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18
2.2 Access and Exposure Techniques in Laparoscopic Surgery
Fig. 2.2.19 Once the initial trocar is placed, and the area is insufflated,
subsequent trocars are placed under direct visualization to avoid trauma.
a
Fig. 2.2.20 Once the peritoneal cavity has been entered, the trocar can
be angled anteriorly to avoid potential danger to underlying organs.
Treatment: (a) increase intensity or gain of light; irrigate and
suction area. (b) frequent cleaning of lens with antifog solution
and warm water as there are no peritoneal surfaces on which to
wipe the scope.
Trocar Placement
Once exposure into the operative field has been obtained utilizing one of the above techniques, working ports for the operative
instruments and retractors must be placed and the procedure
commenced. The importance of visually controlled insertion
cannot be overemphasized since more than 10% of laparoscopic
complications are associated with trocar insertion (Fig. 2.2.19
and Fig. 2.2.20). The skin incision should be one to two millimeters larger than the trocar (Fig. 2.2.21a, b). The trocar is generally placed with a twisting motion, applying pressure with the
wrist, not the shoulder. The middle or index finger is extended
along the trocar to prevent uncontrolled entry. The trocar is
angled slightly toward the operative field, but not to the degree
that the trocar slides along the outside of the peritoneum. Previously the “Z” placement technique was widely used to
decrease leakage of pneumoperitoneum. Although this is less of
a problem with newer trocars and grips, this technique may be
useful in certain patients undergoing lengthy procedures (Fig.
s. S. 2.2.22).
b
Fig. 2.2.21a, b If excessive force is needed, the incision likely needs to
be enlarged to prevent retraction on the trocar sleeve or safety shield.
Check that the safety on a shielded trocar is properly set.
Complication: Localized collection of carbon dioxide
Manually deflate or aspirate prior to end of procedure.
Complication: Poor visualization
Cause: (a) decreased light due to slightly bloodier nature of
potential spaces. (b) dirty scope.
Location
The most important factors in placing the ports are to space
them such that they do not interfere with each other, and to try
to keep instruments in line with the camera. One rule of thumb
is that the distance between the cannula and the operative site
should be approximately half the length of the instrument.
Ports are generally placed in a loosely configured semicircle
around the operative site, although personal experience and
specific patient factors may require a different number and configuration than routinely recommended (Fig. 2.2.23).
Trocar Placement
abc
19
Fig. 2.2.22 The “Z” placement technique: While applying slight pressure
and a constant twisting motion, with the middle or index finger extended
along the trocar, (a) advance the trocar perpendicular to the abdominal
wall until the tapered stylet tip has penetrated the full thickness of the
.
2
fatty tissue, (b) horizontally advance the trocar two to three cm over the
rectus fascia, (c) advance the trocar vertically through the rectus into the
abdominal cavity. The non-dominant hand should be lifting the abdominal wall during the procedure.
.
Fig. 2.2.23 The anatomy of the abdominal wall, as well as underlying or-
gans. In the midline the falciform ligament can get in the way superiorly,
and the bladder can be injured inferiorly. More laterally, one risks injuring
the epigastric vessels. Placing a port in the flanks risks damage to the
colon. Excessive pressure at any site risks damage to all underlying organs
and vessels.
1
The trocars must be removed under direct visualization as a
vessel may be tamponaded with hemorrhage manifesting only
after removal (in the recovery room) (Fig. 2.2.23).
The operative field should be inspected under decreased pressure since bleeding may be tamponaded by the pneumoperi-
Fig. 2.2.24 Complication: Abdominal wall hemorrhage.
Cause: laceration of abdominal wall vessel.
Prevention: transilluminate abdominal wall prior to trocar placement.
Treatment: the trocar should be removed and the vessel cauterized exter-
nally or internally, or ligated through an enlarged incision. The trocar is
then replaced. Otherwise, the trocar may be removed with closure of the
fascia and placement of the trocar elsewhere. Alternatively, a Foley balloon can be placed, inflated, and retracted to tamponade the bleeding.
This method is time consuming, and if unsuccessful, one of the previously
mentioned options must be undertaken.
toneum and only become manifest once the pressure is released
(in the recovery room) (Fig. 2.2.25).
In the case of intestinal injury, the injured area can sometimes
be withdrawn through the incision (which may need to be
slightly extended) and repaired extracorporally. Three rules to
20
Fig. 2.2.25 Complication: Hemorrhage from injury to an underlying
vessel.
