Real-time objective assessment of knot quality with a portable tensiometer is superior to execution time for assessment of laparoscopic knot-tying performance

Ritter, E. Matt; McClusky III, David A.; Gallagher, A. G.; Smith, C. Daniel; McClusky, David A 3rd
September 2005
Surgical Innovation;Sep2005, Vol. 12 Issue 3, p233
Academic Journal
journal article
Objective: Laparoscopic intracorporeal knot tying is a difficult skill to acquire. Currently, time to complete a knot is the most commonly used metric to assess the acquisition of this skill; however, without a measure of knot quality, time is a poor indicator of skills mastery. Others have shown that knot quality can be accurately assessed with a tensiometer, but obtaining this type of assessment has typically been cumbersome. We investigated a new method of real-time assessment of knot quality that allows for more practical use of knot quality as a performance metric.Methods: Eleven experienced endoscopic surgeons tied 100 intracorporeal knots in a standard box trainer. Each of the knots was immediately tested using the InSpec 2200 benchtop tensiometer (INSTRON, Canton MA) where a knot quality score (KQS) is generated based on the load handling properties of the knotted suture. The execution time was also recorded for each knot.Results: The assessment of all knots ended with one of two end points: knots that slipped (n=48) or knots that held until the suture broke (n=52). Knots that slip are generally of poorer quality than those that held. Execution time did not correlate with knot-quality score (r=0.009, P=.9), and the mean execution time did not differ significantly between slipped and held knots (65 vs 68 seconds, P=.8). No completion time criteria were able to accurately predict slipped versus held knots. The mean KQS difference between held and slipped knots was highly significant (24 vs 12, P<.0001). A knot with a KQS exceeding 20 was nearly 10 times more likely to hold than slip.Conclusion: Time to complete a knot is a poor metric for the objective assessment of intracorporeal knot-tying performance in the absence of a measure of knot quality. Real-time evaluation of the knot quality can accurately distinguish well-tied knots from poorly tied knots. This mode of assessment should be incorporated into training curriculum for surgical knot tying.


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