In vitro holding strength of the laparoscopic Miller's knot compared with open Miller's knot, open surgeon's throw, and laparoscopic surgeon's throw in a vascular pedicle model

Abstract

Objective: To compare in vitro knot holding strength of the laparoscopic Miller's knot (LMK), open Miller's knot (MK), open surgeon's throw (Sx), and laparoscopic surgeon's throw (LSx) in a vascular pedicle model when used as the first throw for vascular ligation. Study design: Experimental study. Sample population: Ten constructs each of the Miller's knot and surgeon's throw performed openly and laparoscopically with 2-0 polyglyconate suture. Methods: Knot holding strengths of the LMK, MK, LSx, and Sx knots were evaluated on balloon dilation catheters used as vascular pedicle models. Laparoscopic knots were tied in a laparoscopic box trainer. Knot constructs were pressure tested to failure. Results were compared by Kruskal-Wallis and Steel-Dwass comparisons. Results: Both MK and LMK had mean leakage pressures above 300 mm Hg. The MK leaked at higher pressure than all other knots, including the LMK (P < .001). The LMK leaked at greater pressures compared with the Sx and the LSx (P < .001). No difference was detected between leaking pressures of the Sx and the LSx (P = .226), with both leaking at pressures below 40 mm Hg. Conclusion: The LMK created a more secure first throw compared with the Sx and leaked at supraphysiologic pressures. Clinical significance: The LMK has excellent knot holding strength on a vascular pedicle model and may be further evaluated for clinical application. 1 | INTRODUCTION Minimally invasive surgery (MIS) continues to increase in popularity and demand in veterinary medicine. 1,2 Vascular ligation with suture is a basic skill in traditional surgery that can be challenging and time consuming to perform laparoscopically.

WSAVA guidelines for the control of reproduction in dogs and cats

“…Many different types of knot designs have been used successfully for ligation of both the ovarian pedicle and mesovarium in dogs. Two-pass friction knots (miller's, modified miller's, constrictor and strangle knot) may be preferable to standard surgeon's or square knots, especially for inexperienced surgeons (Belluzzi et al, 2022;Erickson et al, 2020;Hazenfield & Smeak, 2014;Leitch et al, 2012) FIG 4. Sites of forceps and suture placement for transection of the ovarian pedicle.…”

“…Many different types of knot designs have been used successfully for ligation of both the ovarian pedicle and mesovarium in dogs. Two‐pass friction knots (miller's, modified miller's, constrictor and strangle knot) may be preferable to standard surgeon's or square knots, especially for inexperienced surgeons (Belluzzi et al., 2022; Erickson et al., 2020; Hazenfield & Smeak, 2014; Leitch et al., 2012) (Figs 7 and 8). Square knots may slip on the first throw if the tissue is excessively thick, and surgeons' knots can bind or “lock‐up” prematurely, creating a dangerous situation in which the surgeon falsely thinks the knot has been tightly applied when it is not (Smeak, 2019).…”

Laparoscopic Surgery: A Systematic Review of Loop and Knot Security, Varying with the Suture and Sequences, Throws, Rotation and Destabilization of Half-Knots or Half-Hitches

“…Cinch knots are still under active development to find the best balance between a less complicated knot, high loop security, and how to secure the knot afterwards. Also, the superiority of Millers knot [32,33] or constrictor knot [34] for sealing vessels so that they are leakproof will not be discussed.…”