laparoscopic suturing

Laparoscopic Tissue approximation

Dr.S.EaswaramoorthyMS FRCS(England) FRCS (Glasgow) FRCS (Edinburgh)

Head of Dept of Minimal Access SurgeryExaminer, RCS of Edinburgh

Executive Member, South Zone IAGES

2 D ImageNo depth PerceptionNo tactile feedback

It is both humiliating and frustrating to be observed by every one in OR when you take more than 15 min just to do a one square knot!

Dr. Nathaneil Soper Surgical Clinics of North America Oct - 92

Learning Objectives

• Working knowledge of Suturing Equipments• Ergonomics for Suturing• Tissue approximation

– Intra corporeal Suturing– Extra corporeal Suturing– Staplers in Laparoscopy

Laparoscopic Suturing Equipments

• Needle Holders• Knot pushers• Suture Materials

HD Camera30 degree telescope Good Assistants

Invest on Good Needle Holders

TipTungsten carbideDiamond coatingStraight/Curved

Needle holders

Active hand Needle holderAssisting hand Needle grasper

Knot Pushers

Welcome Additions…

Endo Stitch

Self righting Needle holder

Repair of Hiatus with Endostitch

Suture Material

• Before selecting, Consider following qualities– Absorbability/ Strength/tissue reaction– Handling characteristics and visibility

• Favoured suture materials– Absorbable

• Vicryl, Catgut, PDS– Non absorbable

• Ethibond,Prolene• Length of Suture Material

– Intra corporeal suture: 10-12cm– Extra corporeal suture: 70cm

Suture needles

Straight NeedleSki NeedleCurved Needle

25mm½ circle

Learning Objectives

• Working knowledge of Suturing Equipments• Ergonomics for Suturing• Tissue approximation

– Intra corporeal Suturing– Extra corporeal Suturing– Staplers in Laparoscopy

Different Ball Game!

Open Surgery suturing Fast Ergonomics: Optional

Laparoscopic Suturing Slow and steady

Magnification effect Choreographic

movements Ergonomics: Vital

Triangulation Manipulation angle

Ergonomics• Straight Line principle• Triangulation• Manipulation angle• Elevation angle• Low lying table• Gaze down view

Base Ball Diamond Concept& Triangulation

Monitor

S

C

R

L

P

Manipulation angle

Azimuth Angle Manipulation Angle

30-45 degree 60-90 degree

Ergonomics of Hand Instruments

• Tip– Range of movements

• Conventional Vs Robotic instrument: 4: 7

Da Vinci Robot

Wrist like action

PrecisionPrecision

Ergonomics of Hand Instruments

• Tip– Range of movements

• Conventional Vs Robotic instrument

• Length of the shaft

Fulcrum Effect of Hand Instruments

1: 1

Ergonomics of Hand Instruments

• Tip– Range of movements

• Conventional Vs Robotic instrument

• Length of the shaft• Handle design

Ergonomic handles…

Surgeon’s Stance

Ideal relaxed stature Tiring

Ideal Relaxed Position

-straight head, in the axis of the trunk, without rotation or extension of the cervical spine;- shoulders in a relaxed and neutral position;- arms alongside the body- elbows bent to 70 to 90 degrees- forearms in an horizontal or slightly descending axis- -hands pronated (physiological resting position);- hands and fingers lightly grip the handles/handpiece

•Waist line table•Gaze down view of monitor•Straight line principle•Triangulation

Learning Objectives

• Working knowledge of Suturing Equipments• Ergonomics for Suturing• Tissue approximation

– Intra corporeal Suturing– Extra corporeal Suturing– Staplers in Laparoscopy

I can recognize a good surgeon ,not from how he cuts, but from how he sews!

Johan Mikulicz Radecki 1850-1905

Critical Steps of Suturing

1. Introduction of Needle2. Grasping the Needle3. Tissue Penetration4. Knotting

Introduction of Needle• Through 10mm port (with reducer)

– Non dominant hand port– Hold the suture and not the needle

• Through 5mm port• Through abdominal wall

Grasping the needle

• Dominant hand port(right hand)• Grasp with the tip of the needle holder• Grasp at the ‘Sweet spot’

– Deposit- Pick up technique– Dangling needle technique– Nudging

Needle discipline

•A held needle should always be in view.•A trailing needle is a safe needle

Types of Knots• Granny knot• Square knot• Slip knot to square knot• Surgeon’s Knot• Aberdeen knot• Dundee Jamming Slip Knot

Surgeon’s Knot

Guidelines for Suturing• The Passive and Active role of the holders• The formation of the initial “C’ and a tail• The use of the natural bias of the thread• Choreographic movements with needle holders• Economy of motion• Execution of the knots near to the tissue surfaces• Ambidexterity

Slip Knot to Square knot

Continuous Suturing

Laparoscopic Bowel AnastomosisKey points

• Port positioning• Good communications with your assistant• Positioning of sutures, especially at the

corners• Spacing the sutures (remember the

magnification)• Tensioning of sutures

Learning Objectives

• Working knowledge of Suturing Equipments• Ergonomics for Suturing• Tissue approximation

– Intra corporeal Suturing– Extra corporeal Suturing– Staplers in Laparoscopy

Extra corporeal knots

• Roeder Knot• Meltzer Knot• Tayside knot

Roeder’s Knot

No 2 Chromic CatgutEg: Appendix base

Extra corporeal Knotting

Meltzer Knot

1-0 or 2-0 VicrylEg: Cystic duct

Tayside Knot1-0 or 2-0 PDSEg: Azygos vein

Learning Objectives

• Working knowledge of Suturing Equipments• Ergonomics for Suturing• Tissue approximation

– Intra corporeal Suturing– Extra corporeal Suturing– Staplers in Laparoscopy

Staplers: Types & SizesGastric Bypass

Anterior Resection

TypesLinear staplers.Circular staplers.

Color codesWhite - small gut.Blue / Gold - stomach (except pylorus).Green - pylorus / redo surgery.

Guidelines for Staple Anastomosis

•Port positions for stapling•Stay sutures for tensioning•Enterotomy positioning and size•Positioning and angulations of the stapler prior to closure•Checking staple line•Complete closure of residual opening

It is not practice that makes perfect

It’s perfect practice that makes perfect!

- Vince Lombardi, American Foot ball Coach, Green Bay, Wisconsin