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Laparoscopic Surgical Suturing and Knot-Tying Techniques

Introduction to endo suturing and tissue approximation in laparoscopic surgery, highlighting its importance, challenges, and fundamental techniques, especially regarding needle handling.

  • Context and Importance of Laparoscopic Suturing

    • Endoscopic surgery is rapidly becoming a widely recognised alternative to traditional procedures for various diseases. Many of these procedures necessitate the use of laparoscopic suturing for tissue approximation and delivering hemostasis.
    • The adaptation of tissue and suturing for hemostasis and the reformation of anatomical components is considered one of the most demanding endoscopic technical skills.
    • Laparoscopic surgery involves viewing a 2D TV screen with up to 6 times magnification, which eliminates depth perception and tactile feeling of tissues, thus requiring significant hand-eye coordination.
    • Modern endoscopic procedures require the laparoscopic surgeon to master suturing, and every surgeon performing these procedures should be extensively familiar with the basic principles of knotting and suturing.
    • The introduction of laparoscopic surgery led to the development of modified suturing techniques to overcome technical limitations, such as the limited degree of freedom of rigid laparoscopic instruments.
    • Despite the minimally invasive nature of laparoscopic and robotic surgery, surgical incisions and scars remain. In the 1990s, endoscopic surgery of the gastrointestinal tract was developed in Japan as a minimally invasive method to remove early-stage carcinomas, like through Endoscopic Submucosal Dissection (ESD).
    • A major complication of ESD is iatrogenic perforation, making endoscopic suturing devices paramount for endoscopists to close perforations endoscopically, avoiding surgical intervention.
    • Proper suturing technique remains the cornerstone of every surgical procedure performed on any platform.

  • Challenges and Learning Curve

    • Intracorporeal suturing and knot tying are among the most challenging aspects of laparoscopic surgery. Factors contributing to this difficulty include the loss of depth perception and tactile sense, and visual obstruction, making the task time-consuming.
    • Acquiring laparoscopic suturing skills requires the surgeon to overcome a steep learning curve. Studies have shown a significant difference in knot-tying times between experienced and less experienced surgeons.
    • Without necessary experience and practice, performing a suture or knot in laparoscopy increases operative times.
    • Adequate experience is achieved by practicing for a long time on a simulator before performing operations requiring these techniques. Novices specifically benefit from training in a transparent box trainer under direct vision.
    • The ability to manoeuvre the needle into the desired position in the needle holder jaw is one of the first skills to acquire and can cause significant frustration until mastered.

  • Needle and Suture Introduction Techniques

    • Needle Anatomy: A needle has a tip and a hub. Key grasping points are: Point A (approx. 2cm from the hub, for first grasping), Point B (one-third from the tip, for second grasping), and Point C (one-third from the hub, where the needle driver grasps for loading).
    • Methods of Needle Entry into the Body Cavity:
      • Direct Insertion: For a 10-12mm port, a CT1 needle can be inserted directly into the abdomen.
      • Backloading: For a 5mm port, the instrument must be inserted first, then used to grasp the suture and guide the needle into the abdomen.
      • Through a Port Site: A curved needle less than 48mm can be inserted directly through a 5mm incision. The suture is grasped 2cm above the swedge and introduced under direct visualisation.
      • Through the Cannula: Curved needles smaller than 36mm may be passed through a 12mm cannula sleeve. The suture is grasped 2cm above the swedge and introduced directly through the cannula.
      • Percutaneously through the Abdominal Wall: When a larger needle is required, it can be inserted percutaneously, often in the suprapubic area due to less fat.
    • Suture Length and Protection:
      • For continuous sutures, the suture material on the Endoski needle should be trimmed to approximately 15 to 20 cm.
      • The suture length must never exceed 20 cm, as the imaging system magnifies it 2.5 times, making intracorporeal suturing very difficult.
      • An introducer tube is recommended to protect ligatures and sutures from the cannula valve mechanisms during introduction.
    • Steps for Needle Insertion (using introducer tube):
      1. Pass the needle holder through the introducer tube.
      2. Pick up the suture material with the needle holder at a point midway from the tip of the needle and the tail of the thread.
      3. Withdraw the suture and needle entirely inside the tube.
      4. Insert the tube through an appropriate port.
      5. Extrude the needle and suture from the tube by advancing the needle holder and position it on a safe surface, such as the anterior surface of the stomach.

  • Needle Handling and Loading Principles

    • Once the needle is within the box trainer, maintain a grip with one grasper at point A (2cm from hub) and loosely grasp the needle with the other instrument at point B (1/3 from tip). Gentle to-and-fro movement helps swivel the needle freely.
    • To load the needle, swivel it so light reflects evenly off point C (1/3 from hub). Grasp it firmly at point C with the needle driver, release it from the assisting instrument, and do practice throws to ensure it’s loaded approximately 90 degrees to the driver.
    • Adjustments to the needle angle can be made by maintaining a light grip and pulling the thread taut, or gently brushing the needle end against nearby tissues, or reducing the grip and hooking it on superficial serosal fibres in an avascular area. Using the assisting instrument to reposition the needle angle is a popular but inefficient technique.
    • “Needle detection” occurs when the needle is not pushed directly opposite to the tissue resistance, and the extent of deflection is directly related to the applied power at the perpendicular interface with tissue resistance.

  • Errors in Surgical Practice

    • Technical errors are defined as the smallest measurable unit reflecting a non-deliberate action or deviation from a plan.
    • Dropping the needle whilst suturing is cited as an example of a technical error. Such errors alone may not lead to adverse outcomes.

The information collectively stresses that while endoscopic surgery offers many benefits, the mastery of suturing and needle handling is a complex yet critical prerequisite for surgeons adopting this minimally invasive approach.

General Principles of Knotting

  • Purpose: The aim of knotting is to support tissue edges with the correct tension and resist reverse slippage.
  • Characteristics of an Ideal Surgical Knot: An ideal knot should be safe, quick, and simple to tie. The safety of a knot is influenced not only by the knot itself but also by the type of suture material used.
  • Three Procedures in Knotting: Every knotting process involves three critical stages:
    1. Tying the knot (configuration).
    2. Working or drawing the knot (shaping).
    3. Snuggling or locking the knot (securing). All these stages are vital, and a knot is only secure if it is tied correctly, shaped to fit its anatomy, and locked tightly. As Clifford Ashley noted, “a knot is never nearly right; it is either exactly right or is hopelessly wrong”.
  • Suture Material Impact: Materials that swell upon contact with water, like catgut, dacron, polyglactin, and lactomer, are considered safe for knots due to increased tying and tightening capacity, while PDS, silk, or polyamide are less reliable. Stiff hydrophobic monofilament material should be avoided as it provides less frictional hold and has a greater tendency to slip.
Categories of Knots in Laparoscopic Surgery

Knots in laparoscopic surgery are broadly categorized into:

  • Intracorporeal Knots: These are tied within the body cavities using needle holders.
  • Extracorporeal Knots: These are tied outside the body and then “slipped down” into the body cavity using a knot pusher.
Intracorporeal Knots
  • Definition and Technique: Intracorporeal knots are tied inside the body using needle holders and are considered challenging, requiring great manual dexterity. The technique involves a “precisely choreographed set of actions” for smooth and reproducible execution with economy of movement.
  • Types Used in Endoscopic Practice:
    • The Square knot (Reef knot): A safe knot for securing small arteries, comprising two opposite half knots. It can also be a “tumble square knot” which can be made to slip.
    • The Ligature knot: Safer than the reef knot, it uses an initial double knot followed by a single half knot.
    • The Double knot: Consists of two double half knots.
    • The Mayo knot: Involves two identical half knots forming a granny knot, followed by a third and opposite half knot.
    • The Surgeons knot: Consists of a double half knot followed by two single half knots. This is a common and important technique for securely ligating tissues, with a double wrap on the first throw and two opposing single throws.
  • Preferred Internal Knots: The surgeon’s knot or a square knot are favored for interrupted suturing in endoscopic surgical practice.
  • Key Essentials for Intracorporeal Knot Tying:
    • Good magnification.
    • Economy of motion.
    • Directional hold principle.
    • Avoidance of instrument crossing.
    • Correct knot-tying choreography.
    • Execution of knots close to the tissue surfaces.
    • Keeping instrument jaws closed except during grasping.
    • Awareness of dominant versus assisting instruments.
    • Correct wrapping techniques.
    • Knots configured and tied near to the tail.
    • Always keeping the tips of the two-needle holders in view within the operative field.
    • The importance of two-handedness for efficient suturing.
  • Specific Knot Tying Techniques:
    • Drop Needle Technique: This technique involves creating a long, elongated “U” with the suture to decrease the instrument-to-suture angle. The left instrument is placed inside the “U”, the suture is twisted twice around it to create a surgeon’s knot, and then the loose end is grasped and cinched down. For a square knot, the left instrument is placed outside the “U”, and the stitch is twisted around it. Minimizing the instrument-to-suture angle is crucial to prevent loops from slipping.
    • Hold Needle Technique: Beneficial for shorter sutures, this technique involves constantly holding the needle. The key principle is to rotate the needle to align with the suture, minimizing the instrument-to-suture angle to almost parallel, which makes wrapping the suture effortless. Throws should be alternated by placing the left instrument on opposite sides of the suture.

Extracorporeal Knots
  • Applications: Used for ligature of vessels and tubular structures in continuity, transfixation of large vascular pedicles, and interrupted suturing with external knots. They are also recommended in situations of limited access or where substantial force is needed to approximate edges.
  • Mechanism: The knot is tied and drawn outside the body, then “slipped down” to the target with a knot pusher, and stiffened by traction.
  • Types Utilized: Tayside knot, Roeder knot, Melzer knot, square knot.
  • Rules for Safe Ligature with Slip Knots:
    • Thread type must be 1.5m and gauge 2/0 or greater.
    • The choice of slip knot depends on the ligature material; some work with catgut but not other materials.
    • Holding force varies directly with caliber (e.g., 1/0 knot is roughly twice that of 2/0).
    • Stiff hydrophobic monofilament material should be avoided due to less frictional hold and higher tendency to slip.
  • Sliding (Slip) Knot Technique: Involves forming a preformed loop on the distal end of the suture which functions as a lock after piercing tissues and pulling the needle through it. This can be achieved by a full loop with the distal end introduced into itself, or by simple/double knots. An introducer tube or securing the needle within the needle holder’s morsels prevents loosening during trocar passage. The “sliding knot” involves making a square knot, releasing its lock with a dissector, sliding it to the ligation point, and then securing it.

Comparison: Extracorporeal vs. Intracorporeal Knots
  • Preference: Intracorporeal knotting using instrument-tied knots is generally preferred in endoscopic surgery.
  • Situations for Extracorporeal Preference: Ligature in continuity of large vessels, suturing in areas of restricted access, and approximation of edges of defects requiring substantial force.

Challenges and Learning Curve
  • Difficulty: Intracorporeal suturing and knot tying are among the most challenging aspects of laparoscopic surgery. This is due to the loss of depth perception and tactile sense, coupled with visual obstruction, making it a difficult and time-consuming task.
  • Steep Learning Curve: Acquiring these skills demands overcoming a steep learning curve. Studies show significant differences in knot-tying times between experienced and less experienced surgeons.
  • Training: Without sufficient experience and practice, laparoscopic suturing increases operative times. Adequate experience is achieved by extensive practice on a simulator before performing live operations. Novices particularly benefit from training in a transparent box trainer under direct vision, which is a cheap adjustment to standard setups. Formal training programs like the Postgraduate Diploma in Laparoscopic Surgical Skills emphasize hands-on preparation for needle loading, shaping knots, and both intracorporeal and extracorporeal suturing and knot tying through simulation.

knots are indispensable for laparoscopic surgery, serving vital roles in tissue approximation and hemostasis. While challenging due to the technical constraints of the laparoscopic environment, their mastery through dedicated practice and understanding of various tying techniques is fundamental for surgeons.