Cause: Excessive pressure without adequate visualization.
Prevention: Controlled trocar placement under direct visualization without
undue pressure.
Treatment: (a) minimal—pressure and thrombogens; (b) moderate or con-
tinued—if the expertise is available, and the bleeding site clearly seen,
then a maximum of two attempts may be made to control the bleeding by
applying clips, ligatures or suturing; (c) heavy, continued, or expertise not
available—immediate conversion to laparotomy.
2.2 Access and Exposure Techniques in Laparoscopic Surgery
Type of Port
As research and development progress, the number and variety
of ports available have skyrocketed. The ports should be chosen
with the specific procedure in mind, taking into account the
surgeon’s preference, cost, and what exact instrumentation will
be neede d.
Size
(Fig. 2.2.27a−e)
The cannula sizes range from two to 30 millimeters in diameter
with variable lengths. Standard instruments require a five or ten
millimeter port. Although most clipping devices require ten
millimeter ports, five millimeter clipping and hernia tacking
devices are available. EndoGIA* devices require 12 or 15 millimeter ports, depending on the length of the staple line.
The smaller ports (particularly the two millimeter port) have
too snug a fit around the instruments to allow adequate gas insufflation or venting. Both disposable and reusable two millimeter ports are available. They can be used with a two millimeter scope for diagnostic laparoscopy under local anesthesia or
for currently established laparoscopic procedures. The instrumentation is somewhat delicate and needs to undergo further
development prior to widespread use.
Valves
(Fig. 2.2.28a, b)
A plethora of valves and reducers are available. The reducer caps
are reusable or disposable, some attach to the cannula and
others are separate, but most require manual adjustment
should instruments of different sizes be used. Some of the reusable reducers are more prone to wear and tear, necessitating
frequent replacement. In deciding on which valve/reducer to
use, one must consider the procedure to be performed, the
number of instrument changes that are likely to occur, the sizes
of the instruments to be used, and the cost of the ports. The
most versatile is the disposable Versaport** which allows differently sized instruments to be used with no need to manually
change reducer caps. The Versaport** also allows extracorporeal
knot tying without excessive loss of pneumoperitoneum. The
Versaport** can, however, collect debris on the external end and
obscure view as the scope is replaced.
Fig. 2.2.26 Complication: Injury to bladder.
Prevention: Controlled trocar placement under direct visualization, empty
bladder prior to procedure.
Treatment: Damage to any organ is treated in a fashion similar to that for
blood vessel injury. Two attempts if the expertise is available, otherwise,
open. Drain the area and administer antibiotics as indicated.
remember in cases of iatrogenic injury to any organ are 1) Don’t
panic, 2) blind attempts at control are to be condemned, and 3)
opening in a timely fashion rather than proceeding laparoscopi-
cally to the patient’s detriment is the real mark of a good sur-
geon (Fig. 2.2.26).
Trocars
There are many different trocar tips available, each with its own
benefits and limitations. Pyramidal tips are reputed to cause
more damage than conical tips, however, the conical tips require excessive force to introduce. The knife blade tip theoretically causes less abdominal wall trauma, however it cannot be
introduced using the usual twisting method. Reusable trocars
may become dulled over time.
Many feel that the shielded trocars are safer, however, they do
not tend to be as easily introduced, leading to a greater amount
of pressure being applied. The shield is supposed to pop out and
lock around the blade once the trocar has entered the abdomen,
however, if the skin incision is too small, the shield may be held
back (Fig. 2.2.22). Newer shielded trocars with a blade which retracts into the shield should eliminate this problem.
Two newer cannulas minimize dangers associated with trocars.
One is a disposable expandable sleeve, which is introduced
using the Veress neeedle, then dilated to the necessary size
* EndoGIA is a trademark of the United States Surgical Corporation.
** Versaport is a trademark of the United States Surgical Corporation.
Trocar Placement
21
abcde
Fig. 2.2.27 a−e If one is starting with a diagnostic laparoscopy or is un-
sure of exactly what size instruments are going to be needed, the smallest
trocar may be used initially, and changed to a larger one if needed. The
trocar is removed after placement of the guide rod, and the skin incision
extended. The new trocar with threaded converter is placed over the rod
with a twisting motion, then the converter and rod are removed and the
procedure continued.
using a blunt introducer. The other is a reusable threaded
cannula, which is introduced through a small incision in the
anterior fascia. Using rotational force, under direct vision, it
bluntly dissects its way into the abdomen. Both are reported to
decrease trauma to the abdominal wall structures, as well as
leaving smaller defects to close. No matter which product is
used, careful controlled entry is the key.
