Task Analysis of Tumble Square Knot
1) Cutting the suture 24 cm
2) Inserting the Maryland in the reducer
3) Holding the suture in the middle
4) Hiding in the reducer
5) Inserting in the abdomen with the reducer
6) Dropping over the tissue in a way that tip should be left and the tail should be right
7) Align the needle by the following three techniques
a) Pressing the needle by upper jaw of the needle holder at the junction of one third and two third.
b) Holding the needle by left hand at the curvature and pulling suture up near the needle by the right hand
c) Hang the needle by left hand like a pendulum and go with the open jaw of the needle holder keeping the moving jaw to the leftand dragging it to the right
8) Stabilize the tissue by the left hand and prick the tissue by the needle and by rotating the tip of needle to keep it perpendicular to the tissue.
9) Bringing the tip of the needle 1/3rd out and catch it with left hand instrument and keeping the convex end of the instrument towards the tissue.
10) Guard the tissue by the needle holder keeping concave part towards the tissue and pulling the needle by left hand instrument
11) Hold the needle by the needle holder as soon as needle is out and take bite at the other side of tissue to be approximated and then pull the needle with Maryland while supporting the tissue with needle holder and once the needle is out hold the suture with needle holder.
12) Guard the suture by the Maryland and pull the suture by the needle holder to make a tail. The length of the tail should be defect plus 2 cm
13) A ‘C’ shape will form and keep the left hand instrument above and in the centre of the ‘C’
14) Bring the tip of the needle holder near the tip of the Marryland and rotate the needle holder clockwise to make a loop
15) Keep the Maryland static and take one loose wrap by the needle holder
16) Move both the instruments together to catch the tail by the Maryland
17) After catching the tail don’t pull the tail but move the needle holder towards the tip of the Maryland. The Knot should be placed towards the left side with tail facing upwards. The knot should not be placed in the middle neither in the right side.
18) Drop the suture away from the Maryland and keeping the loop loose hold the suture with the Maryland and make a reverse ‘C’
19) Now keep the needle holder static in the centre and above the reverse ‘C’
20) Hold the suture with Maryland and bring the tip of Maryland near the tip of needle holder
21) Rotate the Maryland anti-clockwise to make a loop
22) Keeping the needle holder static, take a single wrap with Maryland
23) Needle holder will catch the tail but tail should not be pulled.
24) Maryland will slide the loop in the direction of the tip of the needle holder
25) Maryland will drop the suture and then tighten the knot. It will be a square knot.
26) Now pull the needle end and the limb on the same side as the needle end in the opposite direction to convert square knot into slip knot i.e tumbling.
27) Now slip the knot with the help of marryland to tighten the tissue and bring them together till buttock sign is formed. The knot should be hold with 3rd or 4th serrated jaw of the marryland. It should not be hold with the tip neither with the base.
28) Now hold the long end with Maryland and tail with needle holder and pull the tail to untumble the slip knot to square knot and lock the knot.
29) Keep the Maryland steady and hold the needle end with needle holder and pull it to make ‘C’.
30) Now hold the suture with needle holder and keep the Maryland steady and in the centre of ‘C’.
31) Rotate the needle holder clockwise to make a loop and take one wrap over the Maryland with the needle holder.
32) Both the instruments move together to hold the tail with the Maryland and needle holder will slide the wrap in the direction of the tip of the Maryland
33) Needle holder will leave the suture away from the knot and come again to catch the suture near the knot
34) Needle holder and Maryland by holding the suture will move in the opposite direction to tight the last knot in the tissue plane.
35) Hold the needle end of the suture with the Maryland and remove the needle holder.
36) Introduce the scissor in the right port and cut the suture.
37) Hide the suture in the reducer by pulling the Maryland and pull Maryland and the reducer together out.
38) Push the Maryland to eject the needle.
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