To minimize tissue friction during an extracorporeal knot, which method is recommended?

• A. Use manual tension with fingers
• B. Use a textured glove to grip
• C. Avoid contact with tissue
• D. Use the instrument as a fulcrum because of the 180-degree angle

Answer: (D)

Minimizing tissue friction comes from redirecting the force so the suture doesn’t drag directly across tissue. Using the instrument as a fulcrum to create a 180-degree change in direction allows the knot to be cinched by the suture sliding around the instrument rather than abrading tissue. This setup reduces shear on the tissue and smooths the tightening motion, helping protect tissue during extracorporeal knot tying. Other methods don’t change the path of the suture in the same way, so they don’t offer the same reduction in friction: pulling with fingers tends to drag tissue, gripping with a textured glove doesn’t address the suture-tissue contact path, and avoiding tissue contact isn’t practical for tying the knot.