Reusable Cannulas
b
Although reusable ports are less expensive and more ecologically sound, they are generally cumbersome and not well suited
to advanced laparoscopic techniques. They are also
radioopaque, and may interfere with intraoperative radio-
graphs. As reusable ports improve, they will likely replace their
currently superior disposable counterparts.
Grips
Grips are designed to keep the port in place, however they necessitate a larger skin incision to introduce them. They are also
not infallible, and are prone to slippage in longer cases or with
too large a skin incision. Some prefer to make the skin incision
a
Fig. 2.2.28 a, b The trumpet valve allows the scope to enter untouched
and remain cleaner. It needs two hands to operate, however, and multiple
instrument changes through these ports can become excessively cumbersome.
22
Fig. 2.2.29 Closure of fascia externally once the ports have been removed. In the obese patient this may be difficult, leading to haphazard
approximation of any tissue, with resultant risk of herniation. Since the
skin incision of the Hasson cannula is larger, the fascial reapproximation at
these sites is significantly easier to accomplish.
just large enough for the cannula and allow the snug fit to keep
the cannula in place. Should this method be employed, the skin
incision must still be large enough to allow placement of the
trocar without undue force. Some ports (both disposable and
reusable) have the threads placed directly on the cannula,
decreasing the incision size necessary.
Note: The above discussion of access equipment is in no way ex-
haustive, we attempt only to present principles, and acquaint
readers with some of the variety of products available, which in-
creases every day. While further development results in techni-
2.2 Access and Exposure Techniques in Laparoscopic Surgery
cal efficiency, operative proficiency, and greater safety, this progress is generally associated with an increased cost. In today’s
world of fiscal constraints, it behooves the surgical team to decide how much is enough for patient safety and surgeon comfort, and how little becomes dangerous and tedious at any price.
In spite of the fact that health care has become an “industry,”
falling prey to speculators who would have been chased out of
the temple of Aesculapius in pre-biblical times, there can be no
rationing of available and needed resources for profit and there
can be no compromise of quality through miserly healthcare assembly lines.
Port Site Closure
We routinely reapproximate any fascial incision ten millimeters
or larger, although there is at least one case report in the literature of a hernia through a five millimeter port site. Closure can
be accomplished in one of two ways, open, or with the
pneumoperitoneum intact using one of the various closure devices on the market. These devices generally introduce the tie
through one side of the fascia, with some requiring use of instruments through other ports to aid in retrieval of the tie on
the other side. Some leave the trocar in place while closing,
others require removal, which leads to air loss and spray of subcutaneous fluid collections. Others simply retract the fascia upward to aid in external closure. They all vary in the amount of
time needed to achieve closure, security of closure, complication rate, and cost. According to one study, even the hand sutured external method (Fig. 2.2.29) had a significant failure and
complication rate. This study found the most reliable closure to
be achieved by the Carter-Thomason device, for which reason
we have chosen to illustrate it here (Fig. 2.2.30 a−c). The exact
method chosen is probably not as important as definite identification of the fascia with an adequate amount of tissue reapproximated. The subcutaneous tissues should be irrigated,
especially if contaminated by the specimen. The skin is generally reapproximated with absorbable subcuticular sutures and
adhesive strips.
ab c
Fig. 2.2.30 a−c Closure with the pneumoperitoneum intact using the Carter-Thomason Needle-Point Suture Passer device. Carter-Thomason NeedlePoint Suture Passer is a trademark of Inlet Medical, Inc.
Visualization
Preparation
The patient, monitors, and scrub team must be appropriately
positioned. The surgeon should have an unobstructed view of
the monitor, as should the assistants. The surgeon should be
working comfortably in line with the camera and monitor to
decrease fatigue and frustration. Gravity is utilized to retract or-
gans out of the operative field. The surgeon should utilize both
hands, and minimize far reaching, which can quickly become
fatiguing. In setting up the camera and scope, all points of at-
tachment must be completely clean and dry and adequately
tightened.
