The presentation covered key aspects of laparoscopic suturing including equipment, ergonomics, intracorporeal and extracorporeal suturing techniques, and the use of staplers. Proper port positioning, needle handling skills, knot tying, and attention to ergonomics were emphasized as important for achieving competent laparoscopic tissue approximation. Different suture materials, needle types, and knot styles were reviewed along with their applications in laparoscopic procedures.

1. Laparoscopic
Tissue approximation
Dr.S.Easwaramoorthy
MS FRCS(England) FRCS (Glasgow) FRCS (Edinburgh)
Head of Dept of Minimal Access Surgery
Examiner, RCS of Edinburgh
Executive Member, South Zone IAGES

2. 2 D Image
No depth Perception
No tactile feedback

3. 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

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

6. Laparoscopic Suturing
Equipments
• Needle Holders
• Knot pushers
• Suture Materials
HD Camera
30 degree telescope Good Assistants

7. Invest on Good Needle Holders
Tip
Tungsten carbide
Diamond coating
Straight/Curved

8. Needle holders
Active hand Needle holder
Assisting hand Needle grasper

9. Knot Pushers

10. Welcome Additions…
Endo Stitch
Self righting Needle holder
Repair of Hiatus with Endostitch

11. 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

12. Suture needles
Straight Needle
Ski Needle
Curved Needle
25mm
½ circle

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

14. Different Ball Game!
Open Surgery suturing
 Fast
 Ergonomics: Optional
Laparoscopic Suturing
 Slow and steady
 Magnification effect
 Choreographic
movements
 Ergonomics: Vital
 Triangulation
 Manipulation angle

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

16. Base Ball Diamond Concept
& Triangulation
Monitor
S
C
R
L
P

17. Manipulation angle
Azimuth Angle
Manipulation Angle
30-45 degree
60-90 degree

18. Ergonomics of Hand Instruments
• Tip
– Range of movements
• Conventional Vs Robotic instrument: 4: 7

19. Da Vinci Robot
Wrist like action
PrecisionPrecision

20. Ergonomics of Hand Instruments
• Tip
– Range of movements
• Conventional Vs Robotic instrument
• Length of the shaft

21. Fulcrum Effect of Hand Instruments
1: 1

22. Ergonomics of Hand Instruments
• Tip
– Range of movements
• Conventional Vs Robotic instrument
• Length of the shaft
• Handle design

23. Ergonomic handles…

24. Surgeon’s Stance
Ideal relaxed stature Tiring

25. 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

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

27. I can recognize a good surgeon ,
not from how he cuts,
but
from how he sews!
Johan Mikulicz Radecki
1850-1905

28. Critical Steps of Suturing
1. Introduction of Needle
2. Grasping the Needle
3. Tissue Penetration
4. Knotting

29. 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

30. 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

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

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

33. Surgeon’s Knot

34. 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

35. Slip Knot to Square knot

36. Continuous Suturing

37. Laparoscopic Bowel Anastomosis
Key points
• Port positioning
• Good communications with your assistant
• Positioning of sutures, especially at the
corners
• Spacing the sutures (remember the
magnification)
• Tensioning of sutures

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

39. Extra corporeal knots
• Roeder Knot
• Meltzer Knot
• Tayside knot

40. Roeder’s Knot
No 2 Chromic Catgut
Eg: Appendix base

41. Extra corporeal Knotting

42. Meltzer Knot
1-0 or 2-0 Vicryl
Eg: Cystic duct

43. Tayside Knot
1-0 or 2-0 PDS
Eg: Azygos vein

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

45. 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.

46. 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

47. It is not practice that makes perfect
It’s perfect practice that makes perfect!
- Vince Lombardi,
American Foot ball Coach, Green Bay, Wisconsin