Fig. 7.

TSOL knot technique. A needle holder goes 360° around the two strands of suture, starting underneath the suture strands (1). The proximal suture is then fed to the needle holder (2). Forceps are inserted into the overhand loop of the first throw to maintain the loop open, then slid down to tie the knot (3), since the knot cannot slide down to approximate the tissue ends if the overhand loop is closed. If the knot is tied under tension, an assistant needs to hold the knot in position, and then the overhand loop can be closed to tie the knot (4[a]). Alternatively, if a strong and low-friction suture material such as braided polyblend is used, the first two-strand overhand knot can be slid by separating the two strand ends (4[b]). Following the first throw of an overhand knot, a 2-throw square knot is added to form the TSOL knot (F).