Ideal stitch

Definition and Core Principles of an Ideal Stitch

An ideal stitch is one that supports tissue edges with the correct tension and resists reverse slippage. To be considered ideal, a surgical knot, which is integral to the stitch, must possess specific characteristics: it ought to be safe, quick, and simple to tie. The overall safety of a knot is not only determined by the knot itself but also significantly influenced by the type of suture material used.

The process of creating a secure and ideal stitch, particularly in knotting, involves three essential procedures:

  1. Tying the knot (configuration).
  2. Working or drawing the knot (shaping).
  3. Snuggling or locking the knot (securing). A knot is only truly secure if it is correctly tied, appropriately shaped to fit its anatomical context, and locked tightly. As quoted from Clifford Ashley, “a knot is never nearly right; it is either exactly right or is hopelessly wrong”.

Factors Influencing an Ideal Stitch

1. Suture Material The choice of suture material plays a crucial role in the reliability of a knot and, consequently, the ideal stitch. Materials that swell upon contact with water, such as catgut, dacron, polyglactin, and lactomer, are considered safer because their swelling theoretically increases their tying and tightening capacity. Conversely, materials like PDS, silk, or polyamide are less reliable. Stiff hydrophobic monofilament materials should generally be avoided for slip knots as they provide less frictional hold and have a greater tendency to slip compared to braided materials. The holding strength of a surgical slip knot varies directly with its calibre; for instance, a 1/0 slip knot’s holding strength is roughly twice that of a 2/0 equivalent.

2. Needle and Needle Handling Achieving an ideal stitch also depends heavily on proper needle selection and manipulation. Surgical needles are designed to pass sutures through tissues with minimum trauma and must provide a secure grip for the needle driver, penetrate the tissue to create a channel, and allow the thread to be trailed.

  • Needle Types: Straight needles are easy to introduce and their tip direction is not altered by swiveling in the needle holder jaws, allowing movement in a 2-D plane. Curved needles, though widely used (often a 25mm half-circle needle), require more experience due to their tendency to swivel. The Endoski needle, a hybrid with a straight shaft and a tapering curve, was specifically developed for laparoscopic use to combine the ease of handling straight needles with the tissue passage benefits of curved needles.
  • Needle Loading and Positioning: The needle should be grasped firmly by the needle driver, ideally at point C (one-third from the hub), and loaded approximately 90 degrees to the driver for effective control. For a right-handed surgeon, the needle is typically held with its tip pointing left, forming an obtuse angle with the holder’s shaft. Proper positioning in the jaws, ideally at the tips, is crucial for precision and maintaining grasping force, avoiding needle swivel. Adjustments to the needle’s angle can be made using other instruments, surrounding tissue, or tensioned suture material.
  • Needle Driving: The needle tip should approach the tissue at right angles to the tissue surface, regardless of the needle’s configuration. The force applied should be perpendicular to the cut surface or tissue edge. Counter pressure or counter traction from the assisting instrument expedites suturing. Slow and deliberate needle passage with a delicate grip, maintaining the pushing force directly against tissue resistance, leads to smoother and more successful passage.
  • Suture Length: For continuous sutures, a length of approximately 15 to 20 cm is recommended. It is crucial that the suture length never exceeds 20 cm, as the imaging system magnifies it by 2.5 times, making intracorporeal suturing very difficult.

3. Knot Tying Techniques for Endosuturing Laparoscopic knots are categorized as either intracorporeal (tied inside the body) or extracorporeal (tied outside and then slipped down). Intracorporeal knotting, using instrument-tied knots, is generally preferred in endoscopic surgery.

  • Intracorporeal Knots: These require great manual dexterity and a “precisely choreographed set of actions” for smooth, reproducible, and efficient execution. Common types include the square knot (reef knot), ligature knot, double knot, Mayo knot, and the surgeon’s knot. The surgeon’s knot or a square knot are favored for interrupted suturing in endoscopic practice.
    • Drop Needle Technique: This involves creating a long, elongated “U” with the suture to reduce the instrument-to-suture angle, which is key to preventing loops from slipping. The left instrument is placed inside the “U” (for a surgeon’s knot with a double twist) or outside (for a square knot with a single twist).
    • Hold Needle Technique: Beneficial for shorter sutures, this technique involves continuously holding the needle. The core principle is to rotate the needle to align with the suture, minimizing the instrument-to-suture angle to near parallel, making suture wrapping effortless. Throws should be alternated by placing the left instrument on opposite sides of the suture.
    • Essentials for Intracorporeal Knot Tying: Good magnification, economy of motion, adherence to the directional hold principle, avoidance of instrument crossing, correct knot-tying choreography, execution of knots close to tissue surfaces, keeping instrument jaws closed except during grasping, awareness of dominant vs. assisting instruments, correct wrapping techniques, and configuring knots near the tail are all vital. Two-handedness is emphasized for efficient suturing.
  • Extracorporeal Knots: These are tied outside and slipped down using a knot pusher, useful for ligating vessels or tubular structures, transfixation of large vascular pedicles, or interrupted suturing with external knots. They are also recommended in situations of limited access or when substantial force is required for tissue approximation. Examples include the Tayside, Roeder, Melzer, square.

Challenges and Training for Achieving Ideal Stitches

Intracorporeal suturing and knot tying are considered among the most challenging technical skills in laparoscopic surgery, due to factors like loss of depth perception, tactile sensation, and visual obstruction. This leads to a steep learning curve. Studies indicate significant differences in knot-tying times between experienced and less experienced surgeons.

To overcome these challenges and master the creation of ideal stitches:

  • Extensive practice on a simulator is essential before performing live operations. Novices particularly benefit from starting training in a transparent box trainer under direct vision, a cost-effective adjustment to standard setups.
  • Formal training programs, such as the Postgraduate Diploma in Laparoscopic Surgical Skills, include modules specifically focused on laparoscopic suturing and knot-tying techniques. These programmes provide hands-on preparation for needle loading, knot shaping (e.g., Roeder’s knot and endoloop), and both intracorporeal and extracorporeal suturing and knot tying through simulation.
  • The transition from open to laparoscopic surgery requires adapting to limited degrees of freedom, 2D vision, and the fulcrum effect. Robotic platforms offer benefits such as increased degrees of freedom of robotic wrists and 3D vision, making intracorporeal suturing easier and more intuitive, especially for inexperienced surgeons, and reducing the steep learning curve associated with laparoscopic suturing. While endoscopic suturing devices like OverStitch have advanced therapeutic endoscopy, they often still require double-channel endoscopes and lack the robotic wrists’ degrees of freedom, presenting their own challenges. The development of endoscopic robotic suturing systems, such as MASTER, aims to overcome these limitations by providing multiple degrees of freedom and allowing recreation of manual wrist movements, which are essential for effective suturing and knot tying.

an ideal stitch in laparoscopic surgery goes beyond simply closing a wound; it embodies safety, precision, and efficiency, achieved through mastery of knot-tying principles, careful selection of materials and instruments, and continuous, dedicated practice

Three Procedures in Knotting

The  three essential procedures in knotting, each critical for the formation of a secure and reliable surgical knot, especially within the challenging laparoscopic environment:

  1. Tying the knot (configuration): This refers to the initial formation of the knot’s structure. In laparoscopic surgery, knots are broadly categorised as either intracorporeal (tied inside the body) or extracorporeal (tied outside and then slipped down).

    • For intracorporeal knots, which are generally preferred, common configurations include the square knot (reef knot), ligature knot, double knot, Mayo knot, and the surgeon’s knot. The surgeon’s knot and square knot are particularly favoured for interrupted suturing in endoscopic practice. Techniques like the “drop needle technique” involve creating an elongated “U” with the suture to reduce the instrument-to-suture angle, which is key for efficient wrapping and preventing loops from slipping. The “hold needle technique” for shorter sutures involves rotating the needle to align it with the suture, making the wrapping effortless by creating an almost parallel angle.
    • For extracorporeal knots, such as the Tayside, Roeder, Melzer, square the configuration is tied outside the body before being pushed into place. This method is suitable for ligating vessels, transfixation of large vascular pedicles, or interrupted suturing with external knots, especially when working in areas of limited access or when substantial force is required for tissue approximation.

  2. Working or drawing the knot (shaping): This stage involves manipulating the knot to ensure it adapts appropriately to the anatomy of the tissue being approximated. This requires precise control and proper handling of instruments and suture material.

    • In intracorporeal suturing, this involves “microsurgical tying,” a precisely choreographed set of actions designed for smooth and reproducible execution with economy of movement. Key points include the conscious assessment of the suture’s position, appropriate rotations of the needle holders, and keeping the instrument ends within the operative field. Two-handedness is crucial for efficient shaping.
    • For extracorporeal knots, after being tied outside, the knot is “slipped down” towards the target using a knot pusher. The process involves stiffening the knot by traction on the standing part against the knot pusher.

  3. Snuggling or locking the knot (securing): This is the final procedure where the knot is tightened firmly to ensure its security and prevent reverse slippage.

    • For both intracorporeal and extracorporeal knots, the tightening must be firm, applying appropriate tension. For slip knots, the knot is locked after being slid to the ligation point, often by pulling both threads. The security of the knot is also influenced by the suture material; materials that swell with water (e.g., catgut, dacron, polyglactin, lactomer) are considered safer as their swelling can increase tying and tightening capacity, while stiff hydrophobic monofilaments are less reliable due to lower frictional hold and greater tendency to slip.

The sources emphatically state that all three stages are essential, and a knot is only truly secure if it is correctly tied, appropriately shaped, and locked tightly. As Clifford Ashley famously noted, “a knot is never nearly right; it is either exactly right or is hopelessly wrong“. This underscores the critical precision required in laparoscopic knotting.

Mastering these procedures in endo suturing is considered one of the most challenging technical skills in laparoscopic surgery due to the loss of depth perception, tactile sensation, and visual obstruction inherent in the 2-D laparoscopic view. This necessitates a steep learning curve. Therefore, extensive practice on simulators, often starting with transparent box trainers for novices, is deemed essential before performing live operations. Formal training programmes, such as the Postgraduate Diploma in Laparoscopic Surgical Skills, specifically include modules on laparoscopic suturing and knot tying techniques, offering hands-on preparation for needle loading, knot shaping, and both intracorporeal and extracorporeal suturing. Innovations like robotic platforms with increased degrees of freedom and 3D vision also aim to make intracorporeal suturing and knot-tying easier and more intuitive, reducing the steep learning curve for inexperienced surgeons.

Ideal Surgical Knot

The ideal characteristics of a surgical knot as follows:

  • It ought to be safe.
  • It ought to be quick.
  • It should be simple to tie.

These characteristics are crucial for effective wound healing, hemostasis, and the overall success of laparoscopic procedures.