Camera Choice
Visualization
23
The most important factor in choosing a camera is the clarity of
the picture (Table 2.2.3). Digitized systems and single chip
cameras tend to produce the best images. Although depth per-
ception was improved, first generation stereoscopic and head
mounted display systems proved to be too expensive and cum-
bersome with decreased lighting and resolution. Improvements
in these systems as well as development of mobile screens are
some of the more recent advances.
Endoscope Choice
Different optical systems each have their unique benefits (clarity, brightness, color) and should be comparatively evaluated
prior to purchase. Endoscopes smaller than the standard ten
millimeter size have a decreased field of view. The endoscope
with a working port moves with every operative stroke. The
various angled endoscopes (30 or 45 degree) have adequate
clarity, however disorientation is directly proportional to the
degree of the angle. The newer endoscope with a user directed
flexible tip combines the best of both worlds, however, the pic-
ture quality is inferior, and the durability of the flexible portion
is unknown.
Complication: Decreased visualization
Cause: (a) increased particulate matter (smoke or water vapor),
(b) condensation on the endoscope, (c) body fluids on lens obstructing view.
Fig. 2.2.31 Complication: Light cord burning drapes.
Cause: End of light cord (or endoscope if attached) in prolonged contact
with tissue or drapes.
Prevention: Turn light on only when in use, keep end of light cord or endoscope from contact with tissue or drapes.
Table 2.2.4 Summary of medical video system components.
Component Necessary aspects
Laparoscope Quality endoscope with good optics, different sizes
and angles as needed.
Camera High resolution and sensitivity to light, true color
and maximum depth of field are key factors.
Monitor High resolution with accurate reproduction of
image.
Light source Adequate brightness and purity of light will keep
the image color true.
Light cables Increased light transmission with increased diame-
ter (should be at least 5 mm wide).
Accessories At least one documentation device should be avail-
able (VCR, video printer, digital photography unit,
or floppy disk memory). These devices should be
hooked up on a secondary line.
Table 2.2.3 Evolution of the laparoscopic video camera.
Year Device Resolu-
tion
(lines)
up to 1981 Vacuum tubes 250 + + Not soakable
1982
1985
1989 3
1992
1992
1992 3-Chip* microchip
1994 EndoLive*** 600 +++ ++ Active 3 dimensional view, lightweight liquid crystal display eye-
MOS−metal oxide silicon
CCD−charged coupled device
The average television has 250−400 lines of resolution.
*3-Chip is a trademark of Stryker Corporation.
** Hyper CCD is a trademark of Sony Corporation.
*** EndoLive is a trademark of Carl Zeiss Inc.
2
/3 in. MOS chip 260 -- + Soakable, one chip, smaller, solid state
2
/3 in. CCD 350 + ++ First CCD, smaller
1
/2 in. CCDs 700 ++ ++ 3 chips, more realistic color, improved resolution
1
/2 in. CCD 470 ++ ++ 1 chip. Super-VHS, improved brightness
1
/2 in. CCD 500−600 +++ ++ 1 chip, improved color and resolution by digital processing
850 +++ +++ 3 prism block filters use all available light
with HyperCCD**
Light
Sens.
Signal
Noise
Comment
ware
-- poor
+ adequate
++ good
+++ excellent
24
2.3 Joining and Sealing Tissues and Hollow Organs
Treatment: (a) evacuate cavity and reinsufflate, (b) warm endo-
scope, insufflate through a different port, dry connection to
camera, (c) irrigate tip of endoscope; touch tip of endoscope to
non-fatty peritoneal surface; remove endoscope, wipe it clean,
and apply antifog solution.
Principles
Although minimally invasive techniques are discussed here, all
surgical principles still apply. The operative field must be ade-
quately visualized, blind groping is to be condemned. Tissue
must be handled gently and only to the extent necessary to perform the procedure. The tenet of traction/countertraction still
applies. Meticulous hemostasis is necessary not only to reduce
postoperative complications, but to maintain visualization
which is more easily decreased in minimally invasive procedures. Time spent setting up is never wasted. Properly position the patient, monitors and port sites, and work in line with
the camera. Reduce far reaching and adjust the table to a comfortable height. These precautions will eliminate disorientation
and frustration which might otherwise lead to an unpleasant
outcome. The specimen should always be retrieved in a speci-
men bag, the ports should be securely placed, and the
pneumoperitoneum should be evacuated through a trocar as
these factors have been implicated in tumor seeding. Most of all
one must remember that converting to an open procedure is
neither a failure nor dereliction, rather a sign of good judgment
and appropriate restraint in the right situation.
