How To Teach Knot Tying: A Kinesthetic Approach

Publication ID Published Volume
9328 January 30, 2013 9
University of California, San Francisco, School of Medicine


This resource is designed to help instructors teach surgical knot tying to novices. It includes an instructor’s manual discussing key kinesthetic aspects of surgical knot tying, and a stepwise pedagogical approach that uses these kinesthetic aspects to effectively teach trainees this basic surgical skill. Surgical instructors should use the manual to understand the theoretical basis for the curriculum prior to teaching it.

Accompanying the manual is a set of six skills exercises designed to help trainees practice to become proficient at tying surgical knots. Each exercise emphasizes kinesthetic principles, requires minimal setup, and is open to further development. A process-based evaluation tool accompanies each exercise, and can be used to measure trainee performance.

Finally, the resource includes an instructional video suitable for both instructors and trainees, demonstrating the key kinesthetic concepts that should be taught at each step. This should ideally be used to augment the teaching curriculum, but can stand alone to be disseminated as a home-based teaching tool.

The American College of Surgeons (ACS) provides online videos and a step-by-step guide to surgical knot tying; however, the standard curriculum does not emphasize kinesthetics such as hand positioning and suture handling. In a pilot study undertaken at our skills lab at UCSF, we randomized seventeen first-year medical students without prior surgical experience into groups utilizing ACS or kinesthetic instruction models. After one week of practice, we videotaped students performing six two-handed square knots; then four experienced surgeons scored the deidentified videos using a visual analog scale (VAS). Students returned their practice knots, and the lengths of these knots were measured as an indicator of practice to assess for confounding. We found that the kinesthetic group scored significantly higher than the ACS group, with no significant difference in the amount of practice between the two groups. This was a relatively small and short study, but the significant difference in a relatively short amount of practice time is expected and very promising. This data will be submitted in full for publication separately.


Kim E, Chern H, Huang E, Palmer B. How to teach knot tying: a kinesthetic approach. MedEdPORTAL Publications. 2013;9:9328.

Educational Objectives

Objectives for learners:

  1. Deconstruct the task of knot tying into its main components.
  2. Explain the key kinesthetic elements necessary for optimal knot tying.
  3. Demonstrate proper technique for tying two-handed square knots and two-handed half-hitches/slip knot.
  4. Describe the most common knots used in surgery.
  5. Compare and contrast the technique for tying a square knot and half-hitches/slip knot.

Objectives for teachers:

  1. Deconstruct the task of knot tying into its main components.
  2. Explain the key kinesthetic elements necessary for optimal knot tying.
  3. Describe how poor execution of the key kinesthetic elements can lead to error among novices.
  4. Utilize standard vocabulary for describing maneuvers and components of knots.
  5. Provide specific constructive feedback using a framework based on kinesthetic knot tying technique.


  • Surgical Closure Techniques, Knot Tying, Kinesthesis, Editor's Choice

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ISSN 2374-8265