-top-left-DRHH-First-Cross-Final1.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/FIgure-3A-Step-1-top-left-DRHH-First-Cross-Final1-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/a><\/p>\n<p>STEP 2. Pinch your left thumb and index finger inside the crossed suture loop you have created over your index finger; then turn your left hand and pinched thumb and index finger outward by pronation, allowing the cross in the suture loop to slip onto the left thumb.<\/p>\n<p><img decoding=\"async\" class=\"size-full wp-image-4375 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3B-Step-2Atop-right-DRHH-Final-first-pinch1.jpg\" alt=\"Figure 3B Step 2Atop right DRHH Final first pinch\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3B-Step-2Atop-right-DRHH-Final-first-pinch1.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3B-Step-2Atop-right-DRHH-Final-first-pinch1-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/p>\n<p>STEP 3. Continue to hold these pinched fingers in place with your thumb tip through the crossed suture loop. Keeping these fingers in position, slightly open the pinch between your thumb and index finger of your left hand. With your right hand, deliver the free strand to the slightly opened thumb and index finger of the left hand.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4376 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3C-Step-2B-bottom-DRHH-Pinch-first1.jpg\" alt=\"Figure 3C Step 2B bottom DRHH Pinch first\" width=\"451\" height=\"296\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3C-Step-2B-bottom-DRHH-Pinch-first1.jpg 451w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3C-Step-2B-bottom-DRHH-Pinch-first1-300x197.jpg 300w\" sizes=\"(max-width: 451px) 100vw, 451px\" \/><\/p>\n<p>STEP 4. As you pinch the free strand with your left thumb and index finger, release the free strand from the right hand. Keep pinching the free strand with your left hand and rotate the pinched set of thumb and index finger as you supinate the left hand. Drag the free strand through the crossed loop and deliver the strand to be re-grasped by the right hand.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4377 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3D-DRHH-Deliver-first1.jpg\" alt=\"Figure 3D DRHH Deliver first\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3D-DRHH-Deliver-first1.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3D-DRHH-Deliver-first1-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/p>\n<p>STEP 5. With the right hand loosely holding the free strand, lightly pull the fixed strand up toward you with the left hand, which shifts the first throw into a half hitch. <strong>Note:<\/strong> <em>This step differs from the standard 2-hand square knot technique (where the throw conformation is kept flat and even tension is applied to both strands).<\/em><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4378 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3E-DRHH-Pull-up-strand1.jpg\" alt=\"Figure 3E DRHH Pull up strand\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3E-DRHH-Pull-up-strand1.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3E-DRHH-Pull-up-strand1-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/p>\n<p>&nbsp;<\/p>\n<p>STEP 6. While holding the fixed strand with the left middle, ring, and little fingers, swing the left thumb under the fixed (<strong>white<\/strong>) strand and, with your right hand, cross the free strand toward you over the top of the fixed strand on top of the thumb; the thumb is now inside the crossed loop.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4379 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3F-DRHH-Second-pinch1.jpg\" alt=\"Figure 3F DRHH Second pinch\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3F-DRHH-Second-pinch1.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3F-DRHH-Second-pinch1-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/p>\n<p>STEP 7. Pinch the left thumb and left index finger and supinate the left hand, drawing the pinched thumb and finger through the crossed loop. Slightly open the pinched thumb and finger, allowing them to receive the free strand from your right hand. Release the free strand from the right hand as the left index finger and thumb grasp it.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4380 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3G-DRHH-pinch-strand-second1.jpg\" alt=\"Figure 3G DRHH pinch strand second\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3G-DRHH-pinch-strand-second1.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3G-DRHH-pinch-strand-second1-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/p>\n<p>STEP 8. Draw the free strand held by the pinched left thumb and index finger through the loop by pronating the left hand.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4381 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3H-DDRH-pull-second-strand-thru-loop1.jpg\" alt=\"Figure 3H DDRH pull second strand thru loop\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3H-DDRH-pull-second-strand-thru-loop1.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3H-DDRH-pull-second-strand-thru-loop1-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/p>\n<p>STEP 9. As you release the free strand from your left hand, pick up this strand with your right hand. Again, with your left hand, purposely pull up slightly on the fixed strand, while keeping the free strand in your right hand loose, creating a double half hitch.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3I-DRHH-second-throw-complete1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4382 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3I-DRHH-second-throw-complete1.jpg\" alt=\"Figure 3I DRHH second throw complete\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3I-DRHH-second-throw-complete1.