Bibliography
Chang W. How the Medical Video Camera Became the Surgeon’s Tool. In
Principles of Laparoscopic Surgery, p. 777−784. New York: Springer-Verlag; 1995.
Elashry O et al. Comparative Clinical Study of Port-Closure Techniques Fol-
lowing Laparoscopic Surgery. J. Am. Coll. Surg. 1996: 183:335−344.
Halpern NB. The Difficult Laparoscopy. Surg. Clin. North. Am. 1996; 76:603−
613.
McKernan JB. Essential Concepts and Skills in Laparoscopic Surgery. In Mini-
mally Invasive Surgery and New Technology, p. 28−31. St. Louis: Quality
Medical Publishing Inc.; 1994.
Paolucci V, Schaeff B. Gasless Laparoscopy in General Surgery and Gyne-
cology. New York: Thieme, 1
SAGES troubleshooting guide available through SAGES 2716 Ocean Park
Blvd., Suite 3000, Santa Monica, CA 90405 web site http.//www.sages.org/
sages.html.
st
ed.; 1996.
2.3 Joining and Sealing Tissues and Hollow Organs
D. B. Earle, L. A. Galibert, M. A. Hopkins, F. M. Steichen
Objectives and Methods
The goal of laparoscopic surgery can be divided into four main
categories: diagnostic, excision only, reconstruction only, and
resection followed by reconstruction. All of these require expertise in various wound repair methods. Joining tissues has been a
major obstacle in laparoscopic operations because of limited
maneuverability, lack of tactile feedback, and the constraints of
a two-dimensional view. There are a variety of instruments and
techniques available to join tissues, and each of these has
advantages and disadvantages. Suturing with needle and thread
possesses the greatest versatility, but is technically challenging.
These difficulties can be overcome by proper trocar placement
and, more importantly, practice. Three-dimensional optical systems may also be helpful, but these have so far not gained popularity. Additionally, computerized robotic systems are being
used and developed to overcome some of these difficulties. Ver-
satility requires knowledge of all of these techniques, but profi-
ciency is necessary in only a few. One should not, however, confine one’s expertise to a single technique at the expense of mastering fundamental suturing and knot tying, resulting in reliable, primary wound healing.
Indications
Joining and/or sealing tissue planes and hollow viscera is indi-
cated in nearly all laparoscopic procedures. The surgeon’s armamentarium for accomplishing this task includes stapling in-
struments, clips, fibrin glue, sewing devices, suture ligatures,
mono/bipolar electrical energy devices, ultrasonic energy devices, and a variety of needles and thread. The basic principles of
ligating blood vessels and creating anastomoses do not differ
from those of open operations. Specific tissue approximation
techniques depend on the clinical situation, and the surgeon’s
familiarity with each technique.
Contraindications
Failure to control blood loss, unclear anatomy, or uncertain
anastomotic integrity are all reasons to abandon minimally invasive techniques and proceed with open operation. Lack of expertise in more than one acceptable method of joining tissues,
and lack of proper equipment should also be considered as contraindications to performing operations requiring these skills.
The surgeon’s assistants and operating room staff must work together as a team to provide adequate visualization, as well as
appropriate equipment availability/positioning and troubleshooting.
Specific Considerations
Proper training in the various techniques of tissue approximation is essential. These techniquesare best tried first on a training
apparatus that can b e obtained commercially, or created with a
cardboard box. Computer simulation will likely play an increasingly important role in training and credentialling. This experience can be followed with anatomic models, human
cadavers, and live animal models. It is helpful to maintain these
skills by having access to a training apparatus on a daily basis. Expertise in laparoscopic suturing and knot tying only comes with a
stepwise approach to learning proper technique, and practice.
This should not be discouraging when one thinks of the rewards
provided by the efforts spent practicing open suturing and knot
tying in times past. Basic surgical principles should not be com-
promised simply because of a minimally invasive approach.
Suturing and Knot Tying Techniques
Trocar Placement
The trocars introducing the working sleeves, or ports, should be
placed along arcs surrounding the operative field (Fig. 2.3.1).
The ports should be at least 10 cm apart, forming the base of an
isosceles triangle, with the apex of the triangle being the opera-
tive field (Fig. 2.3.2). Port placement as well as patient position-
ing should allow the surgeon to work with his/her arms in a
comfortable position—elbows flexed at approximately 90°—no
more than a 45° angle away from the surgeon’s torso.
