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Section 4.2. Laparoscopic Trocars and Complications
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Roger Ferland
The key to successful laparoscopic surgery depends on safeaccess
to the peritoneal cavity.Propertrocarplacementand position will
set the tone for the remainder of the procedure. Poor placement
or injury to the abdominal wall or intraperitoneal structures will
limit visualization, impair instrument handling, and seriously
complicate laparoscopic surgery.
Advances in trocardesign have reduced the potential forsuch
trauma, allow for easier placement, and facilitate performance of
laparoscopic surgery. In spite of these advances, the U.S. Food
and Drug Administration (FDA) received more than 1300 trocar
injury reports resulting in 30 deaths over a 5-year period from
1997 to 2002.[1] This section reviews different trocar designs,
discusses proper placement, and reviews management of complications resulting from trocar placement.
DESIGNS
Trocars available in the late 1970s through the mid-1980s were
typically constructed from reusable stainless steel or composite
materials with a cutting tip. Their design was patterned after
trocars used for thoracentesis. Trumpet valves reduced pneumoperitoneum leakage as scopes were passed, but complete seals
depended on rubber gaskets at the top of the trocar. Insufflation
valves were of a stopcock design and could be dismantled for
cleaning (Figure 4.2.1).
Multiple parts, all with a potential for failure, made maintenance difficult and at times limited the surgeon’s laparoscopic
capabilities. Cutting tips would dull over time, causing the surgeon to useexcessive force forplacement. Gaskets and trumpet or
insufflation valves would fail intraoperatively, leading to leakage
of pneumoperitoneum.
The use ofconductivestainless steel sleeves created thepotential for direct and indirect coupling of electrosurgical energy.
These trocars were typically inserted in a blind fashionafterestablishment of pneumoperitoneum by Veress needle. The historical
record indicates an injury is most likely with the primary trocar
placement.
The first major change in trocar placement technique
occurred in 1971. Hasson [2] reported 14 cases of successful
laparoscopy by opening a small subumbilical incision under
direct vision and later suturing a cannula sheathed in a coneshaped sleeve (Figure 4.2.2) to the fascia to maintain pneumoperitoneum. He theorized thiswouldreducethe risks ofbowel
injury and failed pneumoperitoneum. However, in Molloy’s [3]
2002 meta-analysis of entry techniques, open laparoscopic access
resulted in a 1.1/1000 incidence of bowel injury but no vascular injuries. Hanney [4] reported two cases of aortic laceration
when placing aHassancannulafor laparoscopic cholecystectomy,
one thought to result from the initial skin incision and the other
from the end of the trocar resting against the aorta. Although
bowel injuries have been reported with this technique, it remains
a viable option for peritoneal access. It is clear that if bowel is
firmly adherent to the abdominal wall at the incision, the site is
at risk, even with the open approach.
Another change in technique wasdescribed by Dingfelder [5]
in 1978. He demonstrated safe peritoneal access with sharp primary trocars without the prior establishment of a pneumoperitoneum. Subsequently, multiple authors [6–8] show similar rates
of bowel or vascular injuries with direct placement versus placement following pneumoperitoneum.
These limitations became more problematic with the advent
of video-laparoscopy in the late 1980s. As leaders in the field
expanded the horizons of cases managed laparoscopically, the
need for better trocars became greater. The increased number
and complexity of cases caused the reusable trocars to have a
shorter utility cycle and increased maintenance costs. Additionally,Corson[9] demonstrated reusable trocars thatrequiredgreat
force for placement because of the inability to maintain a sharp
cutting surface at the tip.
It was in this environment that disposable trocars were
introduced. They had several advantages: (1) consistently sharp
tips; (2) simpler valve designs, reducing the failure of gas seals;
(3) faster turnover of cases as reprocessing was eliminated; (4)
nonconductive materials that eliminated risks of electrosurgical
coupling; and (5) safety shieldsthat may reduce but not eliminate
injuries.
