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surgery, because the suture can become caught in the hinge during laparoscopic knottying. Most double action graspers are double-hinged; hence the author recommends use of single action grasper (needle nose grasper). The nondominant, supporting hand of the surgeon should ideally hold long, atraumatic, single-hinged forceps with jaws, without groove marks that would entrap the suture (Fig. 16.3).
Suture Material
Suture material choice is similar as in open surgery, however the rule is to use one “0” thicker than would be used in open surgery. Hence, 2–0 sutures should be used for the various muscular and fascial closures, and 3–0 sutures reserved for fine suturing such as on the esophagus, stomach or colon. Suture length is of paramount importance – 14 cm (6 in.) is sufficient for a single intra-abdominal knotted tie, 24 cm will suffice for a running suture, and a 90 cm (35 in.) thread is ideal for extracorporeal knot-tying. Shorter sutures will render the technique of intra and extracorporeal knot-tying more difficult and a frustrating struggle will ensue. Though there is no general rule, the author’s preferred stitches would probably be a 3–0 Prolene on an SH1 needle (which is smaller than a regular SH) for suturing intra-abdominal organs, and a 2–0 Ethibond on an SH1 needle for muscular structures, such as the crura of the diaphragm.
Interrupted Stitch
The scrub technician prepares the thread by removing the memory and cutting the thread at the appropriate length: 14 cm for one interrupted stitch, 24 cm for a running stitch. The thread is grasped at least 5 mm from the needle and then the needle is introduced through the 10 mm port. As a policy, every time a needle is introduced into or taken out of the abdominal cavity, the surgeon will inform the circulating nurse to document it on the OR board. This prevents the future confusion of having a needle inside the abdominal cavity in case the needle count is incorrect.
As in open surgery, the needle is grasped one-third of the distance from the insertion of the thread to the tip. The movements of the hands should be natural, with the needle at 90° to the shaft of the needle-holder. The left hand grasps the tissue and presents it to the needle-holder as in open surgery, and usually once the needle has passed the first layer, it can be grabbed with the left hand and presented to the empty needleholder again before entering the second, opposite layer.
A general principle of intracorporeal knot-tying is that the needle should always “smile” at the surgeon, and the tip of the needle should be at the Side of The Loose End of the thread (“STLE”). In other words, the thread should create an inverted “C” with the loop facing upwards (Fig. 16.4). With the loose end on the right side of the surgeon, the surgeon rotates the needle-holder (pronation of the wrist), advances the needleholder on top of the grasper, rotates the needle-holder (supination of the wrist), and pulls the needle-holder back, all while the grasper remains unmoving. The tip of the grasper is then opened; the suture is grasped and pulled through to complete the knot. The opposite maneuver is made when the loose end is on the left side of the surgeon
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Chapter 16 Advanced Laparoscopic Suturing Techniques |
Fig. 16.4 The bottom picture illustrates the correct principle of intra-abdominal knotting. The needle “smiles” at the surgeon, and the tip of the needle should be on the side of the loose end (“STLE”)
(Fig. 16.5 a, b). It is also important that the tips of the needle-holder and the grasper do not touch each other, as it will decrease the speed of suturing.
In summary, intracorporeal knotting resembles open microsurgical instrumental knot-tying. In the case of a surgeon who is left handed, the initial steps and the first square knot are achieved in the reverse position.
Running Stitch
Tying an intracorporeal knot after a running stitch follows the same principles as an interrupted stitch. It is important to use the correct suture length (24 cm for a running stitch). To retrieve the needle once the knot has been tied, the thread should be held very close to needle and gently pulled out through the port. If no thread remains, align the needle with the needle-holder and pull the needle out under direct vision of the camera.