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38
2.3 Joining and Sealing Tissues and Hollow Organs
Fig. 2.3.17 Intracorporeal knot tying—square knot tied with mirror
image technique.
a The first throw is accomplished by placing the left-handed instrument
above (outside) the left-sided suture, which is set up to look like a “C.”
b The suture is then wrapped counterclockwise around the left-handed
instrument (twice for a surgeon’s knot). The wrap is facilitated by
moving the left-handed instrument in a piston like motion, and grasping the needle near its tip with the concave surface facing the surgeon
(and camera). This can be performed without a needle, but can be difficult if the suture is too short, or the ports are too close together.
Fig. 2.3.17 c Once the wrap is complete, the left-handed instrument
grasps the tail (right side), and pulls it to the left while, simultaneously
pulling the left-sided suture to the right.
d Once the throw is complete, it is tightened by pulling the tails in op-
posite directions. To avoid inadvertent organ injury, do not allow an instrument grasping a needle to leave the field of view. Set up the next
throw by placing the left suture tail (blue) in a position easy to access
with the right-handed instrument, and pass the right-sided suture
(red) to the left-handed instrument. Fig. 2.3.17 e−h 컄
Suturing and Knot Tying Techniques
39
Fig. 2.3.17 e The opposite throw is begun by placing the right-handed
instrument above (outside) the right-sided suture (with the needle),
which is set up in the mirror image of the previous throw “ɔ.”
f The suture is then wrapped clockwise around the right-handed instru-
ment.
Fig. 2.3.17 g Once the wrap is complete, the right-handed instrument
grasps the tail (left side), and pulls it to the right while, simultaneously
pulling the right-sided suture to the left.
h Once the throw is complete, it is tightened by pulling the suture in op-
posite directions.
40
2.3 Joining and Sealing Tissues and Hollow Organs
Fig. 2.3.18 Intracorporeal knot tying—long tail method.
a Once the needle is through the tissue, the needle is removed. The
short tail should be 7−10 cm (3−4 inches) long. The long tail should
have a clamp placed on the end for traction.
free, it can be either pulled outside the body, or temporarily in-
serted into a safe location of the abdominal wall for removal
once the knot is tied. A clamp is then placed on the long tail, to
provide slight tension on the suture (Fig. 2.3.18 a ). The lefthanded instrument is then placed on the inside of the circle, and
the right-handed instrument (coming through the same trocar
as the long tail) is placed over the left-handed instrument to
grasp the short tail (Fig. 2.3.18 b). The right-handed instrument
is then wrapped counterclockwise (twice for a surgeon’s knot)
around the long tail—taking with it the short tail (Fig. 2.3.18 c ).
Once the wrap is complete, the short tail is passed to the lefthanded instrument, and the two sides of the suture are pulled
taut in opposite directions (Fig. 2.3.18d, e). Crossing the instru-
ments while pulling the ends taut will allow the throw to lay
“flat.” Alternatively, the suture sides could be exchanged between instruments after completion of the throw, but prior to
tightening it. Keep tension on the long tail to avoid slippage between throws. The opposite throw is accomplished by the exact
same maneuvers with the exception of the wrap, which is ac-
complished in a clockwise fashion (Fig. 2.3.18f, g).
If using the Endo Stitch™ (US Surgical Corp.), an additional
method of tying an intracorporeal knot is available. After the
needle and suture have finished their course through the tissues, place the free jaw adjacent to the inside of the left-sided
suture by rotating the instrument along its longitudinal axis
clockwise 180 ° (Fig. 2.3.19a, b). Grasp the tail (right-sided su-
ture), place it between the open jaws of the Endo Stitch™ using
a second instrument, then close the jaws and transfer the
needle (and the suture) to the opposite jaw (Fig. 2.3.19c, d).
Next, open the jaws, bring the needle through the loop, and pull
the strands taut in opposite directions (Fig. 2.3.19e, f). Close the
b The left-handed instrument is then placed on the inside of the circle,
and the right-handed instrument (coming through the same trocar as
the long tail) is placed above the left-handed instrument to grasp the
short tail. This should be grasped about 2.5 cm (one inch) from the
end to facilitate passing the suture between instruments.
Fig. 2.3.18 c After the short tail is grasped, wrap it counterclockwise
around the long tail (twice for a surgeon’s knot).
Fig. 2.3.18b−g 컄
Suturing and Knot Tying Techniques
41
Fig. 2.3.18 d Once the wrap is complete, the short tail is passed to the
left-handed instrument.
e The two sides of the suture are pulled taught in opposite directions
(left side pulled to the right and vice versa). Crossing the instruments
while pulling the ends taut will allow the throw to lay “flat.” Alternatively, the suture sides could be exchanged between instruments after
the throw is completed, but prior to tightening it. Keep tension on the
long tail to avoid slippage between throws.
Fig. 2.3.18 f The opposite throw is accomplished by following the same
initial steps (a and b), but wrapping the right-handed instrument clock-
wise around the long tail.
g The two ends are then pulled taut in opposite directions to complete
the square knot.
42
2.3 Joining and Sealing Tissues and Hollow Organs
Fig. 2.3.19 Intracorporeal knot tying—Endo Stitch™ method.
a Place the suture through the tissues.
b Position the free jaw adjacent to the inside of the left-sided suture by
rotating the instrument along its longitudinal axis clockwise 180°.
Fig. 2.3.19 c Grasp the tail (right-sided suture) and place it between the
open jaw of the Endo Stitch™ using a second instrument. The instruments
don’t necessarily need to be crossed.
Fig. 2.3.19 d Close the jaws and transfer the needle (and the suture) to
the opposite jaw by toggling the lever.
