Full text of DOI:10.1007/s005950070132

Surg Today (2000) 30:571–573
How to Do It
A Simple Technique of Using Novel Thread-Holding and
Knot-Pushing Forceps for Extracorporeal Knot-Tying
Haruhiro Inoue, Youichi Kumagai, Katsunori Ami, Tetsuro Nishikage, Hiroyuki Baba, Tatsuya Yoshida,
and Takehisa Iwai
First Department of Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
Abstract: We designed some novel knot-pushing forceps for
extracorporeal knot-tying and describe herein our simple
technique of utilizing them. These forceps are modified only
by a single 1-mm hole between their jaws, which hold a thread
and push the knot toward the ligating tissue. The application
of this simple device was handled well by surgeons beginning
to perform advanced endoscopic surgery. The simple modifi-
cation explained in this report seems applicable to most of the
forceps currently used.
from the rims of the forceps when the knot is being
pushed, the process is slowed down by the need to re-
peatedly reload them onto the rims. In an effort to
overcome this problem, we designed novel forceps to
achieve easier and faster extracorporeal knot-tying. We
describe this device and the procedural details herein.
Device
Key Words: extracorporeal knot-tying, knot pusher, knot-
tying forceps
The external appearance of the device is similar to that
of the more commonly utilized tissue dissector, and the
novel knot pusher also maintains the same function as
the original forceps. Each blade of the forceps poses a
symmetrical straight groove on its inner surface, that
creates a 1-mm hole when the jaw is closed (Fig. 1),
which loosely holds a single thread inside it, permitting
smooth movement of the forceps along the captured
thread. Each groove on the blade is smooth-edged so as
not to damage the thread itself. The depth of the groove
is equal to the height of the teeth, so that the toughness
of the blade is not compromised from the original. Kelly
forceps with a sharply curved tip are shown in Figs. 1
and 2, but any type and size of tissue dissector available
on the market can accept this simple mechanism only
with a symmetrical gutter on each blade.
Introduction
Knot-tying is one of the basic and fundamental skills
needed to accomplish advanced endoscopic surgery,
and its techniques can be categorized into two groups,
namely, intracorporeal and extracorporeal tying. The
application of each procedure is substantially decided
by the operator’s preference. Intracorporeal knot-
tying demands more than standard skills for smooth
achievement. Many improved methods have been advo-
cated,1–4 but it can still remain time-consuming for un-
skilled hands. The main reason for technical difficulties
is considered to be the limitations of movement of the
forceps used. In other words, if intracorporeal knot-
tying was always technically easy, there might be no
need for extracorporeal knot-tying. Many devices and
procedures have been reported for extracorporeal knot-
tying, the jaw opening-type knot pusher being one of
the most popularly utilized.5 This device usually makes
knot-tying easier, but once threads happen to drop off
Procedures
Any material of thread less than 1-0 in size can be
mounted on the forceps. After making a loop of thread
around the target tissue either by suturing or just by
passing behind it, both ends of the thread are pulled up
outside the patient’s abdomen through a trocar. The
first simple tie is manually created outside the abdomen
and one distal end of thread is held in the hole made at
the tip of the forceps. The knot is pushed into the ab-
dominal cavity through the trocar, being led by these
Reprint requests to: H. Inoue
(Received for publication on June 23, 1999; accepted on Jan.
7, 2000)

572
H. Inoue et al.: Knot-Pushing Forceps
fixation of a fundic patch during laparoscopic Nissen
procedure for reflux esophagitis, and the laparoscopic
Heller-Dor procedure for esophageal achalasia. The
suture materials used were: 2-0 prolene (polypropylene
suture, Ethicon, Somerville, NJ, USA) in eight
procedures; 1-0 silk in six procedures; and 1-0 dexon
(Braided polyglycolic acid suture with polycaprolate
coating, Sherwood Davis & Geck, Cyanamid Medical
Device, Anyang, Korea) in three procedures. No
incidence of misloading or misholding of the thread
occurred during any of these procedures. Knot-tying
was smoothly and successfully achieved in all attempts
by three surgeons. Two surgeons beginning to perform
endoscopic surgery were included, both of whom
successfully completed every procedure.
novel forceps. Both distal ends of the thread are held in
the surgeon’s left hand, and the forceps which hold one
thread are pushed down into the abdomen by the
surgeon’s right hand (Fig. 2a). The forceps never miss
the captured thread unless the jaw happens to open.
The knot is tightly fastened by the countertraction be-
tween the right-handed forceps pushing forward and
the left-handed threads pulling backward (Fig. 2b). To
tightly fasten the knot, countertraction could be applied
by direct grasping of the thread held by the forceps,
after releasing the thread from the hole if necessary. To
complete the knot-tying procedure, the whole process
should be repeated as often as necessary depending on
the thread materials used.
Results
Discussion
These novel ligating forceps were trialed in 17 consecu-
tive procedures for which extracorporeal knot-tying was
required, such as diaphragmatic crural closure and
The most outstanding feature of this novel method is
the simplicity of the device and the procedure itself. The
device is actually made from a commonly used dissector
such as Kelly forceps, modified by only a single gutter
on each blade.
In principle, the extracorporeal knot-tying procedure
consists of four components, namely, mounting a knot
on the knot-pushing forceps; pushing the knot to the
ligated tissue; fastening the tie at the target tissue; and
releasing the device from the threads after ligation. The
initial process using this novel device involves holding a
single thread in the hole at the tip of the forceps by
placing a single thread along the gutter of the blade,
then closing the jaw of the forceps. The second process
involves only advancing the forceps toward the target
tissue. As shown in Fig. 2a, by advancing the thread-
holding forceps, the knot is also pushed toward the
target tissue and the operator never misses the thread
because the forceps keep the thread inside the hole.
The third process involves fastening the tie by sym-
metrical countertraction. As shown in Fig. 2b, both
ends of the tie are countertracted symmetrically
simply by passing the forceps over the target tissue at a
Fig. 1. The modified tip of the forceps. Only a single gutter
exists on the inner surface on each blade of the Kelly forceps.
A 1-mm hole is created by closing the jaw of the forceps
Fig. 2a,b. Process of extracorporeal
knot-tying utilizing the novel thread-
holding forceps. a One end of the
thread is kept in the hole in the forceps,
so the operator can move it back and
forth as desired without losing the
thread. b Countertraction between the
forceps in the operator’s right hand
which holds one thread and the distal
end of the threads in the operator’s left
a
b
hand which creates a tight knot

H. Inoue et al.: Knot-Pushing Forceps
573
short distance. The fourth process involves opening
the jaw of the forceps, whereby the held thread is
automatically released.
We checked pamphlets from 22 companies and re-
searched the literature by Medline, but were unable to
find any similar device. It is considered that this will
benefit many surgeons who perform advanced endo-
scopic surgery.
As the key mechanism is the simple gutter, it is not
necessary to have special forceps. The depth of the
gutter is limited to the height of the teeth on each
blade, which is why the stiffness of the tip of the
forceps is equivalent to the original dissector without a
gutter. The technique involves only pushing the knot
by the forceps and holding one side of the thread;
therefore, even surgeons who have just started per-
forming advanced endoscopic surgery can easily carry
out extracorporeal knot-tying by using these minor
modified forceps. Figure 1 shows a photograph of
modified Kelly forceps with a 10-mm outer diameter,
but the same modification was successfully made to
Maryland forceps with a 5-mm outer diameter. In the
forceps with a 5-mm outer diameter the hole size is
limited to 0.5mm, which permits a 3-0 suture to be
ligated with mild resistance.
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