Suturing

Suturing is the next skill to be relearned for intracorporeal reconstruction. Simple stitches require only one pass through the tissues and one knot to be synched. The goal of the laparoscopic surgeon should be to achieve a perfect stitch: equally apposed entrance and exit bite sizes to avoid tension on one side of the anastomosis or the other

(146). Suture length should be kept to the absolute minimum required for this purpose

(147). During microsurgical laparoscopic suturing, 13 cm is adequate for simple stitches. This allows ample room for the loops necessary for knotting even in thick muscular bladder reconstructions. Urologic reconstruction can require the utilization of simple running, or running locking sutures on the bladder. These stitches require more length of intracorporeal suture material and careful attention to tension along the repair. A good rule of thumb is that twice the length of a linear incision in suture material is required (148). Here as the needle is driven through the tissues at each exit bite, the assistant grasper is utilized to aid in pulling the running stitch through for the given length and the desired tension, while the needle driver with the reloaded needle is utilized to provide counter pressure. Because the intracorporeal suturing is arduous, it behooves the surgeon to make sure the suture line is perfect the first time; even if this takes time, it is still better than redoing it. Attention to detail is paramount to an ideal suture. The running suture should start 2 to 3 mm proximal to the incision and run up to 2 to 3 mm beyond, prior to tying the end knot (145). Locking is not particularly difficult but should also be carefully orchestrated and not started until the suture line's tension has been rechecked. It is far easier to tighten a running line of suture before, rather than after, it has been locked intracorporeally. The suture should run at least one needle-driven point beyond the end of the incision. Knotting a running intracorporeal stitch can be more difficult than a simple suture. This will be discussed in the next section.

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