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(E).

(B).

(D).(E).(G).

(A).

ssss1 Extracorporeal knot tying requires the use of a knot pusher. (A). These can be of open type, as depicted here, ore closed‐and thus threaded onto the suture. (B). By advancing the knot pusher while applying tension on the suture end, the knot is cinched.

Complex slip knots do not accept any tension placed on the loop end while being cinched, and it is more practical to cinch them into the abdomen along the post end of the suture, with a short loop end, and the remainder of the throws are placed with intracorporeal technique.

The simplest of slip knots is a regular single throw advanced and cinched down with the knot pusher, but this does not withstand any tension on the suture line. A great number of more complex knots have been described for the latter purpose, and the veterinary literature has evaluated the performance of a number of these, including the 4S modified Roeder (4SMR), modified Roeder, and Weston and Brooks knots [17]. The 4SMR knot was significantly stronger than the other knots. Weston and many other slip‐knots require added throws for security. The 4SMR and Weston knots have also been compared in smaller suture size, 3‐0 polyglactin and polydioxanone (PDS). The 4SMR, a complex knot without need for added throws, performed comparable to a Weston with three additional square throws in 3‐0 PDS but tended to slip with the braided polyglactin, which was counter‐intuitive. The Weston knot performed well in both braided and monofilament suture, with the added 3 throws [18]. In our experience, the 4SMR knot is very sensitive to errors; with any air in the knot it becomes prone to slippage. We therefore prefer the use of a modified Roeder knot (ssss1), similar to that described by Ragle [19].