Suturing and Knot Tying

Suturing and knot tying are critical skills for the advanced laparoscopic surgeon (8).

The Endoloop™e consists of a preformed loop of suture with a slipknot at the end of a plastic knot pusher. This device may be used for ligating tubular organs such as the appendix.

Extracorporeal knotting involves formation of the knot by a longer suture outside the cavity and pushing it through the port with the help of one of the many available knot pushers. Intracorporeal suturing and knot tying is the author's preferred method of laparoscopic reconstruction. The needle can be easily inserted through a laparo-scopic port by grasping the suture about 3 cm from the needle. The trocar sleeve valve should be kept in an open position while the suture is being inserted. The size of the needle determines the trocar size required. Although a 10-12 mm port is preferred, certain smaller needles may be passed through a 5 mm trocar. The suture is generally cut to a length of 7-10 cm for intracorporeal knot tying. A longer suture may be used for certain applications that require continuous suturing. In general, the longer the suture, the more difficult it is to handle in the laparoscopic environment. The long end of the suture is looped two to three times around the tip of the needle driver and to complete the first throw of the surgeon's knot. The second and the third throws complete a square knot. Suturing can be performed in interrupted or running fashion. A variety of needle drivers with varying tip and handle configurations and locking mechanisms are currently available. A novice laparoscopist may consider starting out with a self-righting needle-driver, although the non self-righting devices afford the greatest versatility for the more experienced surgeon. Our personal preference is the Ethicon needle driver E705R (Fig. 9).

A variety of specialized suturing devices is available to facilitate laparoscopic intracorporeal suturing and knot tying. These include Endostitch™ f and SewRight™ g. Although these devices may facilitate the beginner laparoscopist, in our opinion, they lack the finesse of freehand suturing. Additionally, with these specialized devices, the laparoscopic surgeon is limited in terms of the type of suture and needle configurations available. In contrast, with freehand laparoscopic suturing, the surgeon can use the full array of suture available for open surgery.

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