Achieving these ideal characteristics necessitates proficiency in the three essential procedures in knotting:

  1. Tying the knot (configuration): This refers to the initial formation of the knot’s structure. The goal is to create a configuration that is inherently safe and will not slip. Common knots used in endoscopic practice, such as the square knot (reef knot) and the surgeon’s knot, are favoured for their security, especially in interrupted suturing. The technique of “wrapping” the suture material around the instrument is key here, with methods like the “drop needle technique” and “hold needle technique” emphasizing the importance of minimising the instrument-to-suture angle for ease and efficiency. The initial knot of a continuous suture can also be accomplished using preformed loops or even special threads with reabsorbable clips.
  2. Working or drawing the knot (shaping): This stage involves manipulating the knot to ensure it conforms appropriately to the anatomy of the tissue being approximated. This process, referred to as “microsurgical tying” in intracorporeal suturing, demands a “precisely choreographed set of actions” for smooth and reproducible execution with economy of movement. It requires conscious assessment of the suture’s position, appropriate rotations of the needle holders, and maintaining instrument ends within the operative field. For extracorporeal knots, this involves “slipping down” the knot to the target using a knot pusher and then stiffening it by traction.
  3. Snuggling or locking the knot (securing): This is the final and critical procedure where the knot is tightened firmly to ensure its security and prevent reverse slippage. The tightening must be firm, applying appropriate tension. For slip knots, the knot is locked after being slid to the ligation point, often by pulling both threads.

The sources emphatically state that “All of the three stages are essential along with a knot is secure only if it is tied correctly, drawn (shaped) to adapt to the anatomy of the knot and locked tightly”. This principle is encapsulated by Clifford Ashley’s quote: “a knot is never nearly right; it is either exactly right or is hopelessly wrong”.

Challenges in Laparoscopic Surgery: Achieving these ideal characteristics in laparoscopic surgery is considered “the most demanding of endoscopic technical skills”. This is due to several inherent limitations of the laparoscopic environment:

  • Loss of Depth Perception and Tactile Sensation: Surgeons operate by viewing a 2-dimensional TV screen, which eliminates depth perception and the ability to feel the tissues directly.
  • Limited Degrees of Freedom: Rigid laparoscopic instruments offer restricted movement compared to open surgery, hindering complex manipulations required for knot tying. The “pivoting effect and fulcrum” further compound this difficulty.
  • Visual Obstruction: The operative field can be obstructed, adding to the challenge of precise suturing.

Factors Influencing Knot Security and Performance:

  • Suture Material: The type of suture material significantly impacts knot safety. Materials that swell with water upon contact with bodily fluids (e.g., catgut, dacron, polyglactin, lactomer) are considered safer as they can increase the knot’s tying and tightening capacity. Conversely, stiff hydrophobic monofilament materials (e.g., Prolene) are less reliable due to lower frictional hold and a greater tendency to slip.
  • Instrument Quality and Handling: Good quality instruments, such as needle holders with diamond coating for better grip and coaxial handles for improved maneuverability, are vital. Correct needle handling, including proper loading and maintaining the needle in view, is also emphasised.

Overcoming Challenges through Training and Innovation: Given the complexity, mastery of laparoscopic suturing and knot tying requires a “steep learning curve”. Therefore:

  • Extensive Practice: Surgeons must engage in “extensive practice for a long time on the simulator, before performing any operation in which these techniques are necessary”. Novices particularly benefit from starting their training in transparent box trainers under direct vision, as it reduces frustration and time taken to acquire skills.
  • Formal Training Programs: Courses like the Postgraduate Diploma in Laparoscopic Surgical Skills specifically include modules on laparoscopic suturing and knot tying techniques, offering hands-on preparation for needle loading, shaping, and both intracorporeal and extracorporeal suturing.
  • Robotic Suturing: The introduction of robotic surgical platforms, such as the MASTER system, has made intracorporeal suturing easier and more intuitive. The benefits include increased degrees of freedom of the robotic wrists and enhanced three-dimensional vision. Robotics helps to “eliminate the early learning curve for surgical novices”, and can lead to less surgeon discomfort and potentially shorter surgery times for complex tasks.

In essence, an ideal surgical knot, characterized by being safe, quick, and simple to tie, is achieved through precise execution of its tying, shaping, and securing procedures. While the laparoscopic environment presents significant technical hurdles, advanced training methods, coupled with technological innovations like robotics, are crucial for surgeons to master these fundamental knotting procedures and ensure optimal patient outcomes.

Port Site Triadic Relationship

  • Definition of the Triad: In endoscopic surgical practice, it is advised to always maintain a specific spatial relationship between the port sites. This involves positioning the optical port (which holds the telescope) centrally, with the two suturing ports placed on either side of it. This configuration forms a “triad”.
  • Purpose and Benefits:
    • Ergonomics: The triadic relationship, often referred to as “triangulation,” is a key ergonomic principle that contributes to an “Ideal Relaxed Position” for the surgeon during laparoscopic procedures. It aligns with the “Straight Line principle” and helps manage the “Manipulation angle” to improve efficiency and reduce surgeon discomfort.
    • Enhanced Maneuverability: This setup helps maintain a suitable relationship between the instruments inside the body, making instrument handling and manipulation more efficient. For example, the use of robotic arms, such as in the MASTER system, can explicitly “allow for triangulation while performing knot tying,” highlighting its importance for complex movements.
    • Overcoming Laparoscopic Challenges: Laparoscopic surgery is technically challenging due to factors like the loss of depth perception, absence of tactile sensation, and the limited degrees of freedom of rigid instruments. The triadic port placement helps mitigate these difficulties by providing a more intuitive and controlled working space for the surgeon. This ergonomic advantage can reduce the “steep learning curve” associated with intracorporeal suturing.
    • Facilitating Knotting Procedures: By providing a stable and well-organised operative field, the triadic relationship aids in the execution of the “three procedures in knotting” – tying (configuration), working or drawing (shaping), and snuggling or locking (securing) – all of which are essential for a secure knot. As stated, “a knot is secure only if it is tied correctly, drawn (shaped) to adapt to the anatomy of the knot and locked tightly”.

In essence, the Port Site Triadic Relationship is a fundamental aspect of surgical setup in laparoscopy, designed to maximise the efficiency and effectiveness of endo suturing and tissue approximation, thereby contributing to the creation of an “ideal stitch” that correctly supports tissue edges with appropriate tension and resists slippage. Mastery of this ergonomic principle, alongside extensive practice and appropriate instrumentation, is critical for surgeons to achieve proficiency in laparoscopic suturing.

Wrapping Processes for Knotting

Endo suturing and tissue approximation in laparoscopic surgery, the “Wrapping processes for knotting” refer to the techniques used by endoscopic surgeons to manipulate the suture material around their instruments to form the initial loops of a surgical knot. These processes are critical for achieving an “ideal stitch” that supports tissue edges, maintains correct tension, and resists slippage. Mastery of these techniques directly contributes to the knot being “tied correctly” – a fundamental requirement for a secure knot, as emphasised by Clifford Ashley’s adage: “a knot is never nearly right; it is either exactly right or is hopelessly wrong”.

Two basic wrapping techniques predominantly practised by endoscopic surgeons:

  • Overwrap method.
  • Underwrap method.

Beyond these general categories, the sources detail specific methods that inherently involve distinct wrapping processes for creating intracorporeal knots:

  1. The Drop Needle Technique:

    • This technique begins by creating a long, elongated “U” shape with the suture. The purpose of this elongated “U” is crucial: it decreases the instrument-to-suture angle, which is a key feature for intracorporeal suturing. Minimising this angle is particularly important when using port sites that inherently cause decreased instrument-to-instrument angles.
    • The left instrument is placed inside the “U”, and the suture is then twisted twice around the instrument to create a surgeon’s knot. The loose end is grasped by the left instrument, while the right instrument pulls downward to secure the knot.
    • For subsequent throws (to create a square knot), a second elongated “U” is made, and the left instrument is placed outside the “U” before twisting the stitch around it. The importance of maintaining a minimal instrument-to-suture angle is reiterated, as a large angle can cause the loop to slip.

  2. The Hold Needle Technique:

    • In contrast to the drop needle technique, the needle is constantly held during this method.
    • The key principle here is to rotate the needle to align with the suture, again to minimise the instrument-to-suture angle and create an almost parallel angle. This alignment leverages the sturdiness of the needle, making it virtually effortless to wrap the suture on the left instrument.
    • Surgeons must remember to alternate their throws by placing the left instrument on opposite sides of the suture and always rotate the needle to line up with the suture to minimise the instrument-to-suture angle. A large instrument-to-suture angle makes throws challenging.

In the context of laparoscopic surgery, mastering these wrapping processes is considered “the most demanding of endoscopic technical skills”. This is primarily due to the inherent challenges of the laparoscopic environment, such as operating via a 2-dimensional screen which eliminates depth perception and tactile sensation, and the limited degrees of freedom of rigid instruments. The ability to effectively wrap and manipulate the suture, as described in these techniques, directly addresses these limitations by promoting “economy of motion” and “correct knot-tying choreography”.

Ultimately, these wrapping processes fall under the first essential procedure in knotting: “Tying the knot (configuration)”. Their efficient and correct execution ensures that the initial configuration of the knot is strong and will not slip, laying the foundation for a secure suture line necessary for effective tissue approximation and overall successful laparoscopic outcomes.

Essentials in Intracorporeal Knot Tying

Endo suturing and tissue approximation in Laparoscopic Surgery, intracorporeal knot tying is described as one of the most demanding of endoscopic technical skills, requiring great manual dexterity to perform accurately and efficiently within the body cavities using needle holders. The “Essentials in intracorporeal knot tying” are a set of principles designed to guide surgeons in mastering this challenging aspect of minimally invasive surgery, ensuring that the knots tied are secure and contribute to an “ideal stitch” that effectively supports tissue edges with correct tension and resists slippage.

The sources highlight several crucial essentials for effective intracorporeal knot tying:

  • Good Magnification: Operating on a 2-dimensional TV screen, often with magnification, already eliminates depth perception and tactile sensation. Good magnification, therefore, is an essential element to compensate for these limitations and allow for precise manipulation during knot tying.
  • Economy of Motion: This principle emphasises performing movements efficiently and with minimal wasted effort. It is a key component of “correct knot-tying choreography” and contributes to fluent, choreographed two-handed movements, which are essential for effective tissue approximation. Robotic assistance, for instance, can provide improved economy of motion, particularly in limited workspaces.
  • Directional Hold Principle: While not explicitly detailed, this implies maintaining control over the instruments and suture in a specific direction to facilitate the tying process, crucial in an environment lacking direct tactile feedback.
  • Avoidance of Instrument Crossing: Instruments should not cross each other but move parallel from one side to the other, to maintain a clear operative field and prevent entanglement, which is critical for efficient and safe suturing.
  • Correct Knot-Tying Choreography: This refers to the precise, planned sequence of actions involved in knot tying to make the process smooth, reproducible, and efficient, minimising wasted time.
  • Execution of the Knots Near to the Tissue Surfaces: Tying knots close to the tissue reduces slack and ensures the knot effectively approximates the tissue edges with appropriate tension.
  • Closed Instrument Jaws Except During Grasping: This prevents accidental damage to surrounding tissues or the suture material and maintains control over the instruments.
  • Awareness of Dominant Versus Assisting Instruments Throughout the Knotting Process: Recognising and coordinating the passive and active roles of both needle holders is crucial for efficient microsurgical tying. The needle driver is typically the dominant instrument, while the assisting grasper provides counter-traction or helps manage the suture.
  • Correct Wrapping Techniques: This refers to the methods used to create the initial loops of a knot. The sources specifically mention “Overwrap method” and “Underwrap method” as two basic techniques. More detailed techniques like the “Drop Needle Technique” and “Hold Needle Technique” are also discussed, which both aim to minimise the instrument-to-suture angle to prevent slippage and facilitate wrapping. The ability to effectively wrap and manipulate the suture is considered “the most demanding of endoscopic technical skills”.
  • Knots Configured and Tied Near to the Tail: This ensures a secure starting point for the knot and allows for proper management of the suture ends.

