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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_788_Библиотеки_им_академика_М_И_Перельмана.pdf
28
2.3 Joining and Sealing Tissues and Hollow Organs
a
Fig. 2.3.4 Introducing a large needle through a small trocar
site.
a Grasp the tail of the suture and pull it retrograde through
the trocar sleeve outside of the abdomen.
b Replace the empty needle holder antegrade through the
trocar sleeve, and grasp the suture 1 cm proximal to the
needle.
c The tip of the needle holder grasping the suture is rein-
troduced into the abdomen through the existing trocar
site under direct vision with the dangling needle trailing
alongside the instruments shaft. The scrub nurse should
“preload” the needle holder using an extra trocar to increase efficiency if several sutures are required.
b
c
Fig. 2.3.5 Positioning the needle.
a Set the needle down such that it can be simply picked up already in the
proper position.
b Make small adjustments in needle position with a second instrument
by manipulating the suture just proximal to the needle, prior to locking
the jaws of the needle holder.
Suturing and Knot Tying Techniques
29
Fig. 2.3.6 Placing a suture.
a The needle is advanced through the tissues, that are stabilized by a
second instrument, just as with open suturing, by a semi-circular motion that follows the curvature of the needle.
The Endo Stitch™ (USSC) instrument eliminates the difficulties
of needle introduction and positioning, and simplifies suture
placement. This is a disposable, 10 mm instrument with ex-
changeable cartridges on the tip, each of which has a detachable, straight needle with a long suture attached to it. The needle
can be passed in between each jaw of the instrument, taking the
suture with it (Fig. 2.3.8 a−c). Both intra and extracorporeal knot
tying techniques can be used after suture placement.
The Suture Assistant™ (Ethicon) simplifies knot tying, but util-
izes standard techniques for needle introduction, needle posi-
tioning and suture placement. This is a disposable 5 mm instru-
ment with exchangeable cartridges, each of which has a needle
(straight or curved) with a short suture, and a nearly complete
pre-formed knot. The tail of the suture remains attached to the
instrument (Fig. 2.3.9a). Once the suture is placed, the knot
(five half hitches) is completed by placing the needle through a
small pre-formed loop, pulling the suture taut, and squeezing a
trigger to lock and release the knot from the instrument so both
strands can be cut (Fig. 2.3.9b).
The Quik-Stitch™ (Paré Surgical, Inc.) simplifies needle intro-
duction and knot tying while using standard techniques for
needle positioning and suture placement. This is a reusable
5 mm instrument with disposable cartridges, each of which has
a needle (straight or curved) with a suture attached to it
(Fig. 2.3.10 a). Once the suture is placed through the tissue, it is
withdrawn into the shaft of this instrument (along with the
needle) to complete a pre-tied Roeder’s knot which is released
by squeezing an in-line trigger, and tightened by hand
(Fig. 2.3.10 b).
The Sew-Right™ and Ti-Knot™ system (LSI solutions) simplifies
needle introduction and positioning, suture placement, and
knot tying utilizing two disposable instruments, one with ex-
changeable suture cartridges. The suturing instrument has a
b Once the needle tip has penetrated the tissues, the instrument hold-
ing the tissue is released and used to grasp the needle tip. After the
needle is secure in this instrument, the needle holder is released and
the needle rotated completely through the tissues.
Fig. 2.3.7 Pulling suture through tissues. Grasp the suture proximal to
the needle and use a second instrument as a fulcrum to allow the suture
to be pulled through the tissues in a straight line. This technique allows
the suture to slide through the tissues in a straight line, reducing friction.
The technique is also useful passing free ties around tubular structures
that are to be ligated in continuity, and is generally only necessary when
using extracorporeal knot tying techniques.
30
2.3 Joining and Sealing Tissues and Hollow Organs
a
b
Fig. 2.3.8 Suturing with the Endo Stitch™ instrument.
a The instrument loaded with the needle and attached suture.
b The needle and suture are passed through the tissues by closing the
handle and toggling the lever, which releases the needle from one
side, and grasps it on the other side.
c The suture is advanced through the tissues with the needle locked in
the opposite jaw. When pulling the suture through, close the jaws to
avoid inadvertent organ injury, and use a second instrument as a ful-
c
crum to avoid tension on the tissues.