The surgeon should be facing in the same direction as the laparoscope so as not to work “backwards.” Working in a mirror
image fashion is extremely awkward and should simply be
avoided by proper positioning.
Suturing and Knot Tying Techniques
25
Suture Material
Selecting the proper suture material and employing precise
knot tying techniques are key factors in achieving an efficiently
placed and secure knot. The suture material chosen should fit
the procedure. Braided sutures have handling characteristics
well suited for laparoscopic use. Although monofilament sutures slide well through tissue, they may fray when used with
knot pushers, have too much elastic recoil, may increase the risk
of knot slippage, and require more throws per knot. In addition,
they are more prone to damage while grasping the suture
during needle introduction and manipulation. The particular
color of a suture may be helpful in identifying it with the laparo-
scope. Dark colors are the best, as undyed white sutures will be-
come soaked with blood and blend into their surroundings. The
exception to this is the white ePTFE suture which is easily iden-
tified in the operative field. The choice between absorbable and
nonabsorbable sutures is up to the surgeon, and is procedure
specific. Synthetic sutures tend to promote less of an inflammatory response than do nonsynthetic sutures. Tables 2.3.1 and
2.3.2 list some commonly used sutures and their specifications.
The length of the suture depends on the method use d for tying
the knot. Generally, short sutures (4−6 inches; 10−15 cm)
should be used for intracorporeal knot tying and long sutures
(at least 27 inches; 68 cm) should be used for extracorporeal
knot tying.
Fig. 2.3.1 Trocar placement. Trocars should be placed at least 10 cm
(4 inches) apart along imaginary arcs surrounding the operative field.
They should be set up so that the instrument tips will be pointing in the
same direction as the scope.
Needles
The specific needle attached to the suture is dictated by availa-
bility, trocar sleeve size, and technical expertise of the surgeon.
Straight, standard curved, and combination (“ski” or “canoe”)
needles are equally effective. Larger needles can be used with
smaller trocar sleeves by removing and replacing the sleeves in
a technique described in detail later. Although this seems quite
cumbersome, in practice it can be rather efficient.
Instruments
The most important part of the armamentarium is a good
needle holder and receiving instrument (used in the hand op-
Fig. 2.3.2 Trocar placement. Optimal position of ports for suturing and
knot tying is at least 10 cm (4 inches) apart, forming the base of an isosceles triangle. Suture length will depend on whether a running or interrupted stitch is placed, as well as on the planned method of knot tying.
posite the needle holder). Important considerations regarding
the design of these instruments is listed in Table 2.3.3.
A needle holder with an in-line handle (rather than pistol grip)
allows instrument manipulation with the same wrist movements used during the more familiar open operations. This design reduces shoulder movement and fatigue, as well as digital
nerve compression along the radial aspect of the thumb. A
26
2.3 Joining and Sealing Tissues and Hollow Organs
Table 2.3.1 Commonly used absorbable suture types and characteristics.
Brand Name Material Type Color Strength
Vicryl™ (Ethicon) Synthetic, glycolide/lactide
copolymer
Polysorb™ (USSC) Synthetic, glycolide/lactide
copolymer
Braided Violet, Undyed 65% at 14 days, 40% at 21 days2, complete absorption
56−70 days
Braided Violet, Undyed 140% initial
absorption 56−70 days
Dexon™ (USSC) Synthetic, polyglycolic acid Braided Green, Undyed 65% at 14 days
1
4
, 80% at 14 days, 30% at 21 days, complete
2
, 35% at 21 days, complete absorption
60−90 days
Monocryl™ (Ethicon)
Biosyn™ (USSC) Synthetic, glycolide dioxanone
Surgical gut Serosal layer of bovine or
Synthetic, Polyglecaprone 25 Monofila-
ment
Monofila-
trimethylene carbonate
ment
Monofila-
sheep small intestine
ment
PDS™ (Ethicon) Polydiaxanone Monofila-
ment
Clear 50−70% at 7 days, 20−30% at 14 days, 0% at 21 days,
3
complete absorption 91−119 days
Violet, Undyed 140% initial4, 75% at 14 days, 40% at 21 days, complete
3
3
Yellow, Brown,
Clear
absorption 90−110 days
0% at 7 days, complete absorption 21−42 days
Blue, Undyed 70% at 14 days, 50% at 28 days, 25% at 42 days, no ab-
3
sorption for 90 days, complete absorption within
5
6 months
1
As a percentage of initial tensile strength. Initial tensile strength many vary by suture type and is also a function of suture diameter.
