{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T12:07:25Z","timestamp":1789042045694,"version":"build-2803163510"},"reference-count":25,"publisher":"MJS Publishing, Medical Journals Sweden AB","license":[{"start":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T00:00:00Z","timestamp":1788998400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JPHS"],"abstract":"<jats:p>Background: Various suturing and knotting techniques exist to enhance microsurgical efficiency, yet a comprehensive comparison is lacking. This study evaluates two suturing (interrupted vs. open-loop) and two knot-tying (conventional vs. airborne) techniques to determine how anastomosis time is apportioned between them.\nMethods: Seventy-two femoral artery anastomoses were performed on 36 female Wistar-albino rats by nine microsurgeons, stratified into three groups (&lt;1, 1\u20134, &gt;4 years experience). The four combinations were interrupted or open-loop suture with conventional or airborne knot (IS-CK, IS-AK, OLS-CK, OLS-AK). Each surgeon performed all four before and after a standardised practice session, making technique and practice within-subject factors and experience a between-subject factor, analysed by split-plot repeated-measures ANOVA. Twelve anastomoses from the most experienced group were examined by scanning electron microscopy (SEM), blind to technique and operator.\nResults: The knot-tying method, rather than the suturing technique, was the principal factor associated with anastomosis time. Conventional knotting was approximately 11 min faster than airborne knotting (666 s; p &lt; 0.001), whereas the two suturing techniques differed by 18.6 s within conventional knotting (p = 0.46) and 82.3 s within airborne knotting (p = 0.005) \u2013 approximately 1% and 4% of total time. Experience dominated (51.2 vs. 13.3 min; 3.85-fold; p &lt; 0.001). All techniques improved after practice, and the improvement depended on the technique (F(3,18) = 8.30, p = 0.001): approximately 15% for the airborne-knot techniques vs. 5\u201310% for the conventional-knot techniques. SEM showed a dissociation: suture spacing was determined by the suturing technique (open-loop superior, p = 0.001) and knot quality by the knot-tying technique (airborne superior, p &lt; 0.001); neither affected suture\u2013tissue interaction (p = 0.77).\nConclusion: In elective, uncomplicated anastomoses the knot-tying technique, rather than the suturing technique, was most strongly associated with anastomosis time, while surgical experience outweighed both. The airborne knot costs approximately 11 min but yields better knot quality and improves most with practice; the open-loop suture gives more regular suture spacing at negligible time cost. Technique selection is therefore a trade-off between ischaemia time and technical refinement, informed primarily by the operator\u2019s experience.\nGrant sponsor: \u00c7anakkale Onsekiz Mart University Scientific Research Projects Coordination Unit.\nGrant number: TTU-2024-4668.<\/jats:p>","DOI":"10.2340\/jphs.v61.46794","type":"journal-article","created":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T11:12:35Z","timestamp":1789038755000},"page":"229-236","source":"Crossref","is-referenced-by-count":0,"title":["Suturing and knot-tying techniques in microsurgery: anastomosis time, learning curve and scanning electron microscopic assessment"],"prefix":"10.2340","volume":"61","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4064-6757","authenticated-orcid":false,"given":"\u00c7a\u011fhan","family":"Benli","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3302-0521","authenticated-orcid":false,"given":"Mustafa","family":"Aky\u00fcrek","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1183","published-online":{"date-parts":[[2026,9,10]]},"reference":[{"key":"167963","doi-asserted-by":"crossref","unstructured":"Gardiner MD, Nanchahal J. 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Continuous locked suture technique for arterial anastomosis in rat small bowel transplantation. Microsurgery. 2007;27(2):112\u2013117.","DOI":"10.1002\/micr.20315"},{"key":"167971","doi-asserted-by":"crossref","unstructured":"Mudigonda SK, Murugan S, Velavan K, et al. Non-suturing microvascular anastomosis in maxillofacial reconstruction \u2013 a comparative study. J Craniomaxillofac Surg. 2020;48(6):599\u2013606.","DOI":"10.1016\/j.jcms.2020.04.005"},{"key":"167972","doi-asserted-by":"crossref","unstructured":"Maruccia M, Fatigato G, Elia R, et al. Microvascular coupler device versus hand-sewn venous anastomosis: a systematic review of the literature and data meta-analysis. Microsurgery. 2020;40(5):608\u2013617.","DOI":"10.1002\/micr.30585"},{"key":"167973","doi-asserted-by":"crossref","unstructured":"Davis CR, Rappleye CT, Than PA, et al. Sutureless microsurgical anastomosis using an optimized thermoreversible intravascular poloxamer stent. Plast Reconstr Surg. 2016;137(2):546\u2013556.","DOI":"10.1097\/01.prs.0000475774.37267.3f"},{"key":"167974","doi-asserted-by":"crossref","unstructured":"Broer PN, Weichman KE, Tanna N, et al. Venous coupler size in autologous breast reconstruction \u2013 does it matter? Microsurgery. 2013;33(7):514\u2013518.","DOI":"10.1002\/micr.22169"},{"key":"167975","doi-asserted-by":"crossref","unstructured":"Geierlehner A, Rodi T, Mosahebi A, et al. Meta-analysis of venous anastomosis techniques in free flap reconstruction. J Plast Reconstr Aesthet Surg. 2020;73(3):409\u2013420.","DOI":"10.1016\/j.bjps.2019.11.033"},{"key":"167976","doi-asserted-by":"crossref","unstructured":"Sert G, Aksoyler D, Kara M, et al. Comparison of total anastomosis time between four different combinations of suturing and knot tying techniques in microsurgical anastomosis. J Plast Surg Hand Surg. 2023;57(1\u20136):240\u2013246.","DOI":"10.1080\/2000656X.2022.2052083"},{"key":"167977","doi-asserted-by":"crossref","unstructured":"Sapountzis S, Kiranantawat K, Lim SY, et al. A novel \u2018\u00adcontinuous-interrupted\u2019 method for microvascular anastomosis. Microsurgery. 2014;34(1):82\u201384.","DOI":"10.1002\/micr.22174"},{"key":"167978","doi-asserted-by":"crossref","unstructured":"Simsek T, Eroglu L, Engin MS, et al. End-to-end microvascular anastomosis in the rat carotid artery using continuous horizontal mattress sutures. J Reconstr Microsurg. 2006;22(8):631\u2013640.","DOI":"10.1055\/s-2006-956237"},{"key":"167979","doi-asserted-by":"crossref","unstructured":"Mao K, Tang MY, South JR. A comparison of continuous with interrupted sutures in microvascular anastomosis. Microsurgery. 1986;7(4):158\u2013160.","DOI":"10.1002\/micr.1920070406"},{"key":"167980","doi-asserted-by":"crossref","unstructured":"Tamai S. 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J Hand Surg Am. 1981;6(1):25\u201330.","DOI":"10.1016\/S0363-5023(81)80006-8"}],"container-title":["Journal of Plastic Surgery and Hand Surgery"],"original-title":[],"link":[{"URL":"https:\/\/medicaljournalssweden.se\/JPHS\/article\/download\/46794\/55457","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/medicaljournalssweden.se\/JPHS\/article\/download\/46794\/55457","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T11:12:46Z","timestamp":1789038766000},"score":1,"resource":{"primary":{"URL":"https:\/\/medicaljournalssweden.se\/JPHS\/article\/view\/46794"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,10]]},"references-count":25,"URL":"https:\/\/doi.org\/10.2340\/jphs.v61.46794","relation":{},"ISSN":["2000-6764"],"issn-type":[{"value":"2000-6764","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,10]]}}}