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3I-DRHH-second-throw-complete1-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/a><\/p>\n<p>STEP 10. Simultaneously, while pulling the fixed strand up slowly with your left hand toward you (holding the free strand with your right middle finger and thumb), push the loose knot down with your right index finger toward the intended final knot location. Do NOT tighten this hitch knot with your right hand; just help push it down the relatively taut left strand.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3J-DRHH-FInal-push1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4383 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3J-DRHH-FInal-push1.jpg\" alt=\"Figure 3J DRHH FInal push\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3J-DRHH-FInal-push1.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-3J-DRHH-FInal-push1-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/a><\/p>\n<p>Once the structures you are tying are held firmly in position (or the ligature is tightly bound around a pedicle), and you are pleased with your knot placement, snug both strands equally and firmly to bind the knot in place.<\/p>\n<p>Finally, while holding tension on both strands, firmly pull the strands 90\u00b0 clockwise to the suture loop axis, and again snug the knot tightly. This maneuver converts this double hitch binding knot into a more stable knot that resists slippage as you stack at least 4 square throws over it.<\/p>\n<h2>Step-by-Step<\/h2>\n<h2>Miller\u2019s Knot (Hand Tie Technique)<\/h2>\n<p>STEP 1. Begin with the standard hand and strand setup (<strong>Figure<\/strong>): Cross the free strand held in your right hand over the extended left index finger by moving the right hand away from your body. Keep your left index finger extended inside the loop of suture created; then pinch the <em>crossed suture<\/em>.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-4A-MIllers-first-cross-final1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4384 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-4A-MIllers-first-cross-final1.jpg\" alt=\"Figure 4A MIllers first cross final\" width=\"451\" height=\"297\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-4A-MIllers-first-cross-final1.jpg 451w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-4A-MIllers-first-cross-final1-300x198.jpg 300w\" sizes=\"(max-width: 451px) 100vw, 451px\" \/><\/a><\/p>\n<p>STEP 2. Begin to bring the free end around the backside of the pedicle to the <em>left<\/em> of the first loop.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/FIgure-4B-Millers-second-pass-final1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4385 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/FIgure-4B-Millers-second-pass-final1.jpg\" alt=\"FIgure 4B Millers second pass final\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/FIgure-4B-Millers-second-pass-final1.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/FIgure-4B-Millers-second-pass-final1-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/a><\/p>\n<p>STEP 3. Continue to hold the fixed strand with your left middle, ring, and little fingers, and keep your left palm held toward you. Bring the free strand fully around the pedicle, up, over, and to the <em>left<\/em> of the original pinched cross. Hold both crossed strands with your left thumb and index finger. The fixed strand in your left hand should be to the left of the second pass looped around the pedicle. The second pass loop is to the left of the first pass loop.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-4C-Millers-second-pinch-final1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4386 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-4C-Millers-second-pinch-final1.jpg\" alt=\"Figure 4C Millers second pinch final\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-4C-Millers-second-pinch-final1.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-4C-Millers-second-pinch-final1-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/a><\/p>\n<p>STEP 4. With the right hand, move the free strand over the second loop and then under and between the first and second loops and pull the free strand away from you.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-4D-Millers-pass-under-first-loop-final2.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4387 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-4D-Millers-pass-under-first-loop-final2.jpg\" alt=\"Figure 4D Millers pass under first loop final\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-4D-Millers-pass-under-first-loop-final2.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-4D-Millers-pass-under-first-loop-final2-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/a><\/p>\n<p>STEP 5. Pull the free end away from you with the right hand and the longer fixed strand toward you with the left hand. Final miller\u2019s knot appearance is shown.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/SS-step-5.png\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-8102 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/SS-step-5.png\" alt=\"SS step 5\" width=\"289\" height=\"667\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/SS-step-5.png 472w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/SS-step-5-130x300.png 130w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/SS-step-5-444x1024.png 444w\" sizes=\"(max-width: 289px) 100vw, 289px\" \/><\/a><\/p>\n<h2>Step-by-Step<\/h2>\n<h2>Strangle Knot (Hand Tie Technique)<\/h2>\n<p>STEPS 1\u20133. <strong>Follow Steps 1 through 3 for the miller\u2019s knot<\/strong>.<\/p>\n<p>STEP 4. After you bring the free strand completely around the pedicle, up and over to the left of the original pinched cross, release your thumb on top of the crossed strands, and pinch the tips of your left index finger and thumb together <em>inside<\/em> the double pass loops.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-5A-Left-Strangle-pinch-after-second-pass-final1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4388 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-5A-Left-Strangle-pinch-after-second-pass-final1.jpg\" alt=\"Figure 5A Left Strangle pinch after second pass final\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-5A-Left-Strangle-pinch-after-second-pass-final1.