Initially, the cost of disposable trocars was concerning. However,decreasedcosts, increasing case volume,and the elimination
of reprocessing costs have created a favorable cost/benefit ratio in
most hospitals.
When disposable trocars were first introduced in the mid- to
late 1980s, a retractable shield would expose the sharp cutting
surfaces of the tip, then drop down to cover the tip when the
shield cleared the peritoneum. This feature was held out as an
improvement in patient safety in marketing efforts by the manufacturers. However, the literature is replete with case reports of
bowel or vascular injuries from using such trocars.[10,11] The
limitation stems from the exposure of the sharp tip until the
shield passes through the peritoneum, leaving the tip exposed
during placement. Other case reports describe a “cookie cutter”
injury to bowel or vessels resulting from the shield dropping down
coincident with the force advancing the trocar.
Additional modifications allowed for secure placement without incidental removal during instrument changes, as well as
better gas seals during laparoscopic suturing. Integral designs
57
58 — Roger Ferland
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Figure 4.2.1. Hassan cannula disassembled. Note the multiple parts
and gaskets.
such as the reverse “Christmas tree” pattern on the trocar sleeve
(Ethicon Endo-Surgery [EES]) or the inflatable balloons at the
trocar mouth largely prevent the accidental dislodgement of trocars (SAC, Marlow Medical).
Optical trocars that allow visualization during placement
have had mixed success. Early versions included a sharp blade
that passed over the leading surface by squeezing a trigger mechanism, thereby cutting through the abdominal wall (Visiport,
United States Surgical). These devices were associated with complications related to failure torecognizeperitoneal entry and continued cutting into organs or vessels.[12–15]
The more recent designs, such as that of Endopath (EES;
Figures 4.2.3 and 4.2.4), allow for good visualization of the layers
of the abdominal wall during entry and minimize trauma and
caliber of defect in the fascia. However, peritoneal entry may still
be unrecognized in the event of omental or bowel adhesions to
the abdominal wall at the entry site.
Several trocar tip designs (Figure 4.2.5) have been manufactured to minimizethe risk of placement and reduce thesize of the
Figure 4.2.3. Endopath bladeless optical trocar (Ethicon EndoSurgery).
defect in the fascia. This would eliminate the need for fascial closure or associated risk of hernia formation. Conical or bladeless
trocar tips may require more force for placement but produce a
smaller defectat the fasciallevel. This appearsto be the case based
on the study of Xcel bladeless optical trocars (EES) by McCarus
[16], who demonstrated an incidence of hernias of 0.2% or less
(1/500) with these trocars, even with diameters greater than 10
mm, in the absenceof closing the fascia. The defect in the fascia is
smaller than the peritoneal defect because of the dilating action
of the bladeless trocar (Figure 4.2.5).[16]
Radially expanding trocars (Step,InnerDyne)havetheadvantage reported of secure placement, smaller defects in the fascia, and ease of placement.[17,18] This device is introduced as a
sheath over the Veress needle and later expandedtoaccommodate
the scope and operative instruments.
COMPLICATIONS AND THEIR MANAGEMENT
The commonly accepted incidence of major complications from
trocar injuries was similar among several authors. Bowel injuries
are more common (0.7 to 1.1/1000) than vascular injuries
(0.4/1000).[3,10,19–21]
Figure 4.2.2. Hassan cannula assembled.Notethe conductive stainless
steel sleeve.
Figure 4.2.4. Endopath bladeless optical trocar; detail of bladeless tip
design (Ethicon Endo-Surgery).
Figure 4.2.5. Fascial defect following placement of a bladeless trocar
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(Xcel, Ethicon Endo-Surgery).
