Surgery: Modified Seipser Sliding Knot for Iris Suturing

DR AHMED: This video describes the Siepser sliding knot technique for iris repairs. We’re using a 10-0 prolene on a curved CIF-4 needle. Micrograsper is used to hold one leaflet of the iris defect, while the needle is passed through the iris, and emerging through the other leaflet to create a pass between both sides of the iris defect. The suture needle is withdrawn through the eye, with the use of a 27-gauge cannula, which helps to prevent the needle from being trapped into the cornea. And it’s important to have two paracenteses through which the needles have been passed. At this point, one will note a proximal strand here on the bottom of the screen, as the surgeon’s view shows. And a distal strand, which is visible on the — in this case, the superior aspect of the screen, or the nasal side, from the surgeon’s perspective. It’s important to differentiate the proximal from distal strand, as we’ll show in the next few steps. A Kuglen hook is placed through the paracentesis of the proximal strand, and the distal strand is then grasped with the Kuglen and brought out through that proximal paracentesis, and you’ll see now how the distal strand forms a loop, present here adjacent to the proximal strand. And it’s very important to have these sutures and the suture threaded orientation, as you’ll see here. The distal strand loop has 1 and 2 that’s noted, and the proximal strand, 3. The number 1 suture here is passed, as you see here, it goes through the distal paracentesis, all the way through the eye, and emerges through the proximal paracentesis. It is not engaging the iris. The second strand, number 2, is part of the distal strand, but basically goes from the iris to — through the paracentesis, visible on the conjunctiva now. And the third suture here, which is a proximal strand, is from the iris through the paracentesis, on the proximal side of the suture. So it’s important to have these three suture threads oriented in the right form here, as we’ll show in a subsequent video. At this point, the distal loop is identified. You can see the distal strand is pulled here to show the continuous nature of the suture number 1. The proximal strand is cut short to allow for easy grasping of the curved tier, as the suture is tide. Here you see a higher magnification view of the distal loop. The distal loop will then be grasped with a pair of tying forceps, as we see here. And a triple throw is made, looping the curved tier three times, and then grasping the proximal strand and pulling the proximal strand through that distal loop, and the distal loop is then pulled, to pull that knot and slide the knot along the proximal strand. And that distal strand that was pulled was part of that suture number 1 that we showed earlier. The Kuglen hook is then used to again create a loop of a distal strand to emerge through that proximal paracentesis, and here we see the loop adjacent to the proximal strand. It’s important again to ensure that that distal strand still is visible through that distal paracentesis. Now we do a reverse single throw of the distal loop, to grab the proximal strand, and the distal strand is pulled to slide the distal loop along the proximal strand, tightening the suture and locking the suture in place. The lock is important to ensure we have a secure knot. As you can see, it’s very important to distinguish between the distal and proximal strand and the distal paracentesis and the proximal paracentesis, through which each suture strand emerges. We will then, for the last time, use the Kuglen hook to loop that distal strand, to create that distal loop, visible here. You see here it’s twisted a little bit. So we’re gonna untwist it, to ensure that the number one part of the distal loop is in orientation to the left side of the view here. And that part of the suture strand is what goes directly through that distal paracentesis, as we see on the top part of the screen. We now make that final single throw, to secure the lock. The distal strand is pulled to slide the loop along the proximal strand. We now have a secure knot. A pair of microscissors are used to cut the suture ends.