These essentials are vital because laparoscopic surgery presents significant technical challenges compared to open surgery. These include a two-dimensional view that eliminates depth perception, the absence of tactile sensation, the limited degrees of freedom of rigid laparoscopic instruments, and the fulcrum effect. By adhering to these principles, surgeons can mitigate these difficulties, leading to more accurate and secure tissue approximation and wound healing.

Mastery of these essentials typically requires extensive training and practice, often on simulators, as there is a steep learning curve associated with acquiring laparoscopic suturing skills. Practising techniques like needle loading, needle handling, and various knot-tying methods repeatedly helps surgeons develop the necessary hand-eye coordination and spatial awareness.

Suture Material

suture material are critical for achieving an “ideal stitch” that correctly supports tissue edges, maintains appropriate tension, and resists reverse slippage. The sources emphasise that the safety and security of a knot depend not only on the knot itself but also significantly on the type of material used.

Here’s what the sources say about suture material:

Types and Characteristics of Suture Materials

Surgical knots need to be tied correctly, drawn to adapt to anatomy, and locked tightly for security. Certain suture materials are inherently better suited for laparoscopic knot tying due to their properties.

1. Absorbable Sutures:

  • Catgut: Noted for its poor gliding ability. It is considered a safe material for knotting, especially since materials that swell with water theoretically increase their tying and tightening capacity.
  • Vicryl (Polyglactin): Offers good maneuverability. Polyglactin is also explicitly listed as a safe material for knots. It is frequently used, for example, a CT1 needle connected to 15 centimetres of HO Vicryl is mentioned in a demonstration.
  • PDS (Polydioxanone): Known for its excellent gliding ability and the advantage that there is no need to “follow” during intracorporeal anastomosis. However, PDS is listed as less reliable for forming secure knots. It is also utilised in the form of reabsorbable clips for continuous sutures.
  • Biosyn (Autosuture, USSC): A synthetic monofilament reabsorbable suture. It combines the advantages of intertwined sutures (better knot tightness, high tension strength, quick absorption, and lack of memory) with the unique features of a monofilament (greater smoothness, lack of capillarity, higher inertial force, and minor tissue trauma). It is used with 2/0 and 3/0 gauge and curved needles.
  • Lactomer: Listed as a safe material for knots.

2. Non-absorbable Sutures:

  • Silk: Described as braided and thus more traumatising. It is also categorised as less reliable for knotting.
  • Prolene: A monofilament material that has “memory,” making it very tedious to use.
  • Ethibond: A monofilament suture with less memory and better maneuverability than Prolene.
  • Dacron: Considered a safe material for knots.
  • Polyamide: Listed as less reliable for knotting.

General Suture Material Considerations for Knotting:

  • Holding Strength: The tightness of an extracorporeal knot made from a 2/0 thread is double that of a 3/0 thread. The holding force (resistance to reverse slipping) of any surgical slip knot varies directly with its caliber; for example, a 1/0 slip knot has approximately twice the holding strength of a 2/0 equivalent.
  • Frictional Hold: Stiff, hydrophobic monofilament material should be avoided because it exerts a lesser frictional hold and has a greater tendency to “spill” (slip) than braided materials. This directly impacts knot security.
Suture Length and Handling

Proper suture length is crucial for managing the material within the confined laparoscopic environment, which is magnified by the imaging system.

  • For an intracorporeal separate stitch, the ideal length is 10 cm.
  • For a continuous suture, the thread should be approximately 15 cm long to facilitate the final knot.
  • It is explicitly stated that the suture length must never exceed 20 cm, as the imaging system magnifies the length by 2.5 times, making intracorporeal suturing very difficult.
  • The suture is often introduced into the body cavity using an introducer tube to protect it from cannula valve mechanisms.
  • When retrieving the needle from a 5 mm trocar, it may be necessary to straighten the needle using two needle holders.

Barbed Sutures as an Alternative

Barbed suture is a self-anchoring suture, with barbs at approximately every 1 mm of tissue. This design allows for a uniform distribution of wound tension across the suture line without the need for tying a knot, thus eliminating the associated skill requirements and troubles.

Clips as an Alternative

Medical companies have developed alternatives to traditional knot tying, such as suture materials furnished with reabsorbable terminal clips.

  • One such product, MIC 54 (Ethicon), is 7 cm long and comes with a clip pre-anchored to the suture thread (functioning as the initial knot) and a second loose clip that is attached with special forceps to complete the final knot.
  • These clips can also be used if the suture thread is too short to accomplish a traditional knot at the end of a continuous suture.
Cost Considerations

While sophisticated materials and clips exist, the sources suggest that traditional suture materials are often preferred due to their lower cost. The high cost of materials specifically created for laparoscopy by medical companies encourages the use of “simple” sutures with “ordinary” threads, which are significantly cheaper. The surgeon ultimately chooses the most appropriate solution based on their skill, good sense, functionality, and cost considerations.

In summary, the choice and management of suture material in laparoscopic surgery are not trivial. They directly influence knot security, ease of manipulation, and overall surgical efficiency within the challenging minimally invasive environment. Surgeons must be “extensively acquainted with basic principles of knotting and suturing”, which includes understanding the nuances of different suture materials and their optimal lengths.

Needles

Needles are fundamental penetrating devices designed to pass sutures through tissues with minimum trauma. The sources highlight that mastering needle manipulation is a crucial and challenging aspect of laparoscopic surgery due to limitations such as a 2-D view, loss of depth perception, and absence of tactile feedback.

Surgical needles in this setting is threefold: to provide a secure grip for the needle driver, to penetrate the tissue to be sewn and create a channel for the thread, and to provide a means by which the thread can be trailed.

Needle Anatomy and Types

The sources describe the basic anatomy of a surgical needle, which typically includes a tip and a hub. For precise handling, specific points on the suture and needle are identified: Point A (approximately 2 cm from the hub, for initial grasping), Point B (one-third from the needle tip, for secondary grasping), and Point C (one-third from the hub, where the needle driver firmly grasps the needle).

Several needle shapes and designs are discussed for laparoscopic use:

  • Straight Needle: Offers advantages such as easy introduction even through the smallest port, un-altered needle tip direction by the needle swivel within the jaws of the needle holder, and simpler positioning involving movement in a 2-D plane.
  • Curved Needle: Most often, a 25mm half-circle needle is employed for endosuturing, although it may have a tendency to swivel and requires more experience. One source mentions using a curved needle with 2/0 and 3/0 gauge Biosyn suture.
  • Endoski Needle: This combined needle was specifically developed for laparoscopic use. It is described as a hybrid of the straight and half-circle needle, featuring an atraumatic suture, a straight shaft, and a terminal tapering curve that corresponds to a quarter of a circle, giving it a miniature ski shape. Its shaft transitions from a modified rectangle to a rounded body towards the tip, enabling an easier grip for the needle holder and smooth tissue passage.

Needle Handling and Manipulation Techniques

Proper handling of the needle is paramount for efficient and safe suturing. The ability to accurately position and manipulate the needle within the confined abdominal cavity is one of the first and most frustrating skills to acquire for laparoscopic surgeons.

1. Introduction into the Body Cavity:

  • For a 10-12 mm port, a CT1 needle can be directly inserted into the abdomen.
  • For a 5 mm port, a technique called back loading is often necessary. This involves first inserting the instrument through the trocar, then grasping the suture, and finally guiding the needle into the abdomen.
  • An introducer tube is recommended to protect ligatures and sutures from the cannula valve mechanisms during introduction. The needle holder is passed through the introducer tube, the suture is picked up at its midpoint, withdrawn into the tube, and then passed through the port before the needle is extruded and placed on a safe surface (e.g., anterior surface of the stomach).

2. Suture Length:

  • The ideal length for an intracorporeal separate stitch is 10 cm.
  • For a continuous suture, the thread should be approximately 15 cm long to facilitate the final knot.
  • Crucially, the suture length must never exceed 20 cm, as the imaging system magnifies the length by 2.5 times, making intracorporeal suturing very difficult.

3. Loading the Needle:

  • There are two main techniques for loading the needle onto the needle driver: the deposit-pick-up technique and the dangling pirouette technique.
  • A key step involves swivelling the needle so that light evenly reflects off “Point C” (one-third from the hub). The needle driver then firmly grasps the needle at this point.
  • After loading, it is recommended to perform practice throws to ensure the needle is loaded approximately 90 degrees to the driver.
  • Other suggested techniques for adjusting the needle angle include: maintaining a light grip and pulling the thread taut, gently brushing the needle end against nearby tissues, or reducing the grip and hooking it on superficial fibres of the serosal layer in an avascular area. Using the assisting instrument to reposition the needle angle is noted as a “popular but inefficient technique”.
  • Additional methods include “Lay on tissue,” “Koh technique,” “Wattiez technique,” and “twist”.

4. Needle Driving Principles:

  • Angle of Approach: The needle tip must approach the tissue at right angles, regardless of its configuration. The force applied by the needle driver should be perpendicular to the cut surface or tissue edge.
  • Needle Detection: Occurs when the needle is not pushed directly opposite the plane of tissue resistance.
  • Counter Pressure: Correct use of counter pressure or traction expedites suturing.
  • Technique: The needle driver is the dominant instrument, while the assisting grasper is used for counter-traction or to help manage the suture. A slowly driven needle passage results in a smoother and more successful passage.
  • Entrance Bite: For the entrance bite, the needle tip should be perpendicular to the tissue surface. The driver is pronated (for throwing a stitch, entering at a 70-degree angle) or supinated, rotating the needle clockwise, pushing it down through tissues, and then forward and upwards.
  • Exit Bite: The needle should be pulled from the tissue surface just enough (10 or 20 yards) to allow maneuverability for reloading the needle in the driver.
  • General Manipulation Tips: A trailing needle is a safe needle, while a held needle should always be in view. The tips of the two needle holders must always be visible. It is crucial that the two needle holders never cross each other but move parallel from one side to the other. “Nudge,” “push,” and “twist” techniques help arrange the needle in the desired orientation on the tissues, preferably on a smooth serosal surface and not fatty tissue.

5. Knot Tying Techniques with Needles:

  • The “Drop Needle Technique” involves creating an elongated ‘U’ with the suture to decrease the instrument-to-suture angle, then twisting the suture twice around the instrument to create a surgeon’s knot. The needle is then dropped.
  • The “Hold Needle Technique” keeps the needle constantly held, requiring the surgeon to rotate the needle to align with the suture and minimise the instrument-to-suture angle, making wrapping effortless.

Retrieval of the Needle

When retrieving the needle from a 5mm trocar, it may be necessary to straighten the needle using two needle holders.

Importance and Training

The entire process of acquiring the correct suture depth in endoscopic surgery is technically challenging, involving visualization, eye-hand coordination, the role of the assisting instrument, judgment, and tactile feedback. Mastering needle skills is considered one of the most demanding endoscopic technical skills. This skill allows surgeons to gain confidence and can reduce conversion rates to open surgery. Extensive training and practice, often on simulators, are emphasised to overcome the steep learning curve. Training includes practical sessions on needle introduction, orientation, and tissue approximation.

Laparoscopic Suturing Considerations

Laparoscopic suturing and tissue approximation are considered among the most demanding technical skills in endoscopic surgery. Mastering these techniques is paramount for laparoscopic surgeons due to the unique challenges posed by the minimally invasive environment.

