For Extracorporeal Knotting knot pushers are utilized. These knot pushers are of either closed jaw or of open jaw type.
Extracorporeal knot Ligation for continuous structure:
* A push rod is threaded onto a length of ligature material approximately 1.5 m long.
* A knot is tied at the conclusion of the thread as it emerges from the straight end of the rod.
* The finish of the ligature emerging in the tapered end is grasped by atraumatic endoscopic grasper.
* The grasper and catgut are then passed into an introducer tube
* The introducer tube is then passed with an 11 mm cannula.
* The grasper and ligature are extended to the cavity and passed to 1 side and behind the structure to become ligated.
* A second grasper is introduced through a second port to grasp the ligature from the other part from the structure.
* The very first grasper releases the ligature and the takes it back from the second while watching structure.
* The very first grasper and ligature are withdrawn from the abdomen with the introducer tube as the second can be used to safeguard the structure in the suture.
* Another slip knot is tied externally. The knot tied is dependent upon how big vessel to be controlled and also the material in use.
* The knot is pushed into the abdomen through the push rod and positioned just before tightening.
* The rod is withdrawn a little and scissors brought to cut the thread leaving a reasonably long end
Extracorporeal knotting is preferred within the following situations:
* Ligature in continuity of large vessels
* Suturing in areas of limited access where the working space is restricted
* In the approximation of edges of defects where the force requires to approximate the edges is substantial
Rules governing external slip knotting
* the kind of the thread should be 1.5m and also the guage ought to be 2/0 or greater
* The type of slip knot selected depends on the ligature material being used. Certain slip knots provide sufficient holding strength with catgut although not with other materials.
* For any ligature material, the holding force (potential to deal with reverse slipping) of any surgical slip knot varies directly using its caliber. Thus the holding strength of a 1/0 slip knot is roughly twice that of the 2/0 equivalent.
* Stiff hydrophobic monofilament material ought to be avoided since it exerts a lesser frictional hold and it has a greater tendency to spill than braided.
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