Laparoscopic suturing is an essentialtask for any surgeon who is dealing with laparoscopic procedures intheir clinical practice. Iam presenting the tricks and tips regarding the basics of laparoscopic suturing techniques.

1. How to master in Laparoscopic
Suturing? Practical points
Dr.T.Varun Raju
Senior advanced Laparoscopic surgeon
H.O.D Surgery – Postgraduate teacher - ST Hospital
Course Director Laparoscopic Surgery -TVR Laparoscopy Center
Formerly Bariatric surgeon PACE Gastro Hospital
Visiting professor Osmania University – Biomedical engineering
Member PHd program Osmania university
Zonal Vice-President TSASI
Author, International Surgical illustrator

2. Learning Objectives
#Working knowledge of Suturing Equipments
#Ergonomics for Suturing
#Tissue approximation – Intra corporeal
Suturing – Extra corporeal Suturing – Staplers
in Laparoscopy

3. Headings
• 1.Open surgeon to Laparoscopic surgeon
• 2.Ergonamics
• 3.Instruments & Staplers
• 4.Suture materials
• 5.Entry and retrieval of the needle
• 6.Intra corporeal suturing and extra carporeal loops
• 7.Types of knots
• 8.Dos ,Don’ts and alternatives
• 9.Learning curve
• 10.Take home message

4. 1.Open surgeon to Laparoscopic
surgeon

6. 1.High degree of freedom
2,Work in line with visual axis
3.3-Dimentional Direct vision
4.Direct tactile feedback
1. Less degrees of freedom
2.2-dimentional vision
3.Loss of depth perception
4.View is not under control of the surgeon
5.Fulcrum effect
6.Decoupling of the visual & motor axes
7.Static posture
ERGONAMICS DURING OPEN & LAPAROSCOPIC SURGERIES
• OPEN SURGERY LAPAROSCOPIC SURGERY

7. 2.Ergonamics

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

9. 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.

10. • Base Ball Diamond Concept & Triangulation
Monitor

11. 3.Instruments & Staplers

12. Practical points
• Surgeons should slowly learn these
techniques.
• They will develop their
confidence once capable of
suturing inside the abdominal cavity
and as a result conversion rate will
also decrease.
• Many automatic laparoscopic
suturing devices are invented
for intracorporeal suturing but none
of them are substitutes for manual
laparoscopic suturing

13. Practical points
• The flat grasping surface makes
it possible to turn the needle in all
directions as in conventional surgery.
• Dome-shaped indentation at
the tip automatically orients the
needle in a particular& makes it
easier to grasp the needle.
• Laparoscopic knotting and suturing
should be learned on a good quality
endo trainer.

15. Needle holder

16. Self riding needle holder

17. Needle holders

18. Robotic needle holder
#5mm needle holder
#Expensive
#Fit all hand sizes and one-handed operation.
#Bidirectional flexion and unlimited rotation
#Can access difficult to reach areas in the
abdominal cavity
.# Reusable, space-saving, and easy to use

19. Knot pushers

20. 4.Suture materials

23. Barbed sutures
Barbed suture is a self anchoring suture
at approximately every 1 mm of tissue. There
is a uniform distribution of wound tension
across the suture line without the trouble and
required skill of tying a knot.

24. Holding the needle

25. 5.Entry and retrieval of the needle

26. Three ways
• Through a port site - insert a less than 48mm
curved needle through a 5- mm incision
directly into cavity.
• The suture is grasped 2 cm above the swedge
of the needle and introduced directly
through a 5-mm incision.

27. Directly through the
incision
Grasp the suture 2 cm above the swedge and
insert through the incision under direct
visualization with the laparoscope

28. 2nd technique
• Through the cannula Curved needles smaller
than 36 mm may be passed through the 12-
mm cannula sleeve.
• The suture is grasped 2 cm above the swedge
of the needle and introduced directly
through the cannula.

29. Through the cannula

30. 3d technique
• Through the abdominal wall
• When a larger needle is required, it may be
inserted percutaeously through the
abdominal wall.
• The suprapubic area generally has less fat and
is suitable for insertion of the needle.

31. Through abdominal wall

32. 6.Intra corporeal suturing and extra
carporeal loops

33. Basic Suturing Tips
1.“Move the ground” means to
change the location of targeted
organs or tissues in order to
suture them more efficiently.
2. Check whether the angle is
correct by rotating the needle
driver with a needle.
Alternatively hold it vertically by
twisting your needle driver just
before closing blade of driver.

34. Suture management
• 1) Always work within a specified small
area. “Pull a thread, grab a needle”
means to bring the suture and needle
into a confined work-space, rather than
using a large area while suturing.
• 2) Move the forceps linearly to “grab” a
suture or a needle.
• 3) While “reeling” or drawing the
suture, monitor the short tail more than
the length of suture to avoid the short
end pulling through.
• 4) When reeling in the suture, pull it
with a long “stride.”

35. Ligation
• consists of three elements; 1) Creating a
straight length of suture, 2) Throwing a loop,
and 3) Securing the knot.

36. Ligation
• 1) Making the suture straight
There are ways to make a suture
straight. One is the “The
Pyramid position”
• It is suitable for winding the
suture with a needle driver
• Align the suture and needle
holder and wind the suture by
twisting the needle holder with
the straightened thread as the
axis.

