a

b

Fig. 16.5  (a) First throw and creation of the knot. (b) The suture is looped up to create a virtual suture omega Ω

Pirouette

The pirouette is a simple, elegant maneuver to position the needle on the needle-holder in an efficient manner.In this maneuver,the thread is grasped and used to pirouette the needle into place (Fig. 16.6). Once the needle is in the correct alignment, it can be simply grasped by the needle-holder if needed.This avoids the often clumsy,time consuming transfer of the needle between instruments, further dulling the needle and deforming the shape.

It is difficult to achieve high precision knot-tying using extracorporeal knot-tying. The Extracorporeal author prefers to reserve extracorporeal knot-tying for suturing on the bone or muscle. Knot­Tying

For example, the crura of the diaphragm, the abdominal wall, and Cooper’s ligament are all amenable to extracorporeal knot-tying.

Various knots are possible, but the two most popular techniques are (a) the creation of an external half-knot that is pushed by a knot pusher (Fig. 16.7), and (b) construction of Roeder’s knot that is pushed inside using an atraumatic grasper (Fig. 16.8). It is advisable to leave long branches after cutting the ends of the knot – enough to be able to add an extra intra-abdominal knot to secure the other knots if necessary. This is achieved by using a thread of at least 90 cm (35 in.).

Fig. 16.6   “Pirouette”; the needle is maneuvered into the proper position with a rotation of  the thread by the needle-holder, while the needle nose grasper loosely holds the needle itself

Fig. 16.7  Use of an extracorporeal knot pusher for closure of muscular tissues (crura shown 

here)

Roeder’s Knot

Roeder’s knot is similar to the concept of an Endoloop (Fig. 16.8). Half of a knot is tied, one of the suture tails is rotated three times around both threads, and then the same tail is introduced inside the gap formed by the original half-knot and the first rotation. The tail is then pulled through thus creating a sliding knot.