Here are the key considerations for laparoscopic suturing, in the larger context of endo suturing and tissue approximation in laparoscopic surgery:

1. Fundamental Challenges and Their Impact Laparoscopic surgery presents inherent limitations that significantly impact suturing:

  • Two-dimensional (2-D) Vision: Surgeons operate by viewing a 2-D TV screen, which eliminates depth perception. This contrasts sharply with open surgery’s 3-D direct vision and direct tactile feedback.
  • Loss of Depth Perception and Tactile Feedback: The absence of haptic or tactile sensation and depth perception makes accurate and well-tied knots difficult and time-consuming.
  • Limited Degrees of Freedom: Rigid laparoscopic instruments have restricted movement, further complicating precise manipulation of needles and sutures. The pivoting effect and fulcrum add to this difficulty.
  • Visual Obstruction: The confined abdominal cavity and potential for visual obstruction can make managing the suture and needle challenging.
  • Eye-Hand Coordination: The disjunction between hand movements and visual feedback on screen necessitates significant hand-eye coordination.

2. Needles in Laparoscopic Surgery Surgical needles are penetrating devices designed to pass sutures through tissues with minimal trauma. Their objectives are to provide a secure grip for the needle driver, penetrate the tissue to create a channel for the thread, and allow the thread to be trailed.

  • Needle Anatomy: A surgical needle typically consists of a tip and a hub. For grasping, specific points are identified: Point A (approx. 2 cm from the hub for initial grasping), Point B (one-third from the needle tip for secondary grasping), and Point C (one-third from the hub, where the needle driver firmly grasps the needle).
  • Types of Needles:
    • Straight Needle: Offers advantages such as easy introduction even through the smallest port, un-altered needle tip direction by the needle swivel within the jaws of the needle holder, and simpler positioning involving movement in a 2-D plane. It is applied in areas like the gastrointestinal tract, nasal cavity, skin, tendon, and vessels.
    • Curved Needle: A 25mm half-circle needle is commonly used for endosuturing, though it may have a tendency to swivel and requires more experience. Curved needles (1/4, 3/8, 1/2, 5/8 circle) and compound curved needles are adapted for various applications depending on the tissue and location.
    • Endoski Needle: Developed specifically for laparoscopic use, this hybrid combines the ease of handling straight needles with the tissue passage attributes of curved needles. It features an atraumatic suture, a straight shaft, and a terminal tapering curve corresponding to a quarter of a circle, resembling a miniature ski. Its shaft transitions from a modified rectangle to a rounded body towards the tip, facilitating an easier grip and smooth tissue passage.

3. Needle Holders and Instrumentation The quality and design of instruments, especially needle holders, are crucial for efficient and safe suturing.

  • Features of Needle Holders: Commonly used are 5 mm Cuschieri needle holders, known for their single action tapered jaws. More recent versions may have diamond coating for a better grip on the suture material without damage. A relaxed “open hand” grip is recommended.
  • Ergonomics: A coaxial stem-to-handle relationship in needle drivers allows for greater maneuverability and rotation, making movements more ergonomic and reducing complexity. A cylindrical handle design permits smooth 360-degree rotation. Some needle drivers, like the Szabo-Berci and Cuschieri sets, feature a coaxially curved end on one jaw to facilitate internal half knotting in areas of complicated access.
  • Robotic Needle Holders: Robotic needle holders offer bidirectional flexion and unlimited rotation, allowing access to difficult-to-reach areas and fitting various hand sizes for one-handed operation. These are expensive but reusable, space-saving, and easy to use.

4. Suture Material Considerations The choice of suture material impacts knot security and ease of use.

  • Absorbable Sutures: Catgut (poor gliding ability), Vicryl (good maneuverability), and PDS (excellent gliding ability, no need to follow during intracorporeal anastomosis) are common choices. Biosyn, a synthetic monofilament reabsorbable suture, is noted for combining the advantages of intertwined sutures (better knot tightness, high tension strength, quick absorption, lack of memory) with monofilament features (greater smoothness, lack of capillarity, higher inertial force, minor tissue trauma).
  • Non-Absorbable Sutures: Silk (braided, more traumatizing), Prolene (monofilament with memory, making it tedious), and Ethibond (monofilament with less memory and better maneuverability than Prolene) are mentioned.
  • Special Considerations: Knots made from catgut, dacron, polyglactin, and lactomer are considered safe, while PDS, silk, or polyamide are less reliable. Stiff hydrophobic monofilament material should generally be avoided as it provides less frictional hold and has a greater tendency to slip. Barbed sutures are self-anchoring and offer uniform wound tension without knot tying skill.

5. Practical Techniques and Principles Effective laparoscopic suturing relies on meticulous technique and adherence to specific principles:

  • Suture Length: The ideal length for an intracorporeal separate stitch is 10 cm, while for a continuous suture, it should be approximately 15 cm to facilitate the final knot. Critically, suture length should never exceed 20 cm due to the 2.5 times magnification by the imaging system, which would make intracorporeal suturing very difficult.
  • Needle Introduction and Retrieval:
    • For 10-12 mm ports, a CT1 needle can be inserted directly.
    • For 5 mm ports, back loading (inserting instrument first, then grasping suture and guiding needle) is often necessary.
    • An introducer tube is recommended to protect ligatures and sutures from cannula valve mechanisms during introduction.
    • For retrieval from a 5mm trocar, it may be necessary to straighten the needle using two needle holders.
  • Needle Handling and Loading:
    • Needle Control: Maintaining a trailing needle is safer than a held, rigid one. All instrument tips, especially needle holders, must always be visible. The two needle holders should never cross each other but move parallel from side to side.
    • Loading Techniques: Two main techniques are the “deposit-pick-up technique” and the “dangling pirouette technique”. The needle should be loaded approximately 90 degrees to the driver. Adjustments to the needle angle can be made by maintaining a light grip and pulling the thread taut, gently brushing the needle end against nearby tissues, or reducing the grip and hooking it on superficial fibers of the serosal layer. Other methods include “Lay on tissue,” “Koh technique,” “Wattiez technique,” and “twist”.
  • Needle Driving Principles:
    • Angle of Approach: The needle tip must approach the tissue at right angles. The force applied by the needle driver should be perpendicular to the cut surface or tissue edge.
    • Counter Pressure: Correct use of counter pressure or traction expedites suturing.
    • Technique: The needle driver is the dominant instrument, with the assisting grasper used for counter-traction or suture management. A slowly driven needle passage results in a smoother and more successful outcome.
    • Entrance and Exit Bites: For the entrance bite, the needle tip should be perpendicular to the tissue surface. The driver is pronated (for a 70-degree entry angle) or supinated, pushing the needle through tissues. For the exit bite, the needle is pulled just enough to allow reloading.
  • Suture Management: Work within a specified small area, bringing the suture and needle into a confined workspace. Pulling on the needle is restricted to the initial extraction, then the needle is dropped, and the thread is pulled by an instrument-to-instrument technique. A “two-handed pull” is the most efficient method for advancing the thread but requires experience.
  • Knot Tying Techniques:
    • Intracorporeal Knots: Tied inside the body cavity using needle holders. The square knot (reef knot) and ligature knot are common. The surgeon’s knot (double half knot followed by two single half knots) or square knot are favored for interrupted suturing.
    • Techniques: The “Drop Needle Technique” involves creating an elongated ‘U’ with the suture and twisting it twice around the instrument to form a surgeon’s knot before dropping the needle. The “Hold Needle Technique” keeps the needle constantly held, requiring the surgeon to rotate the needle to align with the suture and minimize the instrument-to-suture angle for effortless wrapping.
    • Essentials: Good magnification, economy of motion, directional hold principle, avoidance of instrument crossing, correct knot-tying choreography, and execution of knots close to tissue surfaces are essential. Knot configuration, shaping, and securing are all critical for a secure knot.
  • Avoiding Errors: Errors in laparoscopic surgery can include dropping the needle while suturing or incorrect needle driver orientation. Careful preparation and meticulous setup of the anastomotic site are as essential for stapling as for suturing.

6. Importance of Training and Learning Curve Laparoscopic suturing is one of the most demanding endoscopic technical skills, requiring a steep learning curve.

  • Training Modalities: Extensive practice on simulators is crucial before performing these techniques in live operations. Training programs, such as those for a Postgraduate Diploma in Laparoscopic Surgical Skills, include modules on laparoscopic suturing skills, covering needle loading, knot shaping, and intracorporeal/extracorporeal suturing and knot tying through simulation. Hand-on instruction on basic laparoscopic skills and practical parts focusing on needle introduction, orientation, and tissue approximation are vital.
  • Benefits of Training: Mastering these skills allows surgeons to gain confidence and can reduce conversion rates to open surgery. Studies show a statistically significant difference in knot-tying times between experienced and less experienced surgeons, highlighting the steep learning curve.
  • Simulators: Learning on good quality endo trainers is highly recommended. Novices benefit from training in a transparent box trainer under direct vision, as it takes less time and reduces frustration while achieving the same results in economy of movement and tissue handling. Such setups are also a cost-effective adjustment to standard box trainers.

7. Evolution and Future (Robotics) While traditional methods are challenging, advancements aim to simplify laparoscopic suturing.

  • Robotic Suturing: The introduction of robotics has made intracorporeal suturing easier to learn due to its intuitiveness and the additional degrees of freedom of robotic wrists and three-dimensional vision. This helps minimize the steep learning curve associated with laparoscopic suturing, particularly for inexperienced surgeons and complex procedures like intracorporeal anastomosis. Robotics also offer improved economy of motion and less surgeon discomfort compared to laparoscopic procedures.
  • Endoscopic Robotic Suturing: This is a developing field. Devices like the Apollo Endosurgery OverStitch allow endoscopists to suture perforations and defects, providing robust tissue approximation. The Master and Slave TransEndoluminal Robot (MASTER) system offers multiple degrees of freedom of robotic wrists, allowing recreation of human wrist movements essential for suturing and knot tying, and allows the user to concentrate on the procedure rather than tedious manual tasks. This platform enables 3-D vision and greater degrees of freedom, which can facilitate even more endoscopic therapeutic procedures.

In summary, needles are indispensable tools in laparoscopic suturing. However, their effective use demands overcoming significant technical hurdles presented by the laparoscopic environment, necessitating specialized needle designs, ergonomic instruments, and rigorous training to achieve proficient tissue approximation and secure knot tying. The ongoing development of robotic systems aims to further enhance the ease and intuitiveness of these crucial skills.

Suturing Techniques & Tips

Laparoscopic suturing and tissue approximation are considered among the most demanding technical skills in endoscopic surgery, essential for purposes such as approximating tissues and achieving hemostasis. These procedures require significant hand-eye coordination due to the reliance on a 2D TV screen with magnification, which eliminates depth perception and tactile feeling of tissues. Mastering suturing is paramount for surgeons performing laparoscopic procedures.

Here’s a comprehensive overview of suturing techniques and tips in laparoscopic surgery, drawing from the provided sources:

I. Core Concepts and Importance

  • Purpose: Laparoscopic suturing is used for tissue approximation and hemostasis, including securing small arteries, ligating vessels, transfixation of large vascular pedicles, and interrupted suturing. It’s crucial for achieving accurate approximation of wound edges to promote healing and tying secure knots without excessive tension.
  • Challenges: The inherent limitations of laparoscopic procedures, such as restricted degrees of freedom of rigid instruments, 2D vision, loss of depth perception, and absence of tactile feedback, make intracorporeal suturing and knot tying difficult and time-consuming. The pivoting effect and fulcrum further add to the difficulty.
  • Mastery: Surgeons must be extensively acquainted with the basic principles of knotting and suturing. Adequate experience is attained through prolonged practice on a simulator before attempting these techniques in actual operations.

II. Types of Knots in Surgical Practice Knots in laparoscopic surgery are categorised into intracorporeal and extracorporeal knots.