Suturing and Knot Tying Techniques
a
31
Fig. 2.3.9 Suture Assistant™ knot-tying device.
a 5 mm disposable instrument. Note small loop on the lower jaw
through which the needle is threaded (after it is passed through the
tissue) to complete the knot (5 half hitches)
b Squeezing the trigger will lock and release the knot from the instru-
ment.
a
b
Fig. 2.3.10 Quik Stitch™ knot-tying device.
a Reuseable 2.1 mm needle driver fits through 5 mm knot introducer
and release device. Disposable cartridges with needle and pre-tied
Roeder knot fits into tip of shaft.
b After suture placement, the knot is completed by pulling the suture
(and needle) into the shaft of the instrument. The knot is released by
squeezing an in-line trigger, and tightened by “hand,” utilizing the instrument’s shaft.
b
32
2.3 Joining and Sealing Tissues and Hollow Organs
Fig. 2.3.11 Sew-Right™ and Ti-Knot suturing and knot-tying system.
a Disposable instrument with 5 mm shaft with exchangeable needle/su-
ture cartridges. Each cartridge contains a long loop of suture that has
open sockets on both tails. The tails reside on the tip of the instru-
5 mm shaft, and pierces tissue with the squeeze of a trigger,
causing the needle to engage in a female socket with a suture attached on the opposite side. The suture is then pulled back
through the tissue by releasing the handle. The steps are repeated with the remaining tissue to be approximated using a
second needle contained in the same cartridge. This will place
both ends (tails) of a single suture through the opposing tissue
to be approximated. Once the suture tails are pulled outside the
body, they are cut free from the instrument and threaded onto
the second 5 mm device, which will slide down, crimp the sutures together with a titanium cylinder, and cut the suture in-
side the body with the pull and release of a trigger mechanism
(Fig. 2.3.11 a , b). There is another 5 mm device under development that is reusable and uses a plastic bead to crimp the suture
tails together. There is also a 10 mm reusable instrument available that applies absorbable clips to hold suture ends together.
ment, and are placed by interposing tissue between the needle within
the instrument shaft and instrument tip, then pulling a trigger to allow
the needle to advance through the tissue, “grasp” the suture tail, and
pull it back through the tissue into the instrument shaft.
Another interesting concept currently under development is
welding suture tails together rather than knot tying or crimping. This could, however, only be used with monofilament sutures.
Sealing blood vessels is necessary in every operation. Small vessels are commonly sealed with simple pressure or monopolar
electrocautery. Commonly used techniques for medium sized
vessels are suture ligatures, ties, clips, bipolar electrocautery,
and ultrasonic energy. Multiple companies manufacture ultrasonic devices that have a variety of tips that vibrate at high
frequency (50,000 Hz), creating enough energy to coagulate
blood vessels. Generally, vessels greater than 3 mm are not
sealed with bipolar electric or ultrasonic energy. Larger vessels
are sealed with clips, ligatures, and ties. Vascular staplers are
excellent for ligating medium-to-large vessels. A new device is
also available for vessels up to 7 mm in diameter. The LigaSure™
Suturing and Knot Tying Techniques
33
b Once the suture is placed, a second disposable instrument with a 5 mm shaft is used to slide a titanium cylinder over both suture tails, crimp them
together, and cut the suture inside the body.
(Valleylab) utilizes bipolar electric energy, but actually welds
the vessel walls together by combining appropriate amounts of
pressure and energy with continuous monitoring by the gener-
ator. This system has both open and laparoscopic instruments
with a combination of reusable handles and disposable tips
(Fig. 2.3.12 a−c)
Knot Tying
There are a variety of knot-tying techniques. Basic, reproducible
techniques that can be reliably mastered will be described. The
guidelines of laparoscopic knot tying are not different from
open knot tying. The particular technique used is dictated by
the surgeon’s experience and the clinical situation. The only
“rule” is that the surgeon have a systematic, reproducible approach for which he has acquired the necessary proficiency
prior to operating. Knots can be tied either intracorporeally or
extracorporeally. In general, extracorporeal knot tying is faster,
but puts more tension on the tissues. As with open operations,
three to four knots are sufficient for braided sutures, and five to
seven knots for monofilament sutures.
