Knots: Stop at three throws deep in the Pelvis. (Surgical Tips and Tricks).

ST. LOUIS -- From tying the best knot to knowing when tension-free vaginal tape is pulled tight enough, experts at the 11th International Pelvic Reconstructive and Vaginal Surgery Conference didn't stop swapping surgical pearls until it was time to go home.

Here are just a few of the highlights:

* Know when less is more. When performing gynecologic surgery, two granny or sliding knots followed by a square knot will slide deep in the pelvis and hold without overdoing it, said Dr. Clifford R. Wheeless Jr. of Johns Hopkins University Baltimore.

After the third throw, adding more throws doesn't improve the strength of the knot and only creates a greater culture medium for bacteria. In addition, the more knots, the weaker the suture line is going to be.

"It took me years to figure out why I was having so much trouble tying a surgeon's knot deep into a woman's pelvis," said Dr. Wheeless, who has now abandoned that knot for gynecologic surgery altogether. "The surgeon's knot is a terrible knot to use in deep pelvic surgery," and yet that's what residents are taught. If the truth be told, "in medical school, knot tying is taught by the detail guy who sells sutures," he said at the meeting, which was jointly sponsored by the Society of Pelvic Reconstructive Surgeons and Emory University.

* Get your priorities in order. When you have a high cystocele, don't ever repair paravaginal defects without reconstructing the pericervical ring, said Dr. Robert M. Rogers of the Reading (Pa.) Hospital and Medical Center.

The pericervical ring is located in the supravaginal portion of the cervix, It's a ring of endopelvic fascia that has to be put back to each ipsilateral uterosacral ligament at the level of each ischial spine.