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Fig. 16.1 Correct position of wrists. (a) depicts wrists in line with the forearms. (b) depicts incorrect flexed wrist position (operating table too high or trocar ports placed too high)
In addition, the table can be manipulated to the advantage of the surgeon. For example, during a laparoscopic appendectomy, tilting the table right side up and head down helps to move the small bowel into the left upper quadrant for better exposure. In essence, tilting the table creates an extra hand.
Trocar Placement and Triangulation
Successful laparoscopic suturing is dependent on a key concept in laparoscopic surgery, the triangulation of instruments. Triangulation occurs when the right and left hands of the surgeon are positioned on either side of the camera and form a 90° angle with the camera. This is the basic trocar position and will avoid the “knitting needle” effect of the instruments when using a two-handed technique. In addition to the triangulation of trocars at the skin at ninety degrees with the laparoscope, it is important to insert the trocar in such a way that the instruments also triangulate inside the abdomen at ninety degrees in a double triangulation (Fig. 1.11, Chap. 1). This is critical and especially important in patients who are morbidly obese with a thick abdominal wall. A trocar that is inserted straight down does not allow any movements of the instruments.
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Fig. 16.2 “Shaft” sign; trocar for the surgeon’s right hand is too medial. Tip of instrument is barely visible. The solution for this is lateral translation of the medialized port. C camera port; A left hand; B right hand, moved laterally
The intra-abdominal triangulation prevents the instruments from aligning themselves parallel to each other,which would make the task of suturing very difficult.Another common problem encountered in port placement is when a trocar is placed too medially and too close to the camera port. In this situation, instead of only visualizing the tip of the instrument in the field, the shaft is partially in line with the camera and will obstruct the view; this is known as the “shaft sign” (Fig. 16.2), and indicates an incorrect trocar position. The solution is to move the trocar by partially removing it and then sliding the skin with the help of the trocar more laterally before reinserting it.
The ideal ergonomic position for the camera is when the laparoscope is in line with the target while preserving the double triangulation. This ensures the optimal view required for successful laparoscopic suturing.
Equipment
Designated advanced laparoscopic equipment is necessary to perform advanced procedures. This equipment includes additional specifications for the purposes of laparoscopic suturing.
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dissector
Needle holder
Needle nose dissector
Fig. 16.3 Ideal instruments for laparoscopic suturing. Avoid exposed hinges associated with double action instruments. The best instruments are usually single-hinged. Needle nose grasper for the receiving and supporting hand is shown here
Needle Holders
Appropriate needle-holders are necessary, at least for the surgeon’s dominant hand. The ideal needle-holder has a long shaft, a straight handle that allows some rotation of the wrist, and jaws with a diamond shape that will grasp the needle appropriately. The trigger mechanism of the needle-holder should be comfortable, and the jaws should grasp firmly enough without use of excessive force, which may crush and break the suture. The needle-holder should be single action without any exposed hinges in which the suture material can be caught (Fig. 16.3).
Graspers
Graspers should be atraumatic and without ratchets. Fenestration is a matter of surgeon’s preference. The only grasper with a ratchet is used to retract the gallbladder during a cholecystectomy. It is important to avoid graspers with exposed hinges in laparoscopic