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ssss1 The “needle dance” for needle positioning. (A). The needle is touching a serosal surface. (B). The instrument is rotated along the axis, and/or pivoted as needed to rotate the needle. (C). The needle has rotated to the correct position. (D). The needle driver grasps the needle.

After obtaining an appropriate needle position as described earlier, the ratchet is engaged with a firm grasp of the needle as the bite is initiated.

With this method, the right‐hand instrument (needle driver) is always creating the throws around the left‐hand instrument. When maximal driving along the arc of the needle has occurred, the right‐hand needle driver is used to grasp the tip of the needle to disengage it from the tissue. The same instrument can then hold the needle without repositioning throughout the tying.

This tying technique lends itself best if a short suture (15 cm or less) and is quick. Disadvantages include tightening of the second throw with crossed instruments. Holding on to the needle instead of the suture material close to the knot also increases the risk for an inadequately tightened knot. Both instruments are located in the vertical plane above the suture site. A common novice mistake is to move the instrument tips from the suture site closer toward the surgeon, which will make knot tying harder.