For extracorporeal tying, sutures should be at least 27 inches
(76 cm) long so that both ends can emerge through the same
trocar, and have enough length outside to tie the knot. Because
of the tension placed on the tissues when extracorporeal ties
are used, caution should be exercised when tying in delicate tissues (e.g. common bile duct); intracorporeal knot-tying techniques may be more appropriate here. An extracorporeal knot is
a standard one-handed or two-handed square knot, but the suture is pushed down with an instrument, just as the index finger
would be used in open operations (Fig. 2.3.13a−d). There are
several types of knot pushers available. Many have an open
34
2.3 Joining and Sealing Tissues and Hollow Organs
b
a
Fig. 2.3.12 LigaSure™ vessel sealing system.
a Open and laparoscopic instruments.
b Intraluminal cross section of vessel sealed with standard bipolar
energy.
c Leave as is section and extraluminal view of vessel sealed with ligasure
system.
c
notch through which the suture is placed, and some have a
closed end. Additionally, the closed jaws of a loaded Endo Stitch™ can be used as a knot pusher. Although the open-ended
knot pushers are easily placed onto the suture, they are also
easily displaced. It is a frustrating experience when the knot
pusher becomes dislodged, especially while the knot is within
the trocar sleeve. Knot pushers with closed ends avoid this
problem. If the closed-end pusher is used, a clamp place d on the
end of the suture that is threaded through the ring will prevent
it from slipping out between throws. The suture can be
threaded through the knot pusher either before or after the first
throw is accomplished. While pushing the knot down, it is im-
portant not to push on the knot itself, but to the side of the knot
as in open knot tying. This avoids fraying of the suture and
excess tissue tension. It is also important to keep tension on
both ends of the suture while pushing the knot down. When
tying a square knot, tension should be kept on one strand to
avoid knot slippage during the second throw. As the first throw
may slip a little, it is a good idea to use the same throw twice in a
row so the knot can be slid down and “locked” on the tissue
(Fig. 2.3.13).
Additionally, Roeder’s knots can be used, which are commercially available pre-tied (Fig. 2.3.14a−c), or can easily be crafted
by hand with practice (Fig. 2.3.15a−e). They are useful for lig-
Suturing and Knot Tying Techniques
35
a b
c
Fig. 2.3.13 Extracorporeal knot tying—sliding down the knot.
a Standard open technique of advancing a knot.
b Extracorporeal view of knot pusher advancing a knot.
Thread one tail through the knot pusher and place a clamp on it to prevent dislodgement from the instrument. Place the first throw (“onehanded” technique is most efficient) distal to the tip of the knot
d
pusher. Advance the knot by keeping tension on both tails, and pushing on the suture beyond the knotted portion. Keep tension on one
strand with the dangling clamp between throws to avoid knot slippage.
c Open and closed-ended knot pushers.
d Intracorporeal view of knot pusher advancing a knot.
36
a
2.3 Joining and Sealing Tissues and Hollow Organs
c
ating structures that naturally have a free end, such as the appendix, or tubular structures to be ligated in continuity, such as
the cystic duct or blood vessels. This is a slip knot however, and
should be used with caution for large arteries. When using the
pre-tied Roeder knots, it is often easier to break the plastic end
holding the tail and pull it out a bit to make the loop smaller and
more managable.
Intracorporeal knots are best accomplished with a short (4−
6 inches; 10−15 cm) suture. After the suture has been passed
through the tissue, the ends will form a circle as the knot is tied.
