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Asian J Endosc Surg ISSN 1758-5902

SURGICAL TECHNIQUE

New suture: Tail clinch knot for transabdominal preperitoneal hernia repair Kazunori Uchida,1 Hiroshi Morimoto,1 Hirotaka Tashiro,1 Hideki Ohdan1 & Manabu Yamamoto2 1 Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan 2 Hiroshima University Hospital, Adachi Kyosai Hospital, Hiroshima, Japan

Keywords Hernia repair; transabdominal preperitoneal (TAPP); suture Correspondence Kazunori Uchida, Department of Surgery, Chuden Hospital, 4-27, 3 Chome, Ohtemachi, Nakaku, Hiroshima 730-8562, Japan. Tel: +82 241 8221 Fax: +82 541 3404 Email: [email protected]

Abstract Introduction: There is some controversy regarding the proper surgical method for inguinal hernia repair and whether transabdominal preperitoneal or totally extraperitoneal repair should be used. The greatest difference between these procedures is the need for absorbable sutures to close the peritoneal incision. Materials and Surgical Technique: The clinch knot is a kind of slip knot that is used for securing a fishing lure, hook, or swivel to a fishing line. This knot is used by fishermen and has historically proven to be secure. Discussion: When a clinch know is placed at the tail end of a suture thread, a running suture can be started without knot tying.

Received 29 June 2014; accepted 13 July 2014 DOI:10.1111/ases.12133

Introduction There is some controversy regarding the proper surgical method for inguinal hernia repair and whether transabdominal preperitoneal or totally extraperitoneal repair should be used. The greatest difference between these procedures is the need for absorbable sutures to close the peritoneal incision. The clinch knot is a kind of slip knot that is used for securing a fishing lure, hook, or swivel to a fishing line. This knot is used by fishermen and has historically proven to be secure. When a clinch knot is placed at the tail end of a suture, a running suture can be started without knot tying.

Materials and Surgical Technique Usually, manipulating a suture more than 20 cm in length is difficult in laparoscopic surgery. If the suture material is cut at a length of about 25 cm, it will be about 20 cm in length after a tail loop is made. The method for tying a clinch knot is described and pictured herein. First, make a horseshoe-shaped loop. Hold the suture thread with the left hand, and pinch the

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tag with the thumb and index finger. Place the suture hook adequately close to the needle, and pull the suture with the little finger to prevent injury by the needle. Then, insert the first two right fingers into the loop. Turn the right hand clockwise, and twist the horseshoe-shaped loop five times (Figure 1). Next, pass the tag back up through the loop, and then, pass it down under the final turn. A slip knot can be easily created at the tail end of the suture (Figure 2). When the suture material is inserted into the abdomen through a trocar, the loop should be held tightly against the loose thread. If the suture thread is held alone, the loop will be clinched by the trocar valve. After the first stitch, pass the needle through this loop, and slowly pull the suture thread. The pre-tied loop will form a secure knot (Figure 3).

Discussion This new clinch knot technique is very useful for starting a running suture in a transabdominal preperitoneal closure, for example. This avoids stress at the first knot.

Asian J Endosc Surg 8 (2015) 98–99 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.

Tail clinch knot for TAPP repair

K Uchida et al.

Figure 1 First step in creating the pre-tied clinch knot.

Figure 3 Actual clinical use.

nique for tying the clinch knot is an inherited and popular fisherman’s technique. If the running suture is secured at the start with a simple overhead knot, the knot will easily loosen when the thread is pulled. If a simple knotted loop is placed at the end of the suture thread, the knot can become stuck at the stitch hole instead of fastening the suture thread. In this case, if the thread is pulled more tightly, the knot will tear the stitch hole. \Thus, the pre-tied knot is an improvement over the slip knot. Figure 2 Completion of the knot.

Acknowledgment The idea of the tail clinch knot is similar to that reported by Weston (1). He described a new technique for making a slip knot and proposed that it be used to start a running suture. Our technique differs from his in several aspects. Firstly, the suture thread is clinched by the pre-tied slip knot, and the starting knot is made simply by pulling the suture thread. Moreover, the tech-

The authors have no financial ties to disclose.

Reference 1. Weston PV. A new clinch knot. Obstet Gynecol 1991; 78: 144– 147.

Asian J Endosc Surg 8 (2015) 98–99 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.

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