  • Intracorporeal Knots: These are tied inside body cavities using needle holders. They are generally preferred over extracorporeal tying in endoscopic surgery. Common intracorporeal knots include:
    • Square Knot (Reef Knot): A safe knot for securing small arteries, composed of two opposite half knots. It is a favoured internal knot for interrupted suturing in endoscopic surgical practice. A “Tumble Square Knot” can be made to slide by straightening the same side of the thread, then locked by pulling both threads.
    • Ligature Knot: Considered safer than the reef knot, it involves an initial double knot followed by a single half knot.
    • Double Knot: Consists of two double half knots.
    • Mayo Knot: Includes two identical half knots forming a granny knot, followed by a third and opposite half knot.
    • Surgeons Knot: Composed of a double half knot followed by two single half knots. It is also a favoured internal knot for interrupted suturing. For intracorporeal surgeon’s knot, a “C” loop is made, two winds are taken with the right instrument, slipped in line with the left, and then tightened.
  • Extracorporeal Knots: These external slip knots are tied and drawn outside the body, then “slipped down” to the target with a knot pusher and stiffened by traction. They are recommended for:
    • Ligature in continuity of large vessels.
    • Suturing in regions of limited access where space is restricted.
    • Approximation of defect edges where substantial force is needed.
    • Examples include the Tayside knot, Roeder knot, Melzer knot, square knot.
    • Rules for safe slip knotting: Thread type (1.5m, 2/0 or greater), slip knot choice dependent on ligature material (some knots hold with catgut but not other materials), holding force directly varies with caliber (1/0 slip knot is roughly twice that of 2/0 equivalent), and avoidance of stiff hydrophobic monofilament material due to lesser frictional hold and greater tendency to spill.

III. Ideal Stitch and Knotting Principles

  • Ideal Stitch: Supports tissue edges with correct tension and resists reverse slippage.
  • Three Procedures in Knotting:
    1. Tying the knot (configuration): Creating the knot’s shape.
    2. Working or drawing the knot (shaping): Adapting the knot to the anatomy.
    3. Snuggling or locking the knot (securing): Tightly securing the knot.
    • A knot is secure only if all three stages are performed correctly. As Clifford Ashley noted, “a knot is never nearly right; it is either exactly right or is hopelessly wrong”.
  • Ideal Knot Characteristics: Should be safe, quick, and simple to tie.

IV. Needle Anatomy and Manipulation

  • Needle Anatomy: A needle has a tip, a hub, and a body.
  • Needle Types:
    • Straight Needle: Easy to introduce, movement in a 2D plane. Used for gastrointestinal tract, nasal cavity, nerve, oral cavity, pharynx, skin, tendon, vessels.
    • Curved Needle: Tendency to swivel, requires more experience. Half-circle needles (25mm) are commonly used for endosuturing. Various curvatures (1/4, 3/8, 1/2, 5/8 circle) are used for different applications.
    • Endoski Needle: A hybrid developed for laparoscopic use, combining positive attributes of curved needles (tissue passage) with ease of handling of straight needles. It has a straight shaft and a terminal tapering curve, with the shaft designed for easier grip and smooth tissue passage.
  • Needle Entry and Retrieval:
    • Entry: Needles can be introduced through a port site (e.g., less than 48mm curved needle through a 5mm incision), through the cannula (curved needles smaller than 36mm through a 12mm cannula sleeve), or percutaneously through the abdominal wall (for larger needles, suprapubic area preferred). An introducer tube is recommended to protect ligatures and sutures from cannula valve mechanisms.
    • Retrieval: For a 5mm trocar, the needle may need to be straightened using two needle holders.
  • Needle Handling and Loading:
    • Handling: Once inside, the needle should be manipulated to the desired orientation on the tissues (preferably a serosal surface) using techniques like “nudge,” “push,” and “twist”. A trailing needle is safer than one held rigid. A grasped needle should always be in view.
    • Loading: The needle should be grasped firmly by the needle driver at approximately 90 degrees to the driver. It is a mistake to grasp the needle by the back of the jaws as this impairs precision and reduces grasping force. Techniques for loading include “deposit-pick-up” and “dangling pirouette”. Angles can be adjusted by light grip and pulling the thread taut, or brushing the needle against nearby tissues, or gently hooking it on superficial fibres.
  • Needle Driving Principles:
    • Angle of Approach: The needle tip must approach tissue at right angles, and the force applied by the needle driver should be perpendicular to the cut surface or tissue edge.
    • Counter Pressure: Correct use of counter pressure or traction expedites suturing.
    • Technique: The needle should be driven slowly with a delicate grip, maintaining the pushing force directly against tissue resistance. The dominant hand’s instrument drives the needle, while the assisting grasper supports.
    • Bites: For the entrance bite, the needle tip should be perpendicular to the tissue surface. The driver is supinated to rotate the needle clockwise, pushing it through tissues, then forward and upwards. For the exit bite, the needle is pulled just enough to allow maneuverability for reloading.

V. Suture Material

  • Types: Suture materials are categorised as absorbable or non-absorbable.
    • Absorbable Sutures:
      • Catgut: Poor gliding ability.
      • Vicryl: Good maneuverability.
      • PDS: Excellent gliding ability, no need to follow during intracorporeal anastomosis. Also available with reabsorbable clips for continuous sutures.
    • Non-Absorbable Sutures:
      • Silk: Braided, thus more traumatising.
      • Prolene: Monofilament with memory, making it tedious to use.
      • Ethibond: Monofilament with less memory and better maneuverability than Prolene.
  • Characteristics: An ideal suture length for an intracorporeal separate stitch is 10 cm, and for a continuous suture, it is 15-20 cm (never exceeding 20 cm due to magnification). The material should swell on contact with water (e.g., catgut, dacron, polyglactin, lactomer) to theoretically increase tying and tightening capacity. Stiff hydrophobic monofilament material should be avoided as it exerts less frictional hold and has a greater tendency to spill. Barbed sutures are self-anchoring and distribute wound tension uniformly without requiring a knot.

VI. Instruments

  • Needle Holders: The most commonly used is the 5mm Cuschieri needle holder, featuring single-action tapered jaws, a spring-loaded design, and diamond coating for grip without damage. Coaxial handles improve maneuverability and rotation for laparoscopic suturing, reducing complexity. A cylindrically shaped handle allows 360-degree rotation. Some needle drivers (e.g., Szabo-Berci, Cuschieri) have a coaxially curved end for internal half knotting in difficult access areas. It’s vital for surgeons to become accustomed to and consistently use a particular type of needle holder for efficient and safe suturing. Robotic needle holders (5mm) are expensive but offer bidirectional flexion and unlimited rotation, allowing access to difficult areas.
  • Knot Pushers: Used to slip down extracorporeal knots towards the target.

VII. General Suturing Techniques & Tips

  • Suture Management: Work within a specified small area, bringing the suture and needle into a confined workspace. Move forceps linearly to grasp suture or needle. Monitor the short tail when reeling in suture to prevent it from pulling through. Pull suture with a long “stride”.
  • Ligation Steps:
    1. Creating a straight length of suture: The “Pyramid position” is suitable for winding suture with a needle driver, aligning the suture and needle holder and twisting the needle holder with the straightened thread as an axis.
    2. Throwing a loop: An ideal loop has a short tail and a big loop, created by taking suture with a dissector and looping it around the needle driver.
    3. Securing the knot: Tighten firmly, utilising haptic sensation, and effectively use sliding and surgeon’s knots.
  • Triadic Relationship of Port Sites: Ideally, the optical port is in the center, with suturing ports on each side, forming a triad. This also aligns with the “Baseball Diamond Concept” in ergonomics.
  • Ergonomics: Key ergonomic principles include the “Straight Line principle,” triangulation, appropriate manipulation and elevation angles, using a low-lying table, and a “gaze down view” of the monitor. The ideal relaxed position involves a straight head aligned with the trunk, relaxed shoulders, arms alongside the body with elbows bent 70-90 degrees, and hands pronated. This reduces surgeon discomfort compared to laparoscopic procedures.
  • Economy of Motion: Microsurgical tying involves precisely choreographed actions designed for smooth, reproducible movements with minimal wasted time. Key aspects include understanding the passive and active roles of holders, formation of the initial “C” loop, conscious assessment of position, using the thread’s natural bias, appropriate rotations of instruments, and two-handedness.
  • Avoiding Errors: Be aware of potential technical errors such as dropping the needle or incorrect needle driver orientation. Practicing throwing the stitch after loading the needle ensures proper orientation. Creating an elongated “U” with the suture minimises the instrument-to-suture angle, preventing loops from slipping. For the “hold needle” technique, rotate the needle to align with the suture to minimise the instrument-to-suture angle. Touching tissue can help overcome the 2D display and provide some tactile feedback in a 3D environment. Moving the two instruments as a unit makes actions more directed and efficient.

VIII. Learning and Training

  • Laparoscopic suturing is a challenging skill with a steep learning curve. Novices benefit from training in a transparent box trainer under direct vision, which takes less time and causes less frustration while yielding similar results in economy of movement and tissue handling skills.
  • Formal training programs, like the Postgraduate Diploma in Laparoscopic Surgical Skills, include modules specifically on laparoscopic suturing and knot tying, with hands-on preparation and simulation, often providing take-home simulators and VR headsets for practice.
  • It’s important to practice constantly, follow ergonomic principles, and invest in quality equipment and instruments. Surgeons should also work under the guidance of mentors and gain complete knowledge of laparoscopic equipment.

Staplers in Laparoscopic Surgery

Staplers are an important aspect of endo suturing and tissue approximation in laparoscopic surgery, often complementing or serving as an alternative to manual suturing and knot-tying techniques. While mastering manual intracorporeal suturing is considered a fundamental and demanding skill, automatic laparoscopic suturing devices, including staplers, have been developed to aid surgeons, although none are a complete substitute for manual suturing.

Here’s what the sources indicate about staplers in laparoscopic surgery:

1. Role and Indications Laparoscopic staplers are used for tissue approximation and are an effective way of delivering hemostasis. They are indicated for various complex procedures, including:

  • Gastrectomy
  • Gastric Bypass
  • Resection anastomosis
  • Splenectomy
  • Bilio-pancreatic diversion
  • Gastrojejunostomy
  • Colo-Rectal surgery

2. Requirements for Laparoscopic Surgery Fulfilled by Staplers Staplers are designed to meet specific requirements crucial for effective laparoscopic surgery:

  • Maximum reach and versatility
  • Staple line security
  • Hemostasis
  • Thick tissue penetration
  • Precise staple formation

3. Types of Staplers There are two primary types of staplers used in laparoscopic surgery:

  • Linear staplers
  • Circular staplers – these are often described as having characteristics like single use, head tilt/straight head options, double staple rows, and a circular knife blade. Preferred sizes for circular staplers are 21mm and 25mm, which are considered safe and ensure an optimum size stoma. Curved staplers are also noted as very useful.

4. Specific Stapler Models and Features Several specific stapling devices are mentioned:

  • Autosuture Endo GIA Universal: This device can be used up to 25 times. A single gun can accommodate all staple heights and cartridge sizes. An XL size is available for obese patients.
  • Tyco Gun and Cartridge: Features include two triple staggered rows of staples. Both straight and articulating cartridges are available. A new knife is provided for every application. Available sizes are 2.0/2.5/3.5/4.8.
  • Ethicon Stapling Gun: This gun can be fired up to 8 times. Different guns are required for different cartridge lengths. It can be a straight or articulating stapler, and an XL size is available for obese patients.
  • Echelon: This innovation utilizes a multiple-squeeze method for cutting and stapling, enhancing efficiency, intuitiveness, and overall surgeon satisfaction.

