Minimal access knotting and suturing
The performance of knotting and suturing
during laparoscopic and thoracoscopic surgery is difficult because as well as
working in a three-dimensional cavity looking at a two-dimensional screen, one
is working with a needle and suture at some distance from one’s fingers. Large
needles cannot be introduced into the peritoneal cavity through a small port and
long sutures become difficult to control whilst the instruments are less perfect
than those used conventionally.
Endoloop
ligation
Endoloop ligatures can be used to ligate
tissue pedicles and vessels during laparoscopic and thoracoscopic procedures.
They can also be used to close defects in structures, e.g. gall bladders and
ovaries, thus preventing spillage of contents. The placement of an endoloop is a
two-handed procedure. Pretied commercial ligatures are available in plain and
chromic catgut, Vicryl and PDS; however they are expensive and they can be
easily made out of the same ligatures utilising a Roeder or similar knot (Fig.
49.12).
Procedure
The endoloop ligature is ‘back-loaded’
into the introducer and the loop is completely retracted to protect the knot (Fig.
49.13). This introducer is then inserted via a 5-mm port and the endoloop
advanced until the loop is exposed, resting it directly on the tissue with the
pedicle centred in the loop. This pedicle is then held with a second grasper
through the loop utilising it to pull the tissue upwards. The plastic shaft
should be perpendicular to the knot, which helps to prevent suture breakage and
ensures knot security. The endoloop is
This
movement allows the knot to slide forwards closing the loop. Once the knot has
been moved down, the ligated tissue is released from the grasper. The knot is
locked down securely, the plastic shaft withdrawn from the knot and the suture
then cut at the required length. Alternatively, the small plastic end can be cut
off by dividing the ligature at this point, the plastic pusher then removed and
scissors introduced through the same port alongside the
suture which is then cut and removed (Fig. 49.14d).
Extracorporeal
knotting
This technique differs from intracorporeal
knot-tying in one basic respect: once the needle/suture has been passed through
the tissue, the suture is then brought outside the body and the knot is tied.
The completed knot is then reintroduced into the abdominal cavity and then
secured into position. Extra-corporeal knot-tying can be used to ligate vessels,
reconstruct organs, approximate opposing tissue surfaces and suture anastomoses.
Procedure
The needle/suture is loaded into the jaws of
the needle holder by lightly grasping the needle below the swage point so that
the needle will collapse into the introducer. The loaded introducer is then
inserted through a 5-mm port (Fig. 49.15a, b). Once the needle appears in the
peritoneal cavity it is passed to a grasper introduced from another port. The
needle is steadied and then it is regrasped in the desired position by the
needle holder. The needle and suture are then passed through the tissue and the
tip of the needle is then regrasped with the needle holder. The suture will not
be pulled out of the tissue if it is controlled with the second grasper;
additional suture length is pulled into the peritoneal cavity. One must be
careful
not to bring the whole suture intraperitoneally as one
An
assistant then covers the introducer channel with a finger to prevent loss of
pneumoperitoneum. With both suture ends outside the body, the needle is cut off
and a single throw knot made with the two suture ends (Fig.
49.16). The knot is
held securely with the thumb and third finger of one hand (Fig.
49.17) whilst
with the other a Roeder or Melzer knot (Fig. 49.18a—b) is completed. The
suture tail is then cut off and a pusher used to slide the knot down as with the
endoloop knot. An alternative is to make the first throw of the knot as
described and then pass the suture ends through the jaws of a knot pusher which
is introduced through the 5-mm port and the knot slid down on to the tissues.
The knot pusher is then removed and a second conventional part of the knot.
fashioned, the ends of the sutures again being passed through the knot pusher.
This second throw is then pushed down in a like manner to the first and the
third knot can also be fashioned and slid down in a like manner. The suture is
then cut using the scissors through the same port.
Intracorporeal
suturing
Straight needle
technique
A commercially available ski needle is
available with different
The
tail of the suture is then pulled through the two loops creating a knot which is
slid down. Whilst holding the needle in a 5-mm grasper, two additional loops in
the opposite direction are made by bringing the grasper around the needle holder
shaft and then down around the needle holder tip.
Once again the tail of the suture is grasped and pulled through the loops to tighten the knot. The suture is then cut at the desired length and the needle removed through the port.
lntracorporeal
suturing using a curved needle
Endoscopic suturing with a curved needle
offers the surgeon many of the same benefits experienced when suturing at
laparotomy: precise needle placement and control in confined areas, rotational
needle passage through tissue and a wide variety of needles and different suture
materials from which to choose.
Technique.
A needle holder is passed through an introducer and the end of the suture
grasped. The entire length of the suture is then pulled back through the
introducer leaving the needle free at its distal end. The tail of the suture is
released and the needle holder then advanced again down the length of the
introducer taking care not to crimp or damage the suture. The needle/suture is
then grasped at the swage point keeping the needle curve parallel to the needle
holder and introducer. The needle is then pulled into the distal end of the
introducer (Fig. 49.20a—b). Excess suture is excised. A loaded needle holder
and introducer is then introduced through a 10-mm port and it lies in the same
fashion as for a straight needle. A different type of intracorporeal knot can be
performed using the Topel or twist knot (Fig. 49.21). If the needle is too large
for the port, then the cannula is removed and the needle passed through the
incision and reintroduced through the port (Figs 49.20 and
49.21). Autosuture
has developed a disposable straight needle ‘endostitch’ that uses a short
straight needle which passes from jaw to jaw (Fig.
49.22). Knotting with this
method is very easy.
Stapling
Linear stapling
An endo-GIA can be introduced through a 12-mm
port and used thoracoscopically and laparoscopically. It is a haemostatic
staple giving three rows of staples on either side of the tissue which is
divided. Thoracoscopically it is used to divide the azygos vein and to staple
off the lung. Intraperitoneally, it can be used on vascular pedicles and across
the intestine. It is produced with different sizes of staples and in both 3-cm
and 6-cm lengths. Further cartridges can be applied so that multiple uses of a
disposable instrument can be effected during one operation. The resulting
stapled ends are exactly the same as fashioned with the conventional GIA
stapler.
It
can also be used to anastomose two organs or loops of intestine together in the
same manner as it is used conventionally at open operation. The defects left
for the introduction of each jaw of the stapler then have to be closed either
using a further stapler or closing it with a running suture.
The
circular stapling devices are used at laparoscopic anterior resection and it
is possible to place purse-string sutures across the divided colon and rectum.
The anvil of the stapling device can be inserted through the rectum with its
spike attached and then the purse string tightened. However, most surgeons
performing laparoscopic colorectal surgery have moved towards laparoscopic-assisted
colectomies and anterior resection so that the specimen would be brought out
through a small iliac fossa or Pfannenstiel incision, which makes the placement
of a purse-string suture in the proximal end of the colon and insertion of the
anvil very much easier and quicker. The rectum can either be closed using a
stapler or oversewn. At laparoscopic-assisted right hemicolectomy, the specimen
is removed through a right hypochondrial or right iliac fossa incision and the
anastomosis is most easily performed extracorporeally.
New innovations
Anastomosis can be performed using single
staples and the peritoneum after a transabdominal preperitoneal hernia repair is
usually closed with
Another innovation is to have a stopper applied to
the end of a suture so that a knot is not required.