Perhaps the most common complication of trocar placement
is laceration of abdominal wall vessels, particularly the deep inferior epigastric vessels. Although these should always beidentified
before port placement, occasionally they are lacerated by a medially directed path of trocar placement, even though the skin incision is properly placed. Several techniques have been advocated
for control of this complication. In the author’s experience, the
simplest ispassage of a 12F Foleycatheter through the port, inflation of the balloon, and tamponade of bleeding by pulling back
on the catheter. The catheter can then be secured by an umbilical cord clip and left in place for 12 hours. After deflation of the
balloon and removal of the catheter, patients can be observed for
intraperitoneal bleeding (Figure 4.2.7).
Others have described suture ligating the vessels above and
below the point of laceration by an intraperitoneal approach [22]
Although this is a reliable method, it can be time consuming
and requires good laparoscopic suturing skills. External ligation
under laparoscopic guidance is also an effective option as shown
in Figure 4.2.8.
Pyramidal Conical
(Sharp)
Figure 4.2.6. Common trocar tip designs.The pyramidal orcuttingtip
is associated with a larger fascial defect. From Fuller et al.[1]
Conical
(Blunt)
Blunt
(Hasson)
Laparoscopic Trocars and Complications — 59
Figure 4.2.7. Placement of Foley catheter to tamponade laceration of
the inferior epigastric vessels. From Nezhat et al.[22]
Electrodessication by bipolar forceps is also a technique
that has been described; however, the resultant ischemic
injury at the site may lead to adhesion formation, or even a
larger defect in the fascia and subsequent hernia formation
(Figure 4.2.9).
Small bowel or prepped large bowel perforations, when recognized, can be managed by primary repair (Figure 4.2.10). The
site of perforation should be marked by grasping with a laparoscopic instrument and the loop of bowel then delivered through
a small laparotomy incision. After controlling any bleeding in
the mesentery, and ruling out a through-and-through perforation, the defect can be closed in two layers. Mesenteric bleeding or through-and-through lacerations should be managed by
resection. Unfortunately, many bowel injuries are not recognized
at the time of surgery. Delayed diagnosis is marked by intraperitoneal sepsis or obstruction. The morbidity and mortality are
much higher with delayed diagnosis. Most prudent laparoscopic
surgeons routinely administer a bowel preparation as used for
colonoscopy. As a rule, any telephone complaints of abdominal
distention, pain, nausea, vomiting, or fever should be immediately evaluated.
Retroperitoneal vascular injuries have the greatest morbidity
and mortality. In our institution, the right common iliac vessels
are the most commonly injured. This agrees with case reports
from Dixon [23]showing theobserved sites of injury in five cases
(Figure 4.2.11).
Immediate steps are tamponade ofthebleeding with alaparoscopic instrument if visualization permits. Injudicious use of
energy sources should be avoided as the ureter may be at risk
for electrosurgical injury and thrombosis of the distal external iliac or femoral vessels has been known to lead to amputation of the lower extremity on the affected side. Rapid laparotomy by vertical incision will allow adequate exposure for vessel
repair or graft placement. While this is being done, the patient
should be crossmatched for replacement blood components,
60 — Roger Ferland
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Step 1
Step 3
Figure 4.2.8. Suture management of inferior epigastric vessel laceration. From Nezhat et al.[22]
vascular surgical consultation called for, and maximum supportive therapy by anesthesia started. After identification of the laceration site, gentle manual tamponade will stop the hemorrhage
and allow time for assistance to arrive. One may consider heparinizing the distal vessel with 10,000 units of heparin in 20 mL
of saline to avoid distal thrombosis. Delay in these steps will
often lead to shock with subsequent adult respiratory distress
syndrome, acute tubular necrosis, and prolonged ICU management. A plan with designation of vascular consultants, instrument sets, and coordination of nursing and anesthesia support
should be established in any hospital performing laparoscopic
surgery.
Other organs at risk include the uterus, adnexa, and uri-
nary tract. If injured primarily, control bleeding. If expo-
Step 2
sure is adequate and the operator’s skills permit, laparoscopic
suturing can be accomplished. Repair of cystotomy should
be followed by catheter drainage for up to 7 days. Retrograde cystogram will confirm bladder closure after catheter
removal.