2
Sizes 6−0 and larger.
3
Does not handle as well, and requires more throws per knot compared to braided suture.
4
As a percentage of United States Pharmacopoeia (U.S.P.) recommended minimum knot strength.
5
Plain absorbs more rapidly and induces more of an inflammatory reaction than chromic. Increased rates of absorption are seen with infection,
and in tissues with high levels of proteolytic enzymes such as stomach, vagina, and cervix.
Note: Braided suture requires 3−4 throws/knot (assuming proper knot-tying technique). Monofilament requires 5−7 throws/knot (utilizing
proper knot tying technique).
Table 2.3.2 Commonly used nonabsorbable suture types and characteristics.
Brand Name Material Type Color Comments
Surgidac™ (USSC) Synthetic, polyester Braided Green Silicone coated, good handling characteristics
and knot security
Ethibond™ (Ethicon) Synthetic, polyester Braided Green Silicone coated, good handling characteristics
and knot security
Tevdek™ (Genzyme) Synthetic, polyester, impreg-
nated with ePTFE**
Braided Green, Undyed Silicone coated, good handling characteristics
and knot security
Ti·cron™ (USSC) Synthetic, polyester Braided Blue, Undyed Silicone coated, good handling characteristics
and knot security
Surgical silk Silk protein from domestic
silkworm species B. mori
Nylon Polymer of nylon Monofila-
Braided Black Silicone coated, good handling characteristics
and knot security; gradual loss of tensile strength
ment
Black, Green,
Undyed
Slides through tissue well; tends to fray with knot
pusher; elastic recoil makes knot tying difficult;
requires 5−6 throws per knot
Prolene™(Ethicon) Polypropylene Monofila-
ment
Blue Slides through tissue well; tends to fray with knot
pusher; elastic recoil makes knot tying difficult;
requires 5−6 throws per knot
Gore-Tex (WL Gore) ePTFE** Monofila-
ment
White Good handling characteristics and knot security;
slides through tissue well; requires 6−7 throws
per knot
* Nonabsorbable sutures have high tensile strength, and are not known to lose tensile strength or absorb with time; the exception is surgical
silk which can lose strength over time, but is not absorbed.
**Expanded polytetraflouroethylene
Note: Braided suture requires 3−4 throws/knot; requires monofilament 5−7 throws/knot (utilizing proper knot-tying technique).
Table 2.3.3
Important instrument design characteristics to consider for
instruments used in laparoscopic suturing and knot tying
쐌 handle shape (ergonomically sound)
쐌 locking mechanism (secure and easy to use)
쐌 jaws (surface, shape, single/dual action)
쐌 ability to clean and sterilize
쐌 durability
mechanism that locks or unlocks easily with one hand is a
desirable feature that is mildly in conflict with the need to
firmly grasp the needle—the tighter the grasp of the needle, the
more force is required to operate the locking mechanism. The
jaw’s surface, shape, and movement should all be considered. A
flat, tungsten-carbide surface with fine grooves generally provides the best means for gripping needles. Both straight and
curved jaws can hold a needle equally well, but curved jaws can
help with subsequent knot tying. Whether one (single action)
or both (dual action) jaws move as the handle is opened and
closed depends on surgeon preference. Dual action jaws have
proximal hinges that may interfere with subsequent knot tying.
An in-line handle is also preferable for the receiving instru-
ment. The ability to lock the instrument is not as important as
with the needle holder, and depends on surgeon preference.
The jaw surface should dif fer from that of the needle holder in
that it should grasp both tissues and needles well, without
damaging tissues. This would allow proper needle manipulation with the possible exception of driving the needle through
tissue with the receiving instrument.
There are needle drivers available with piston locking mecha-
nisms that hold the needle very securely, but these cannot be
used for needle and tissue manipulation, or for introducing the
needle. Some of these “automatically” position the needle appropriately in the needle driver, potentially requiring less
manipulation for needle positioning.
Suturing and Knot Tying Techniques
27
Introducing and Positioning the Needle
Regardless of the needle type, the suture is grasped approximately 1 cm away from the needle and pushed through the tro-
car sleeve (Fig. 2.3.3). This technique is used for two reasons.