37. 2) Winding the loop
• An ideal loop is created by taking a suture
with a dissector and looping the suture
around the needle driver.
• This is ideally achieved with a short tail
and a big loop.
• Daily training of circulating a dissector
clockwise and counterclockwise
alternately more and more quickly
without scratching the instruments
together will train the surgeon to throw
elegant knots.

38. 3) Tighten the knot
• Do it firmly Feel the haptic sensation and
use a sliding knot and surgeon’s knot
effectively.

39. Handling the
needle
• In laparoscopic surgeries,
Surgeons must be able to
correctly grasp a needle
at a perpendicular angle.
Correct and quick
grasping techniques are
needed.

40. Pivot point

41. Grasping techniques
• Direct
• One can change the direction of a
needle by using a dissector to
adjust it and re-egrasping the needle
with the needle driver.
• Use both instruments to correctly
adjust the angle to 90 degrees.
• “Dancing Needle” 1. Hold the thread
15 mm above the swedge of the
needle with a needle driver. 2. Grasp
the middle of the needle gently with
a dissector. 3. Pull the thread by the
needle driver to adjust the needle to
the proper angle.

42. Grasping techniques
• “Wake me up” Insert the
needle driver with its tip open
between a needle and the
tissue below. Then, close the
tip slowly while pushing the
tissue away from the needle.

43. Grasping techniques
• Stab Stick a needle into non-vascular area of
peritoneum to change the direction of needle
by drawing the suture to adjust the angle
• “Roll” Pick up the suture with the needle
driver and roll it to adjust the needle to the
desired right-angle position.

44. 7.Types of knots

45. Techniques for Laproscopic Surgeon’s
Knot
• The Surgeon’s Knot
is one of the most important
techniques for ligating tissues
securely. After the first loop is
thrown, a second loop is wound in
the same direction before
grasping the tail and securing the
knot.
• A square knot
is a double loop in which the first
throw is around a needle-driver’s
shaft clockwise and the second
throw around the needle-driver’s
shaft counterclockwise. This
creates a knot that allows for
sliding versatility along the suture.

46. • “Moon walk”
• Barber King
• “Thumbs up”
• “Funky fishing”
• “Screw Driver”

47. Auto suture device

48. Sliding (Slip) Knot Technique
• “Sliding Knot” is a
convenient method for
ligating tissues securely by
sliding the knot along the
suture. Before securing the
knot, make a square knot
• Make a square knot
• Release the lock of the knot
by a dissector.
• Slide the knot to the ligation
point and secure the tissues

49. 8.Dos ,Don’ts and alternatives

50. • 1.Do practice by training with a mentor
• 2.Do have a complete knowledge on
laparoscopic equipment
• 3.Do follow the ergonomics
• 4.Do invest on standard instruments
1.Don’t loose patience
2.Don’tbe panicky when there is bleeding
3.Don’t become a patient with wrong
posture
4.Don’tchange your assisting staff
frequently

51. 9.Learning curve

52. Laparoscopic suturing learning curve in an open versus closed box trainer
S. P. Rodrigues, T. Horeman, M. S. H. Blomjous, E. Hiemstra, J. J. van den
Dobbelsteen, and F. W. Jansen
Surg Endosc. 2016; 30: 315–322
• In conclusion, novices benefit from starting their
training of difficult basic laparoscopic skills, such as
suturing, in a transparent box trainer under direct
vision.
• It takes them less time, and they get less frustrated by
the training with the same end result on their economy
of movements and tissue handling skills.
• Furthermore, it is a cheap adjustment to the standard
box trainer setup, making it possible to provide
trainees with their own training setup for the start of
their basic laparoscopic skills training.

53. Learning curve
• Only five articles (55%) provided a
precise cut‐off value to see
proficiency in the learning curve,
ranging from 13 to 200
laparoscopic cholecystectomies.
• For a surgeon with basic
laparoscopic training, around 13–
15 cases are required initially to
become well versed with both TEP
and TAPP and there is no significant
difference in the learning curve
between the two procedures

54. Stapplers
• Staplers: Types & Sizes Gastric Bypass Anterior
Resection Types Linear staplers. Circular staplers.
Color codes White - 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

55. 10.Take home message
• 1.Learn the basics of laparoscopic equipment
• 2.Identify the mentors and work under their gidence
• 3.Practice –Practice –Practice
• 4.Follow the ergonomic principles and be healthy
• 5.Get your endotrainer and at home practice the
suturing techniques
• 6.Instead of easy devices/loops, start suturing in all the
cases
• 7.Invest on the quality equipment & instruments
• 8.Use all the available techniques for the best
approximation of the tissues

56. REFERENCES
• Nezhat C, Nezhat F, Nezhat CH. Nezhat's Video-Assisted
and Robotic-Assisted Laparoscopy
• with DVD. 4th edition. New York: Cambridge University
Press, 2013. Takayasu K, Yoshida K, Mishima T,
Watanabe M, Matsuda T, Kinoshita H. Upper body
position analysis of different experience level surgeons
during laparoscopic suturing maneuvers using optical
motion capture. Am J Surg. 2019 Jan;217(1):12-16.
• Lim S, Ghosh S, Niklewski P, Roy S. Laparoscopic
Suturing as a Barrier to Broader Adoption of
Laparoscopic Surgery. JSLS. 2017 Jul-Sep;21(3)

57. Videos

58. THANK YOU !