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 tightened by first snapping off the top end of the plastic shaft if a commercial endoloop is used and then pulling back on the small end piece whilst sliding the shaft forwards (Fig. 49. 14a—c).

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 The knot is locked down securely, the plastic shaft withdrawn from the knot and the suture then cut at the required length.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 needs the end of the suture outside the port for knotting. The needle is then released and once again regrasped below the swage point with the needle holder so that it can then be withdrawn through the port removing the excess suture with it.

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 suture materials. The ski needle is a straight needle with a slight bend at its point. The suture should be cut to its desired length prior to introducing it into the peritoneal cavity. The suture/needle is held in the needle holder as previously described, holding it below the swage and then introducing the needle into an introducer. The needle and suture are manipulated in the same manner as for extracorporeal suturing, being careful to keep the swage point of the needle orientated towards the needle holder. Once the needle has been passed through the tissue to be sutured, two loops of suture are wrapped around the needle shaft utilising the second grasper. This is most easily performed by depressing the 5-mm grasper down around the tip of the needle holder and back up around its shaft. This motion is repeated to make the second loop (Fig. 49.19). After completing the two loops, one must be sure to keep the swage point of the needle orientated towards the needle holder.

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 these staples, loaded in a multifire instrument. Absorbable staples a] being manufactured.

Another innovation is to have a stopper applied to the end of a suture so that a knot is not required.