Hernia formation at the trocar site has been reported with
trocars as small as 5 mm.[23–26] Richter’sherniasthatincarcerate
only part of the circumference of bowel are likely to occur at port
site defect and are more difficult to diagnose because of the lack
of complete bowel obstruction signs. Consequently, the prudent
laparoscopic surgeon would elect to close all ports 10 mm or
greater at the fascial level and all 5-mm ports that are subject to
trocar reinsertion or excessive instrumentation during a major
case.
Figure 4.2.9. Electrodessication of lacerated inferior epigastric vessels.
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From Nezhat et al.[22]
Laparoscopic Trocars and Complications — 61
A
B
Figure 4.2.10. Bowel perforation at site of adhesions by primary trocar.
From Nezhat et al.[22]
Figure 4.2.11. Common sites of vascular injuries. From Dixon and
Carrillo.[23]
CONCLUSION
Proper technique of insertion and trocar placement is essential
for successful laparoscopic surgery. Bladelesstrocars or thosethat
dilate rather than incise the fascia are less traumatic and may
reduce the incidence of hernia formation. Major complications
occur rarely but are of high morbidity and mortality. Complications should be promptly recognized and aggressively managed
to avoid poor outcomes.
REFERENCES
1. Fuller J, Scott W, Ashar B, Corrado J. Laparoscopic trocar injuries:
a report from a US FDA center for devices and radiological health
systematic technology assessment of medical products committee.
Report from the FDA November 2003. Available at: http://www.
fda.gov/cdrh/medicaldevicesafety/ stamp/trocar.html. Accessed
February 2, 2007.
2. Hasson H. A modified instrument and method for laparoscopy.
Am J Obstet Gynecol. 1971;110:886–887.
3. Molloy D, Kaloo P, Cooper M, Nguyen T. Laparoscopic entry:
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4. Hanney R, Carmalt H, Merrett N, Tait N. Use of the Hasson cannula producing major vascular injury at laparoscopy. Surg Endosc.
1999;13:1238–1240.
5. Dingfelder J. Direct laparoscope trocar insertion without prior
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6. Bonjer H, Hazebroek E, Kazemier G, Giuffrida M, Meijer W,
Lange J. Open versus closed establishment of pneumoperitoneum
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7. Brill A, Cohen B. Fundamentals of peritoneal access. J Am Assoc
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8. Jansen F, Kolkman W, Bakkum E, de Kroon C, Trimbos-Kemper
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9. Corson S, Batzer F, Gocial B, Maislin G. Measurement of the force
necessary forlaparoscopic trocarentry. JReprodMed1989;34:282–
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10. Bhoyrul S, Vierra M, Nezhat C, Krummel T, Way L. Trocar
injuries in laparoscopic surgery. JAmCollSurg. 2001;192:677–
683.
11. Corson S, Chandler J, Way L. Survey of laparoscopic entry
injuries provoking litigation. J Am Assoc Gynecol Laparosc. 2001;8:
341–347.
12. Kaali S. Complications associated with optical access laparoscopic
trocars. Obstet Gynecol. 2002;100:614–615.
13. Sharpe H, Dodson M, Draper M, Watts D, Doucette R, Hurd W.
Complications associated with optical access laparoscopic trocars.
Obstet Gynecol. 2002;9:553–555.
14. Thomas M, Rha K, Ong A, et al. Optical access trocar injuries in
urological laparoscopic surgery. JUrol. 2003;170:61–63.
15. U.S. Food and Drug Administration. Manufacturer Device Report
#18216. 1994; Rockville, MD: U.S. Department of Health and
Human Services.
16. McCarus SD, et al. Improving herniation outcomes without trocar site fascial closure: a multicenter trial. Presented at American
College of Surgeons 90th Annual Clinical Congress, New Orleans,
LA; October 10–14, 2004.