Fig. 2.3.19e−l 컄
Suturing and Knot Tying Techniques
43
e Open the jaws and bring the needle below the left suture (red), i. e.
through the circle.
jaws while tightening the knot to cover the needle and avoid in-
advertent tissue penetration. The opposite throw is created by
substituting counterclockwise for clockwise and exchanging
the words right and left in the previous description (Fig.
2.3.19g−l). This completes the square knot.
In general, multiple throws in the same direction will allow the
knot to slide down and “lock” on the tissues. A final square knot
is completed by placing the opposite throw. There is, however, a
method of sliding down and “locking” a square knot. This is par-
ticularly useful when approximating tissues that are under
slight tension. First, a square knot is tied using one of the techniques previously described, and the knot is pulled snug, but
not too tight. Make sure to leave a space between the knot and
tissue (“air” knot). Next, the two strands on the same side (left)
of the knot (the tail with the needle above the knot) are pulled
in opposite directions to reposition the knot (Fig. 2.3.20 a, b).
The knot is then advanced by pulling the left-sided suture above
the knot taut with one instrument, and pushing the knot onto
the tissue with the other instrument. This will “lock” the knot
on the tissue (Fig. 2.3.20 c). Next, reposition the knot to a true
square configuration by pulling the tails in opposite directions
in a horizontal plane (Fig. 2.3.20 d). Additional throws are added
according to the suture type.
A running suture may sometimes be necessary, such as for closing mesenteric and peritoneal defects, creating bowel anastomoses, and repairing the diaphragm. Following passage of the
needle, the first knot can be tied with a standard intracorporeal
technique as described, or with one of two other methods.
These are the loop technique (Fig. 2.3.21 a, b) and the technique
of using a starting knot as an anchor (Fig. 2.3.22 a, b). To keep
f Pull the strands taut in opposite directions. While tightening the knot,
the jaws should be closed to cover the needle and avoid inadvertent
organ injury.
Fig. 2.3.19 g Open the jaws with the needle in the right jaw.
Fig. 2.3.19h−l 컄
44
2.3 Joining and Sealing Tissues and Hollow Organs
Fig. 2.3.19 h Position the free jaw adjacent to the inside of the right-
sided suture by rotating the instrument along its longitudinal axis counterclockwise 180°.
i Grasp the tail (left-sided suture) and place it between the open jaws of
the Endo Stitch™ using the second instrument.
Fig. 2.3.19 j Close the jaws and transfer the needle (and the suture) to
the opposite jaw by toggling the lever.
Fig. 2.3.19 k Open the jaws and bring the needle below the right suture
(red) , i. e. through the circle.
Fig. 2.3.19 l 컄
Fig. 2.3.19 l Close the jaws and pull the strands taut in opposite
directions. This completes the square knot.
Suturing and Knot Tying Techniques
45
Fig. 2.3.20 Intracorporeal knot tying—sliding a square knot.
a Tie a square knot using one of the techniques previously described,
and pull the knot snug, but not too tight. Next, pull the two strands on
the same side of the knot in opposite directions to reposition the knot.
The knot will “pop” when repositioned. The knot is pictured loose for
illustrative purposes.
b Pictured loose for illustrative purposes, the appearance of the re-
oriented square knot.
Fig. 2.3.20 c, d 컄
46
2.3 Joining and Sealing Tissues and Hollow Organs
Fig. 2.3.20 Advance the knot onto the tissues with the right-handed in-
strument while simultaneously pulling in the opposite direction with the
left-handed instrument to “lock” the knot on the tissues.
d Once the knot is “locked,” pull the tails in opposite directions to reposi-
tion the knot to a true square knot orientation. Place additional throws
as necessary for the clinical scenario.
ab
Fig. 2.3.21 Intracorporeal suturing and knot tying—using a running su-
ture with the loop technique.
a After placing the first stitch, pull the suture through the loop. This is
easiest if the free instrument is first passed through the loop, the
needle grasped, and then pulled back through the loop.
c
b The suture line is run in a standard fashion.
c To end the suture line, cut one strand of the loop off the needle before
the last stitch is pulled through.
d Both ends are now on the same side of the suture line and can be tied
using one of the intracorporeal knotting techniques describes earlier.
d
the suture line snug, tighten the previous loop of the suture
with the free instrument. Additionally, the suture can be pulled
through the previous loop (“locked”) periodically (Fig. 2.3.23 a,
b). Ending the suture line depends on which technique is used.
If the loop technique is used, the loop can be cut from the needle
prior to the last stitch. This will leave the two free ends on the
same side of the suture line to be tied with one of the intracorporeal knotting techniques described earlier (Fig. 2.3.21c, d).
Alternatively, the suture line can be ended with a standard in-
tracorporeal tie using the suture with the needle as one end,
and the previous loop as the other end (Fig. 2.3.24 a, b). An addi-
tional method of ending a running suture line is with a knot
which is used frequently to end a running suture line used for
skin closures, and is similar to that used for attaching hooks to
fishing line (Fig. 2.3.25 a−h).
Staplers and Fibrin Glue
47
ning suture with the anchored knot technique.
a First, a knot is placed at the end of the suture. Second, a loose knot
is created and the entire suture introduced through the trocar. The
tail behind the loosely tied knot should be short. After the first
stitch is placed, the needle is threaded through the loose knot. This
is then tightened by pulling the suture on both sides of the knot.
b The suture line is then run in a standard fashion.
컄Fig. 2.3.22 Intracorporeal suturing and knot tying—beginning a run-
Fig. 2.3.23 Intracorporeal suturing and knot tying—keeping a running
suture line snug.
a “Follow” yourself by maintaining tension on the suture from the pre-
vious loop with the free instrument after each stitch.
b Periodically pull the suture through the previous loop to “lock” the su-
ture line.