SURGEON AT WORK

Portless Laparoscopic Stay-SutureAkos Kiss, MD, FCS(SA)

In laparoscopy, retraction is achieved most frequently byfan-type retractors that can be gripped by self-retainingdevices. Elevation can be achieved by Babcock or softclamps but ischemic pressure necrosis is an ever-presentthreat and the steady grip of an assistant is required.Described here is a method of exposure by elevation thatis well suited mainly to laparoscopic procedures per-formed on hollow viscera.

TECHNIQUEThe number of ports should be kept as low as possiblebut in complex laparoscopic procedures their numbercan reach six or more. Once a port is in place itsposition cannot be changed. If a difficult situation iscreated additional ports must be placed, which addsto both the postoperative pain and the cost. Stay-sutures are extensively used in open surgery but inlaparoscopy their use seems to be rather limited. De-scribed here is a simple method of using stay-suturesfor laparoscopic bowel anastomosis without the needfor additional ports.

A full-length suture is introduced into the abdom-inal cavity through one of the existing ports. Onecorner of the anastomosis is sutured together and areliable intracorporeal knot is tied close to the free endof the suture material. Once the knot is in place a longstraight needle–like suture-passer (Fig. 1, items 1 and2), such as the crochet needle–like Endoclose(TYCO), is introduced into the abdominal cavity tograsp and to remove the suture end through the ab-dominal wall. Once in sight the suture is grasped witha hemostat at such a level that the bowel to be anas-tomosed is partially suspended in the pneumoperito-neum (Fig. 1, item 3). The bowel ends are thus ele-vated to the desired level. If necessary a secondportless stay-suture can be placed into the other endof the anastomosis to provide further stability (Fig. 1,item 4). The anastomosis should be oriented so that

its long axis is parallel with the view of the surgeon.The very same sutures can be used to fashion a single-layer running anastomosis.

Even a single properly placed stay-suture ensures asurprising degree of stability. With some practiceintracorporeal anastomoses can be fashioned withsurprising ease. Use of a low-drag monofilament su-ture material such as polypropylene is suggested todistribute the tension evenly along the suture line. Asin any other anastomosis slippage of the securing knotmay lead to disaster and here special attention is re-quired. Another advantage of the portless stay-sutureis that it can easily be replaced if the initial site is notadequate.

Received January 8, 2003; Revised May 21, 2003; Accepted May 21, 2003.From the Department of Surgery, Chris Hani Baragwanath Hospital, Uni-versity of the Witwatersrand, South Africa.Correspondence address: Akos Kiss, MD, FCS(SA), PO Box 198, JukskeiPark 2153, South Africa.

Figure 1. Elements of a simple method of using portless laparas-copic stay-sutures for anastomoses. (1) The crochet needle–likedevice. (2) The tip of the crochet needle–like device. (3) Portlessstay-suture to elevate one corner of the anastomosis. Because agrasper or a second needle-holder is usually in the nondominanthand of the surgeon to exert counter-traction one stay-suture willsuffice. (4) Both corners of an anastomosis on portless stay-sutures.

691© 2003 by the American College of Surgeons ISSN 1072-7515/03/$21.00Published by Elsevier Inc. doi:10.1016/S1072-7515(03)00606-9

Practitioners should note that in case of erratic an-esthesia, if the patient moves or retches during theprocedure the stay-sutures might damage the delicatestructures involved. The anesthetist must to be askedto provide a very tranquil environment for satisfactoryuse of these portless stay-sutures. The method has beendeveloped in the animal laboratory in a porcine model

and has been used on a few patients for cholecysto-jejunostomy and gastroenterostomy. Other applicationsare to be anticipated.

Acknowledgment: I express my gratitude to Professor RAHinder for guidance and inspiration.

692 Kiss Portless Laparoscopic Stay-Suture J Am Coll Surg