17. TurnerDJ.Anewradially expanding accesssystemforlaparoscopic
procedures versus conventional cannulas. J Am Assoc Gynecol
Laparosc. 1996;3:609–615.
18. Yim S,Yuen P. Randomized double-masked comparison of radially
expanding access device and conventional cutting tip trocar in
laparoscopy. Obstet Gynecol. 2001;97:435–438.
19. Harkki-Siren P, Kurki T. A nationwide analysis of laparoscopic
complications. Obstet Gynecol. 1997;89:108–112.
20. Philips P, Amaral J. Abdominal access complications in laparoscopic surgery. JAmCollSurg. 2001;192:525–536.
21. Schafer M, Lauper M, Krahenbuhl L. Trocar and Veress needle injuries during laparoscopy. Surg Endosc. 2001;15:275–
280.
22. Nezhat C, Nezhat F, Luciano A, Siegler A, Metzger D, Nezhat
C. In: Operative Gynecologic Laparoscopy Principles and Tech-
niques, “Complications” New York: McGraw Hill; 1995:293,
295.
23. Dixon M, Carrillo E. Iliac vascular injuries during elective laparoscopic surgery. Surg Endosc. 1999;13:1230–1233.
24. Boughey J, Nottingham J, Walls A. Richter’s hernia in the laparoscopic era: four case reports and review of the literature. Surg
Laparosc Endosc Percutan Tech. 2003;13:55–58.
25. Nezhat C, Nezhat F, Seidman D, Nezhat C. Incisional hernias
after operative laparoscopy. J Laparoendosc Adv Surg Tech A.
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26. Nezhat F, Nezhat C, Seidman D. Incisional hernias after advanced
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Bhoyrul S, Payne J, Steffes B, Swanstrom L, Way L. A randomized
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surgery. J Gastrointest Surg. 2000;4:392–397.
Chapron C, Cravello L, Chopin N, Krieker G, Blanc B, Dubuis-
son J. Complications during set-up procedures for laparoscopy
in gynecology: open laparoscopy does not reduce the risk of
major complications. Acta Obstet Gynecol Scand. 2003;82:1125–
1129.
ChapronC,DubuissonJ,BernardH, FeldmanS.Predicting riskof com-
plications with gynecologic laparoscopic surgery. Obstet Gynecol.
1999;93:318–319.
Hasson H, Galanopoulos C, Langerman A. Ischemic necrosis of small
bowel following laparoscopic surgery. JSLS. 2004;8:159–163.
Jacobson M, Oesterling S, Milki A, Nezhat C. Laparoscopic control
of a leaking mestenteric vessel secondary to trocar injury. JSLS.
2002;6:389–391.
Jugool S, McKain E, Swarnkar K, Vellacott K, Stephenson B. Random-
ized clinical trial of the effect of pneumoperitoneum on cardiac
function and haemodynamics during laparoscopic cholecystectomy. Br J Surg . 2004;91:1527. Comment on: Br J Surg . 2004;91:
848–854.
McKernan J, Finley C. Experience with optical trocar in perform-
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2002;12:96–99.
Merlin T, Hiller J, Maddern G, Jamieson G, Brown A, Kolbe A. Sys-
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establish pneumoperitoneum in laparoscopic surgery. Br J Surg .
2003;90:668–679.
Nezhat C, Childers J, Nezhat F, Nezhat CH, Seidman D. Major
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previous pneumoperitoneum with Veress needle. Obstet Gynecol.
1991;78:148–150.
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use of open techniques in laparoscopic operations. JAmCollSurg.
1997;184:58–62.
Orlando R,Palatini P, LirussiF. Needleandtrocar injuries indiagnostic
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Rosen D, Lam A, Chapman M, Carlton M, Cario G. Methodsofcreating
pneumoperitoneum: a review of techniques and complications.
Obstet Gynecol Surv. 1998;53:167–174.