5. Cartridge Types and Tissue Applications Stapler cartridges often come with color codes, indicating their recommended use for specific tissue types:

  • Gold Cartridge: Has 6 rows of staples and a tissue penetration of 1.8mm for compressible tissue. It is mainly used on gastric tissue.
  • Grey: Recommended for mesentery.
  • White: Recommended for small gut.
  • Blue / Gold: Recommended for the stomach, excluding the pylorus.
  • Green: Recommended for the pylorus or redo surgery.

6. Precautions and Guidelines for Use To ensure safe and effective use of stapling devices, several precautions and guidelines should be followed:

  • Avoid excessive use of the gun.
  • Ensure no excess tissue is included.
  • Use the correct cartridge for the task.
  • “Under run” when in doubt.
  • Ensure good vascularity of the tissue.
  • Surgeons must understand the assembly and performance of the devices.
  • Careful preparation and meticulous setup of the anastomotic site are as essential with stapling as with suturing.
  • These instruments should not be used where surgical stapling is contraindicated.
  • It is crucial to choose the correct sized instrument for the expected task.
  • Guidelines for staple anastomosis also include considering port positions, using stay sutures for tensioning, correct enterotomy positioning and size, and checking the staple line after use.

7. Training in Stapling The importance of training in laparoscopic suturing, which includes stapling, is highlighted in the sources. Courses aim to equip surgeons with the skills needed to perform procedures on their patients. The Postgraduate Diploma in Laparoscopic Surgical Skills specifically teaches the use of surgical stapling devices as part of its “Bowel Anastomosis” module. This indicates that the use of staplers is a recognized and taught skill within advanced laparoscopic training programs.

Suturing Platforms

Endo suturing and tissue approximation in laparoscopic surgery, various “suturing platforms” have been developed to address the inherent technical challenges, such as the loss of depth perception and tactile sensation, and the limited degrees of freedom of instruments. These platforms include traditional laparoscopic suturing, robotic suturing, endoscopic suturing, and the emerging endoscopic robotic suturing. Staplers also play a significant role as a method of tissue approximation and hemostasis in laparoscopic procedures.

1. Laparoscopic Suturing (Manual Intracorporeal Suturing)

Laparoscopic suturing, particularly intracorporeal suturing and knot-tying, is considered one of the most challenging aspects of laparoscopic surgery. It demands great manual dexterity and is probably the most demanding of endoscopic technical skills. Surgeons performing laparoscopic procedures must be extensively acquainted with basic principles of knotting and suturing.

Challenges and Limitations:

  • Two-dimensional (2D) vision: Procedures are performed by looking at a 2D TV screen, eliminating depth perception.
  • Loss of tactile feedback: Surgeons lose the tactile feeling of the tissues.
  • Limited degrees of freedom: Rigid laparoscopic instruments offer restricted movement, which adds to the difficulty.
  • Fulcrum effect: This further complicates the movements.
  • Steep learning curve: Acquiring the skill of laparoscopic intracorporeal suturing has a statistically significant steep learning curve, especially for less experienced surgeons and residents.
  • Need for hand-eye coordination: Significant hand-eye coordination is involved.

Techniques and Requirements:

  • Involves using two laparoscopic needle drivers and a curved needle to perform intracorporeal suturing and knot tying.
  • Requires advanced skills to mount the needle, pass it between instruments, form loops, and tie secure knots.
  • An ideal stitch supports tissue edges, provides correct tension, and resists reverse slippage.
  • Essential for execution of knots near tissue surfaces, good magnification, economy of motion, directional hold principle, and avoidance of instrument crossing.
  • Advantages: Laparoscopic suturing equipment is generally light, portable, and readily available.
2. Robotic Suturing

Robotic suturing represents an advancement designed to make intracorporeal suturing easier to learn and perform compared to traditional laparoscopic suturing.

Advantages:

  • Increased degrees of freedom of the robotic wrists.
  • Three-dimensional (3D) vision: Enhances depth perception.
  • More intuitive to learn: Benefits inexperienced surgeons by minimizing the steep learning curve associated with laparoscopic suturing, especially for complex procedures like intracorporeal anastomosis.
  • Improved economy of motion: Particularly useful in confined workspaces like pelvic surgeries.
  • Better ergonomics: Surgeons often experience less physical discomfort compared to laparoscopic procedures, potentially leading to shorter surgery times.

Disadvantages:

  • Requires an additional robotic console for the operator to control.
  • For expert surgeons, the learning curve may be similar to laparoscopic suturing, with the main benefit being improved economy of motion.

3. Endoscopic Suturing

This platform has emerged with advances in therapeutic endoscopy, primarily for procedures within the gastrointestinal tract, especially for early-stage cancers.

Purpose and Indications:

  • Allows endoscopists to suture iatrogenic perforations or full thickness defects endoscopically, potentially avoiding surgical intervention.
  • Can be used for procedures such as endoscopic submucosal dissection (ESD), peroral endoscopic myotomy, and Natural Orifice Transluminal Endoscopic Surgery (NOTES).

Specific Devices and Features:

  • Endoscopic string clip suturing method: Developed by a Japanese group, uses string and clips for single-channel endoscopes, and has shown to significantly shorten the length of patient stay.
  • Apollo Endosurgery OverStitch: Currently the only Food and Drug Administration (FDA)-approved endoscopic suturing device on the commercial market.
    • Provides robust tissue approximation, comparable to open surgery.
    • Used for various applications, including closing anastomotic leaks and managing bleeding peptic ulcer disease, especially in cases where conventional hemostatic methods have failed.
    • Achieved 100% technical success and immediate hemostasis in reported cases of bleeding peptic ulcer disease.

Challenges and Limitations:

  • Many current endoscopic suturing devices remain challenging to use.
  • Often requires the use of a double-channel endoscope, which restricts the depth of insertion and overall flexibility of the endoscope.
  • The lack of extra degrees of freedom of robotic wrists in conventional endoscopic devices is a main problem.
  • Suturing in deep locations, such as the duodenum and right colon, is extremely challenging.
  • Advantages: Like laparoscopic equipment, endoscopic suturing equipment is typically light, portable, and readily available.

4. Endoscopic Robotic Suturing

This is a developing field that combines the benefits of robotic technology with flexible endoscopy to overcome some limitations of traditional endoscopic suturing.

Specific Device Mentioned:

  • Master and Slave TransEndoluminal Robot (MASTER): A robotic endoscopic platform clinically validated for ESD of early gastric neoplasia.

Advantages:

  • Multiple degrees of freedom of both robotic wrists.
  • Three-dimensional (3D) vision.
  • Allows the operator to recreate manual human wrist movements crucial for effective surgical suturing and knot tying.
  • Enables the user to focus on the procedure rather than tedious manual tasks.
  • Permits the deployment of two robotic arms for triangulation during knot tying.
  • Capable of performing both intraluminal and transluminal endoscopic procedures, with operation times comparable to conventional methods.
  • Preclinical studies have demonstrated its potential for transluminal gastric full thickness resection and liver wedge resection.
  • Animal studies have shown its ability to suture perforations resulting from ESD without additional surgical intervention.

Disadvantages:

  • Requires an additional robotic console for the operator to control.

5. Staplers in Laparoscopic Surgery (as a Tissue Approximation Method)

Staplers are a distinct method of tissue approximation and hemostasis in laparoscopic surgery, often used as an alternative or complement to manual suturing. While not a “suturing platform” in the same sense as the manual or robotic systems, they are a crucial tool for achieving tissue approximation.

Role and Indications:

  • Effective for tissue approximation and delivering hemostasis.
  • Used in a variety of complex procedures including gastrectomy, gastric bypass, resection anastomosis, splenectomy, bilio-pancreatic diversion, gastrojejunostomy, and colo-rectal surgery.

Requirements Fulfilled:

  • Designed to provide maximum reach and versatility, staple line security, hemostasis, thick tissue penetration, and precise staple formation.

Types and Models:

  • Linear staplers and circular staplers are the two primary types.
  • Circular staplers are often single-use, may have head tilt or straight head options, feature double staple rows, and a circular knife blade. Preferred sizes are 21mm and 25mm for safe, optimum stoma creation, and curved staplers are noted as very useful.
  • Specific models mentioned include:
    • Autosuture Endo GIA Universal: Can be used up to 25 times, accommodates all staple heights and cartridge sizes with a single gun, and an XL size is available for obese patients.
    • Tyco Gun and Cartridge: Features two triple staggered rows of staples, available in straight and articulating cartridges, and provides a new knife for every application in various sizes (2.0/2.5/3.5/4.8).
    • Ethicon Stapling Gun: Can be fired up to 8 times, requires different guns for different cartridge lengths, available as straight or articulating, and has an XL size for obese patients.
    • Echelon: Utilizes a multiple-squeeze method for cutting and stapling, enhancing efficiency, intuitiveness, and surgeon satisfaction.

Cartridge Types and Precautions:

  • Stapler cartridges are color-coded for specific tissue applications: Gold (gastric tissue, 6 rows, 1.8mm penetration for compressible tissue), Grey (mesentery), White (small gut), Blue/Gold (stomach, except pylorus), and Green (pylorus or redo surgery).
  • Precautions for safe use include avoiding excessive use, ensuring no excess tissue is included, using the correct cartridge, “under running” when in doubt, ensuring good tissue vascularity, and surgeons must understand the assembly and performance of the devices. Meticulous setup of the anastomotic site is as crucial with stapling as with suturing. These instruments are contraindicated in certain situations, and the correct size must be chosen for the task.
  • Guidelines for staple anastomosis also encompass port positions, use of stay sutures for tensioning, correct enterotomy positioning and size, and checking the staple line after use.

While mastering manual laparoscopic suturing is a fundamental, albeit challenging, skill, the development of various suturing platforms and stapling devices aims to enhance efficiency, safety, and ease of use in laparoscopic tissue approximation. Robotic suturing offers significant advantages in freedom of movement and 3D vision, making complex intracorporeal procedures more accessible. Endoscopic suturing addresses the need for internal closure in flexible endoscopy. Endoscopic robotic suturing further advances this by integrating robotic dexterity into flexible endoscopes. Staplers provide a rapid and effective means of tissue approximation and hemostasis for specific indications, complementing traditional suturing techniques. All these methods are integral components of modern laparoscopic surgery, requiring specific training and adherence to precautions for optimal patient outcomes.

Operating room (OR) efficiency

Operating room (OR) efficiency in laparoscopic surgery is a multifaceted concept influenced by technical challenges, the choice of suturing and tissue approximation platforms, surgeon skill, team dynamics, and environmental factors. The sources provide extensive discussion on how these elements interact to impact the overall efficiency of laparoscopic procedures.

Challenges to Operating Room Efficiency

Minimally invasive surgery, including laparoscopic procedures, introduces specific requirements and limitations that can lead to time delays if not managed efficiently. Key challenges that hinder OR efficiency include:

  • Technical Demands: Laparoscopic suturing and knot-tying are widely regarded as among the most demanding endoscopic technical skills, requiring great manual dexterity and hand-eye coordination. Performing these without sufficient experience and practice increases operative times.
  • Visual and Tactile Constraints: Procedures are performed by viewing a 2D TV screen, which eliminates depth perception and tactile feedback, making precise movements and secure knot-tying difficult and time-consuming.
  • Instrument Limitations: Rigid laparoscopic instruments offer limited degrees of freedom, and the pivoting effect and fulcrum further complicate movements within the body cavity.
  • Complex Setup: Laparoscopic surgery necessitates special equipment and multiple steps during set-up, which can contribute to delays if not executed efficiently.
  • Non-Technical Factors: Beyond the technical aspects, OR efficiency is significantly impacted by non-technical skills and team performance. Common causes of delays include communication errors, equipment failure or malfunction, lack of teamwork among nursing, surgical, or anesthesia teams, duplication of tasks, human resource absenteeism, and unscheduled emergency add-on cases. Technical errors, such as dropping the needle whilst suturing or incorrect needle driver orientation, though not always leading to adverse outcomes, are considered “non-deliberate action[s] or deviation[s] from a plan” that can affect efficiency.