The first is to enable the needle to fit through the sleeve, and the
second is to avoid inadvertent tissue penetration with the
needle. If the needle is grasped with the needle holder, the
needle position becomes rigid and potentially dangerous. A
“converter” can be used to protect the suture and the valve
mechanism of the trocar sleeve, but is not essential. It is helpful
to use a trocar sleeve that has a rubbery valve mechanism that
conforms to objects passing through it. Such mechanisms
decrease trauma to the suture and the valve, as well as reduce
gas leakage, especially while performing extracorporeal tying.
Reusable trocar sleeves usually have metal valve mechanisms
that are not easily damaged and are friendly to suture material.
A technique for introducing a larger needle when using a
smaller trocar sleeve is to first remove the sleeve completely,
and have an assistant place a finger over the open abdominal
wall wound to prevent gas leakage. The needle holder is placed
through the trocar, the tail of the suture grasped and pulled retrograde through the trocar sleeve (if using an extracorporeal
knot tying technique). A short suture that would be used for in-
tracorporeal knot tying does not need to be pulled retrograde
through the sleeve (Fig. 2.3.4a). The empty needle holder is
then placed antegrade through the sleeve (alongside the su-
ture), and the suture grasped just proximal to the needle
(Fig. 2.3.4b). Next, the tip of the needle holder grasping the su-
ture is reintroduced through the trocar site under direct vision,
with the dangling needle following alongside the instrument’s
shaft (Fig. 2.3.4 c). The sleeve is then advanced into its previous
position over the needle holder similar to the Seldinger technique for passing a catheter over a guide wire. The time required
to perform this maneuver is markedly reduced by utilizing an
extra trocar sleeve and having the scrub nurse “pre-load” the
needle holder in the described fashion. A standard sized
gastrointestinal needle can easily fit through a 5 mm trocar site
using this technique. The potential disadvantages are subcu-
taneous emphysema, trauma to the abdominal wall, potential
implantation of cancer cells and dislodgement of the needle in
the subcutaneous tissue, especially in obese patients. These are
rarely significant problems with appropriate use of the technique.
After the needle has been introduced, it must be oriented in the
needle holder. There are a variety of techniques to achieve this.
One is to set the needle down in such a way that it can simply be
picked up already in the proper position. (Fig. 2.3.5a). Needle
position can be further adjusted by grasping the suture just pro-
Fig. 2.3.3 Introducing a needle through a trocar. This method is used
with any needle type small enough to fit through the trocar. Grasp the suture approximately 1 cm away from the needle and introduce the needle
and suture into the trocar. The needle trails behind the tip of the instrument while being pushed through the trocar.
ximal to the needle (or the needle itself) with a second instrument prior to locking the jaws of the needle holder (Fig. 2.3.5b).
Another technique is to use two instruments (both of which can
adequately grasp the needle), and pass the needle back and
forth, each time rotating the instrument with the needle along
its longitudinal axis, until it is properly oriented. Using these
techniques in combination is helpful.
Suturing
The technique for placing a suture laparoscopically is no different than in open methods. Interrupted or running sutures can
be used. The tissue to be sutured is grasped in an atraumatic
fashion and the needle is driven through by rotating the wrist to
follow the curve of the nee dle, just as is taught with open suturing (Fig. 2.3.6a). Once the needle tip has penetrated the tissue,
the instrument holding the tissue is released and used to grasp
the needle tip, and further rotate it through the tissue
(Fig. 2.3.6b). When the needle has completed its course through
the tissue, it should be grasped in proper orientation to place
the next stitch. If another stitch is not needed, grasp the suture
1 cm proximal to the needle to pull through the necessary
length of suture material. Alternatively, the needle holder can
be released and used to grab the tip of the needle to accomplish
its course through the tissues, leaving the instrument grasping
the tissues in place. By using the latter technique, crossing the
instruments may impede a smooth sequence of operative steps.
As the suture is pulled through the tissue, it is important to
avoid inadvertent penetration into neighboring organs and
excess leverage on the tissue. This is accomplished by releasing
the needle from the needle holder, then grasping and pulling
only the suture. Tension is taken off the tissue by using the free
instrument as a fulcrum. The instrument is placed adjacent to
the tissues on the side of the tissue that has the most tension;
leverage is transferred from the tissue to the instrument thus allowing the suture to slide through the tissue in a straight line
(Fig. 2.3.7). This maneuver is also useful in passing free ties
around a tubular structure that is to be ligated in continuity.
This is generally only necessary when using extracorporal knot
tying techniques.