Rubenstein J, Blunt L Jr, Lin W, User H, Nadler R, Gonzalez C. Safety
and efficacy of 12-mmradial dilatingports forlaparoscopic access.
BJU Int. 2003;92:327–329.
Saber A, Boros M. Chilaiditi’s syndrome: what should every surgeon
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2
5 LAPAROSCOPIC SUTURING
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Camran Nezhat, Ceana Nezhat, and Farr Nezhat
The ability to suture laparoscopically increases a laparoscopist’s
versatility. Suturing is used for hemostasis and to oppose tissues
during reconstructive procedures. Different types of sutures are
available for endoscopic use. The Endoloop (Ethicon) suture, a
preformed slipknot attached to a rigid, disposable 5-mm applicator, is available in 0-chromic gut, polyglactin, polydioxanone,
and polypropylene (Figure 5.1). The loop is positioned around
the pedicle by grasping the structure to be removed and pulling
it through the loop. The loop is tightened against the applicator,
and the suture is cut with scissors or the laser beam against a
backstop.
Suture material is available with a straight or curved swaged
needle specifically designed for laparoscopic use. It is available in
0-chromic catgut, 4-0 polydioxanone with a swaged ST-4 needle
(PDS, Ethicon), and polyglactin. The suture is grasped with forceps several centimeters from the needle. The grasper with suture
is inserted intra-abdominally through the 5-mmaccessory trocar
sleeve.
To place the needle intra-abdominally, the grasper or needle
driver is removed along with the trocar sleeve, which remains
around the grasper’s shaft. The suture is grasped about 5 cm
from the needle, and the grasper is reintroduced with the trocar
sleeve into the suprapubic incision site. The needle follows the
grasper into the abdominal cavity. A needle larger than a CT-1
is awkward to use intra-abdominally. Once the suture is placed,
several techniques can be used to secure the knot. An Endoloop
with a pre-made knot is tightened around the pedicle with the
plastic knot pusher. Other types of extracorporeal knots are the
Duncan [1] and clinch knots, but their closure depends on a
single knot thatmayslip.Theknot may not slide because ofsuture
friction. Tissue trauma may result from the suture being pulled
in opposite directions through transfixed tissue as the needle is
withdrawn from the abdomen when a sliding knot is applied.
Intracorporeal knotting is difficult and requires practice. An
instrument-tying method employed within the abdomen uses
two forceps and suture material. The suture may get caught in
the articulation point of the forceps and break. However, variations of the fisherman’s clinch knot prevent some difficulties.
The use of the knot pusher was described originally in 1972.[2]
The principles ofthis instrument donot differ from those oftying
sutures deep in the pelvis, where thesurgeon uses a finger to push
and securethe knot.Length of sutures used in intracorporeal and
extracorporeal suturing differs,with about 13cmand 90–100 cm,
respectively.[3]
Extracorporeal knot tying simplifies laparoscopic suturing.