Impact of Suturing Platforms on Efficiency

Different suturing and tissue approximation platforms have distinct implications for OR efficiency:

  1. Laparoscopic Suturing (Manual Intracorporeal Suturing)

    • Advantages: Laparoscopic suturing equipment is light, portable, and readily available.
    • Disadvantages: It has a statistically significant steep learning curve, particularly for less experienced surgeons and residents, which can lead to longer knot-tying times and overall increased operative times.
    • Efficiency Enhancement: Mastering this skill requires good magnification, economy of motion, adherence to the directional hold principle, avoidance of instrument crossing, correct knot-tying choreography, and execution of knots near tissue surfaces. Tips for new learners include creating an elongated ‘U’ with the suture to decrease the instrument-to-suture angle and rotating the needle for the “hold needle technique” to minimize the angle, making knot tying easier and more efficient. Moving the two instruments as a unit can make actions more directed and efficient.

  2. Robotic Suturing

    • Advantages: Robotic systems offer increased degrees of freedom of the robotic wrists and 3D vision, which make intracorporeal suturing easier and more intuitive to learn. This significantly minimizes the steep learning curve for inexperienced surgeons, especially for complex procedures like intracorporeal anastomosis. For experienced surgeons, the main benefit is improved economy of motion, particularly valuable in confined workspaces like pelvic surgeries. Surgeons also report less physical discomfort during robotic procedures compared to laparoscopic ones, potentially leading to shorter surgery times.
    • Disadvantages: The system requires an additional robotic console for the operator to control.

  3. Endoscopic Suturing

    • Advantages: Endoscopic suturing equipment, like laparoscopic tools, is typically light, portable, and readily available. Devices such as the Apollo Endosurgery OverStitch provide robust tissue approximation, comparable to open surgery, and have shown 100% technical success and immediate hemostasis in cases like bleeding peptic ulcer disease, potentially avoiding surgical intervention.
    • Disadvantages: Many existing endoscopic suturing devices remain challenging to use. They often necessitate a double-channel endoscope, which restricts the depth of insertion and overall flexibility of the endoscope. The absence of robotic wrist-like degrees of freedom is a primary limitation, making suturing in deep anatomical locations (e.g., duodenum, right colon) “extremely challenging”.

  4. Endoscopic Robotic Suturing

    • Advantages: This emerging platform, exemplified by the Master and Slave TransEndoluminal Robot (MASTER), offers the benefits of multiple degrees of freedom of both robotic wrists and 3D vision. It allows the operator to recreate manual human wrist movements essential for effective surgical suturing and knot tying, enabling the user to focus on the procedure itself rather than tedious manual tasks. The system permits the deployment of two robotic arms for triangulation during knot tying. Operation times have been found comparable to conventional methods for some intraluminal and transluminal procedures.
    • Disadvantages: Like other robotic systems, it requires an additional robotic console for control.

  5. Staplers (as a Tissue Approximation Method)

    • Role: Staplers are a distinct and effective method for tissue approximation and delivering hemostasis in laparoscopic surgery, often used as an alternative or complement to suturing. They are utilized in a variety of complex procedures including gastrectomy, gastric bypass, resection anastomosis, splenectomy, bilio-pancreatic diversion, gastrojejunostomy, and colo-rectal surgery.
    • Efficiency Features: They are designed to provide maximum reach and versatility, staple line security, hemostasis, thick tissue penetration, and precise staple formation. Innovations like the Echelon’s “multiple-squeeze method” for cutting and stapling enhance efficiency, intuitiveness, and overall surgeon satisfaction.
    • Precautions: While efficient, their safe use necessitates a thorough understanding of their assembly and performance, careful preparation and meticulous setup of the anastomotic site, correct cartridge selection based on tissue type, and ensuring good tissue vascularity. The proper size must be chosen for the task.

Training and Ergonomics for Enhanced Efficiency
  • Training: To improve efficiency, surgeons must master suturing techniques and practice extensively on simulators to gain adequate experience, which directly reduces operative times. Novice surgeons benefit from starting their training in a transparent box trainer to overcome frustration and improve economy of movements and tissue handling. Comprehensive training programs include modules on laparoscopic suturing and knot tying, offering hands-on preparation, virtual reality simulations (e.g., Touch Surgery), and take-home simulators for regular practice.
  • Ergonomics: Adhering to ergonomic principles is crucial for surgeon comfort and efficiency. This includes maintaining a straight head and trunk, relaxed shoulders, elbows bent at 70-90 degrees, and hands in a physiological resting position. Principles like the “Straight Line principle” and “Triangulation” are essential for effective instrument manipulation and preventing surgeon discomfort, which in turn can lead to shorter surgery times.

Monitoring and Improvement of OR Efficiency

The “OR Black Box” technology is an innovative approach to objectively identify patterns and root causes of OR time delays. This system records the surgical field, anesthetic equipment, noise levels, and precisely time-stamps all activities within the OR to highlight areas for efficiency improvement. The aim of such monitoring is to:

  • Identify chains of events leading to prolonged case durations.
  • Assess how non-technical skills and team performance correlate with case duration and cancellations.
  • Ultimately, develop a standardized framework to improve individual and team performance and increase OR efficiency across all surgical disciplines. Anticipated outcomes from such initiatives include reduced cancellation of cases, increased OR utilization, reduced time delays, an increased number of completed cases, and improved patient flow within the peri-operative department, alongside an improvement in non-technical skills of the entire OR team.

Achieving optimal operating room efficiency in laparoscopic surgery necessitates a comprehensive approach that addresses the inherent technical complexities, leverages advanced suturing and tissue approximation platforms like robotics and staplers, emphasizes rigorous training and ergonomic principles, and employs objective monitoring to identify and mitigate factors contributing to delays.

Laparoscopy Training & Education

Laparoscopy training and education, particularly concerning endo suturing and tissue approximation, are critical due to the technical complexities inherent in minimally invasive surgery. The sources highlight various aspects of this training, from overcoming steep learning curves to leveraging advanced technologies and structured curricula.

The Challenge of Laparoscopic Suturing and the Need for Training

Laparoscopic suturing and knot-tying are widely considered among the most demanding endoscopic technical skills. This is primarily because procedures are performed by viewing a 2D TV screen, eliminating depth perception and tactile feedback. Additionally, rigid laparoscopic instruments offer limited degrees of freedom, and the pivoting effect and fulcrum further complicate movements within the body cavity. Mastering these skills is paramount for any surgeon pursuing a minimally invasive approach, as insufficient experience and practice can increase operative times.

The Learning Curve

There is a statistically significant steep learning curve for acquiring laparoscopic intracorporeal suturing skills, particularly for less experienced surgeons and surgical chief residents. For example, studies have shown that experienced surgeons take significantly less time for intracorporeal knot-tying compared to less experienced surgeons or residents (e.g., 97.3 seconds vs. 237.2 seconds vs. 265.3 seconds, P < 0.01). This steep curve necessitates extensive training and practice on simulators before performing operations. However, once this skill is mastered, many other laparoscopic tasks may come with ease.

Training Methodologies and Practical Tips

Effective training programs emphasize hands-on practice and adherence to specific principles:

  • Simulators and Box Trainers: Surgeons must practice extensively on simulators to gain adequate experience and reduce operative times. Novices particularly benefit from starting their training in a transparent box trainer under direct vision, which reduces frustration and improves economy of movements and tissue handling skills. These transparent trainers are also a cheap adjustment to standard box trainers, making it feasible for trainees to have their own setup.
  • Needle Handling and Loading: Training covers precise techniques for needle introduction into the body cavity, including using introducer tubes to protect sutures and backloading for smaller ports. Specific methods for loading the needle within the needle driver are taught, such as the “deposit-pick-up” and “dangling pirouette” techniques. It’s crucial to grasp the needle firmly at approximately 90 degrees to the driver. The ability to maneuver the needle into the desired position is one of the first skills to acquire and needs practice.
  • Suturing Principles: Key elements for efficient suturing include:
    • Good magnification.
    • Economy of motion.
    • Directional hold principle.
    • Avoidance of instrument crossing.
    • Correct knot-tying choreography.
    • Execution of knots near tissue surfaces.
    • Closed instrument jaws except during grasping.
    • Awareness of dominant versus assisting instruments.
    • Correct wrapping techniques.
    • Knots configured and tied near to the tail.
    • Maintaining suture length (e.g., 15-20 cm for continuous suture, never exceeding 20 cm as magnification makes it harder).
    • Using counter pressure to expedite suturing and tensioning.
    • Moving two instruments as a unit for more directed and efficient actions.
  • Knot Tying Techniques: Training covers both intracorporeal and extracorporeal knots. For intracorporeal knots, common types include the square knot (Reef knot), ligature knot, double knot, Mayo knot, and surgeon’s knot. Techniques like the “drop needle technique” and “hold needle technique” are taught, emphasizing creating an elongated ‘U’ with the suture and minimizing the instrument-to-suture angle for easier tying.
  • Tissue Approximation: Besides suturing, training covers the use of staplers for tissue approximation and hemostasis. This includes understanding their assembly and performance, meticulous site preparation, and correct cartridge selection based on tissue type.
  • Ergonomics: Following ergonomic principles is crucial for surgeon comfort and efficiency, including maintaining a straight head and trunk, relaxed shoulders, elbows bent at 70-90 degrees, and hands in a physiological resting position. Principles like the “Straight Line principle” and “Triangulation” are essential.
Impact of Technology on Training
  • Laparoscopic Suturing: While challenging, laparoscopic suturing equipment is light, portable, and readily available. The training focuses on adapting traditional suturing methods to the constraints of rigid laparoscopic instruments.
  • Robotic Suturing: Robotic systems, such as the da Vinci system (implied by the discussion of robotic wrists and 3D vision, though not explicitly named in this set of sources), make intracorporeal suturing easier and more intuitive to learn due to increased degrees of freedom of the robotic wrists and 3D vision. This significantly minimizes the steep learning curve for inexperienced surgeons, especially for complex procedures like intracorporeal anastomosis. For experienced surgeons, the main benefit is improved economy of motion, particularly in confined spaces. Surgeons also report less physical discomfort during robotic procedures, potentially leading to shorter surgery times. However, it requires an additional robotic console.
  • Endoscopic Suturing: Current endoscopic suturing devices remain challenging to use, often requiring a double-channel endoscope, which restricts depth of insertion and flexibility. The absence of robotic wrist-like degrees of freedom is a primary limitation in deep anatomical locations. The Apollo Endosurgery OverStitch is mentioned as an FDA-approved device providing robust tissue approximation, but it shares the limitation of requiring a double-channel endoscope.
  • Endoscopic Robotic Suturing (MASTER): This emerging platform, like the Master and Slave TransEndoluminal Robot (MASTER), offers the benefits of multiple degrees of freedom of both robotic wrists and 3D vision, allowing operators to recreate manual human wrist movements and focus on the procedure rather than tedious manual tasks. It enables the deployment of two robotic arms for triangulation during knot tying. Like other robotic systems, it requires an additional robotic console.

 

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