For explanations of instrument placement while tying knots,
the particular side of a given suture will be referred to as being
on the inside or outside of this circle. Right change to left and
above/below will be referred to as they appear to the surgeon
(Fig. 2.3.16 ). For explanations of wrapping the suture around in-
struments, clockwise and counterclockwise will be referred to
from the surgeon’s perspective as well. The descriptions all assumes the needle has been placed with the right-handed instrument from right to left.
b
Fig. 2.3.14 Extracorporeal Roeder slip knot—pre-tied.
a Place the structure to be ligated through the loop, and place the tip of
the knot pusher precisely at the desired knot location on the tissues.
b Break the plastic sheath at the preformed groove, and tighten the loop
by pulling the suture end with one hand, and securing the knot pusher
on the tissue with the other hand. Cut the plastic cap off the end of the
suture to remove the knot pusher.
c Cut the ligature with a short tail.
The most efficient method of tying intracorporeal knots is one
in which both instruments are used in a mirror image fashion to
create opposite throws of a square knot. The first throw is accomplished by grasping the end of the suture on the left with
right-handed instrument, and positioning the sutures in a semicircle with the concave side facing the center of the circle. Utilizing the left-handed instrument to create this suture position
is helpful. Next, place the left-handed instrument above (outside) the suture on the left (Fig. 2.3.17 a ). The right-handed instrument is the used to wrap the left-sided suture (with the
needle attached) counterclockwise (twice to create a surgeon’s
knot) around the left-handed instrument (Fig.2.3.17 b ). Once
the wrap is complete, the left-handed instrument grasps the tail
(right side) of the suture, and the instruments pull the suture
ends in opposite directions (Fig. 2.3.17 c). While tightening the
knot, the needle should be released and only the suture pulled
to avoid inadvertent penetration of adjacent organs (Fig.
2.3.17 d ). The exact mirror image is then used to create the opposite throw. Follow the previous explanation and switch the
Suturing and Knot Tying Techniques
a
37
c
b
Fig. 2.3.15 Extracorporeal Roeder slip knot—tied by hand. The surgeon
manipulates both ends of the suture, and the assistant’s finger may be
used to keep the strands apart. Place a clamp on one end to keep tension.
This end (blue) should be approximately one fourth the length of the end
(red) used to wrap the parallel strands (measured from the future position
of the knot on the clamped strand).
a The initial step is the same as the first throw of a square knot. The su-
ture lies “flat” after the throw, and is tightened over the surgeon’s finger.
words right and left, and substitute clockwise for counterclockwise (Fig. 2.3.17 e−h). This completes the square knot.
There are four tricks to facilitate the wrap. First, the needle can
be grasped at its tip, with the concave surface facing the surgeon (and camera). Second, the instrument being wrapped can
be pushed in and out in a piston-like motion during the wrap.
Third, the two instruments could have curved jaws, with the
concave sides complimenting each other—one curved left and
one curved right. Forth, the ports should be at least 10−20 cm
apart. If the shafts of the instruments are aeparated by 0° (paral-
lel), it is very difficult to wrap the suture for each throw. If they
are separated by 180°, the wrap is accomplished easily, but the
position of the surgeon’s arms is very awkward. Separation of
approximately 90° is a good balance.
Another method of performing an intracorporeal tie is accomplished with a long (at least 15 inches; 38 cm) suture. After the
suture has been passed through the tissues, the long tail is left
coming out the trocar and the needle is removed from the su-
ture, leaving a short tail inside the body. Once the needle is cut
d
e
b Wrap the free end counterclockwise around both taut strands three
times.
c Feed the free end between the two parallel strands into the last loop,
and pull it tight.
d Cut the excess tail back to 1 cm.
e Advance the knot with a small-tipped or notched knot pusher to ligate
the structure. Unlike the previously described extracorporal knot, a
Roeder knot must be pushed directly on the knot.
above
inside
outside,
left
below
Fig. 2.3.16 Intracorporeal knot tying. When a stitch is placed, a circle will
be formed when the knot is tied. For explanations of instrument placement, the particular side of the suture will be referred to as being on the
inside or outside of this circle. Right/left and above/below will be referred
to from the surgeon’s perspective. Explanations of wrapping the suture
around instruments, clockwise and counterclockwise will also be given
from the surgeon’s perspective.
outside,
right