Instruments thathelp this processinclude a needle holder, needle
driver, suture introducer, and scissors. A suture is loaded into the
needle holder, holding the suture below the swage point so that
the needle will collapse into the introducer. The needle holder is
inserted into the introducer(Figure5.2). The introducer is placed
into a 5-mm trocar, and the needle driver is placed into a contralateral trocar. A needle is advanced into the abdominal cavity
and passed from the holder to the driver. While the needle is
steadied with the driver, the holder is repositioned to the desired
location. Theneedleistappedwith the drivertolockitintoa rightangle position. The needle is rearmed with the driver. A driver
is used to pass the needle through the tissue, and then grasp the
tip and pass the needle to the holder (Figure 5.3). To reduce the
risk of pulling the suture out of the tissue, tension on the suture
line is kept to a minimum. The holder, needle, and excess suture
line are withdrawn from the abdominal cavity through the introducer. An assistant covers the introducer channel to maintain a
pneumoperitoneum (Figure 5.4). The surgeon cuts the suture
below the swage point and makes a single-throw knot with the
two suture ends. The knot is held securely with the thumb and
third finger while three revolutions are made around both suture
strands with the free end of the suture (Figure 5.5). The tail of the
suture is inserted through the first loop directly above the assistant’s hand. After the tail is passed through the loop, the operator
pulls up on the tail to form the knot and cuts the tail approximately 0.6 cm above the knot. The end of theEndoknot (Johnson
& Johnson) shaft is snapped off at the colored band, allowing the
shaft to slide the knot downward (Figure 5.6). Placing the shaft
perpendicular to the knot reduces suture breakage and ensures
knot security. The Endoknot cannula is placed in the introducer
(Figure 5.7). When the surgeon pulls back on the small end piece
of the Endoknot shaft while sliding the plastic shaft forward, the
knot is allowed to move forward as the loop decreases insize. The
Endoknot cannula acts as an integral knot pusher for placement
of the formed knot. Scissors inserted through the contralateral
trocar are used to cut the excess suture. The procedure for pretied knot is similar to the technique described above except for
forming the knot (Figures 5.7 through 5.12).
Intracorporeal knot tying is used during microsurgery and
fine suturing. It is more difficult and time consuming than extracorporeal knot tying. The instructions for introducing the needle
and suture into the abdomen are the same as those for extracorporeal knot tying. The needle and the entire suture are placed in
the abdominal cavity. After the needle is positioned, it is grasped
with the needle holder (Figure 5.13). While the grasping forceps
apply pressure to the tissue being sutured, the suture is inserted
through the tissue (Figure 5.14). Graspers hold the needle, and
the needle holder applies counterpressure to the tissue (Figure
5.15). The needle is removed from the tissue. Enough suture to
64
A
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Figure 5.1. (A) Endoloop suture, a pretied slipknot, is attached to a
rigid disposable applicator. (B) It is inserted into the trocar sleeve.
Laparoscopic Suturing — 65
Figure 5.3. The needle driver was placed into a contralateral sleeve.
The needle was advanced into the abdominal cavity and passed from
the holder to the driver. While the needle was steadied with the driver, the holder wasrepositioned to thedesired location. Theneedle was
tapped with the driver to lock it into a right-angle position. The needle
is rearmed with the driver.The driver is usedto pass theneedle through
B
the tissue and then grasp the tip and pass the needle to the holder.
Figure 5.2. The needleholderisinsertedintotheintroducer.Theintroducer is placed into a 5-mm sleeve.
Figure 5.4. The needle holder and excess suture lines were withdrawn
from the abdominal cavity through the introducer. (Anassistant covers
the introducer channel to prevent the loss of pnuemoperitoneum.)
After the surgeon cuts the suture beneath the swage point, a single
throw knot is made with the two suture ends (inset).
66 — Camran Nezhat, Ceana Nezhat, and Farr Nezhat
https://t.me/med1917
Figure 5.5. Three revolutions are made around both suture strands
with the free end of the suture (left). The tail of the suture is inserted
through the first loop (right). The tail of the suture is inserted through
the first loop directly above the surgeon’s thumb.
Figure 5.7. The Endoknot cannula acts as an integral knot pusher for
placement of the formed knot.
Figure 5.6. The suture tail is cut about 0.6 cm above the knot. The
end of the Endoknot shaft is snapped out at the colored band (inset),
allowing the shafttoslidetheknotdownward.Placingtheshaft perpendicular to the knot lessens suture breakage and ensures knot security.
Figure 5.8. The scissors, inserted through the contralateral trocar, are
used tocut the knot (inset). The pretied Endoknot consistsof synthetic
absorbable suture material with a hollow plastic tube that is narrowed
at one end and scored at the other. The center of the plastic tube has a
4-0 stainless steel suture that is looped at the narrowend andswaged at
the surgical needle. The scored end of the device serves as the handle.
The primary advantage of this device is that the knot is preformed and
does not have to be made manually by the surgeon.
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