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-5A-Left-Strangle-pinch-after-second-pass-final1-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/a><\/p>\n<p>STEP 5. Rotate your pinched thumb and index finger through the passes from right to left by pronating your left hand, and grasp the free strand. Now your left thumb is within the loops of the 2 passes.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-5B-right-Strangle-thumb-inside-second-loop1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4389 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-5B-right-Strangle-thumb-inside-second-loop1.jpg\" alt=\"Figure 5B right Strangle thumb inside second loop\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-5B-right-Strangle-thumb-inside-second-loop1.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-5B-right-Strangle-thumb-inside-second-loop1-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/a><\/p>\n<p>STEP 6. With the pinched left index finger and thumb, draw the free strand under both passes to exit on the right of the 2 crossed strands. Pull the free strand away from you with the right hand, and pull the fixed strand toward you with the left hand.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-5C-Stangle-strand-under-both-loops-final1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4390 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-5C-Stangle-strand-under-both-loops-final1.jpg\" alt=\"Figure 5C Stangle strand under both loops final\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-5C-Stangle-strand-under-both-loops-final1.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-5C-Stangle-strand-under-both-loops-final1-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/a><\/p>\n<p>STEP 7. When this knot is configured correctly, the 2 loops are crossed in the middle, the fixed strand extends under and to the left of the 2 loops, and the free strand is under and to the right.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-5D-Strangle-final-knot-final1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4391 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-5D-Strangle-final-knot-final1.jpg\" alt=\"Figure 5D Strangle final knot final\" width=\"450\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-5D-Strangle-final-knot-final1.jpg 450w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-5D-Strangle-final-knot-final1-300x200.jpg 300w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/a><\/p>\n<div class=\"orange-box\">\n<h3>Modified Miller\u2019s Knot: Caution \u2014 Not Recommended<\/h3>\n<p>A modified miller\u2019s knot is demonstrated below to show the difference in appearance and mechanics between this knot and the recommended ones demonstrated in this article.<sup>1,5<\/sup> When placed under expansile force, particularly on larger pedicles, this knot does not consistently resist loosening to the degree of the traditional miller\u2019s or strangle knots; therefore, we <strong>do NOT<\/strong> recommend its use.<\/p>\n<p>In the miller\u2019s knot, the strands are crossed on the first pass, and the second pass is to the <em>left<\/em> of the first formed loop.<\/p>\n<p>In the modified version:<\/p>\n<ol>\n<li>The first pass is wrapped around the pedicle but, instead of crossing the free strand over to the left as in the other 2-pass binding knots, the second pass remains to the <em>right<\/em> of the fixed strand.<br \/>\n<a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-6A1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-4392 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-6A1.jpg\" alt=\"Figure 6A\" width=\"402\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-6A1.jpg 402w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/Figure-6A1-300x224.jpg 300w\" sizes=\"(max-width: 402px) 100vw, 402px\" \/><\/a><\/li>\n<li>The free end is then brought over the top of the 2 passes (A) and fed through the dual loops from left to right (B).<br \/>\n<a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/SS-2A-copy-png.png\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-8103 size-full aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/SS-2A-copy-png.png\" alt=\"SS 2A copy png\" width=\"402\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/SS-2A-copy-png.png 402w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/SS-2A-copy-png-300x224.png 300w\" sizes=\"(max-width: 402px) 100vw, 402px\" \/><\/a><br \/>\n<a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/SS-2B-copy-png.png\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-8104 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/SS-2B-copy-png.png\" alt=\"SS 2B copy png\" width=\"402\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/SS-2B-copy-png.png 402w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/03\/SS-2B-copy-png-300x224.png 300w\" sizes=\"(max-width: 402px) 100vw, 402px\" \/><\/a><\/li>\n<\/ol>\n<\/div>\n<\/div>\n<h2>Summary<\/h2>\n<p>Ideally, a tightly placed binding knot will remain taut around a pedicle until subsequent square throws are completed, permanently binding the tight ligature knot in place and safely maintaining hemostasis.<\/p>\n<hr \/>\n<p>DRHH = double reverse half hitch<\/p>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Follow these step-by-step instructions for creating double reverse half hitch, miller\u2019s, and strangle knots.<\/p>\n","protected":false},"author":1,"featured_media":626,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":3344,"footnotes":""},"categories":[357],"tags":[13],"class_list":["post-465","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-march-april-2015","tag-peer-reviewed","column-features","clinical_topics-soft-tissue-surgery"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO v27.3) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Creating a Leak-Proof Ligature with Confidence, Part 2: Step-by-Step Approach to Surgical Binding Knots | Today&#039;s Veterinary Practice<\/title>\n<meta name=\"description\" content=\"Follow these step-by-step instructions for creating double reverse half hitch, 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