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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_197_библиотеки_им_акад_М_И_Перельмана
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138
Laparoscopic scissors Straight Needle driver / holder Merryland grasper/receiver
https://t.me/med1917
U. A. Menakaya and H. Olalere
3.1.2 Needle Receiver/Assisting
Instrument
An ideal laparoscopic suturing assisting instrument
should be capable of manipulating the needle and
[11]. This is especially so for monolament
sutures like PDS or Monocryl. Their memory can
aid in spontaneously forming the loops needed
for performing intracorporeal knotting [11].
suture without slippage. It should also be able to
grasp the tissue of interest without trauma [11]. In
addition to the needle receiver, laparoscopic scissors
should also be available for cutting the excess suture
3.2 Steps inLaparoscopic
Suturing
length (see Fig.4). Laparoscopic scissors could have
a curved (Metzenbaum), hook or straight tip.
The key steps in laparoscopic suturing include
the following:
3.1.3 Suture Material
Most suture materials used in open surgery are
also suitable for laparoscopic suturing. However,
the length of the suture material is important as it
is different for different applications, e.g. for
interrupted intracorporeal suturing (10–12 cm),
gure-of-eight stitches (15cm), and continuous
running stitches (30cm) [9]. Another important
characteristic of suture materials is their memory
• Introducing the suture into the abdomen
• Loading the needle
• Going through tissue
• Preparing for knot tying
• Knot tying
– The rst knot
– Subsequent knots
• Removal of needle from the abdomen
abc
Fig. 4 Images of instruments required for laparoscopic suturing: (a) laparoscopic scissors, (b) straight needle driver/
holder, (c) Maryland grasper/receiver
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139
3.2.1 Introducing theSuture into
theAbdomen
Introducing the selected suture into the abdomen
is the rst step in laparoscopic suturing. The
suture can be introduced into the abdomen via a
number of ways, viz.:
1. Direct trocar entry
2. Back loading
3. Directly through the abdominal wall
4. Through the open vagina cuff
Direct Trocar Entry
This is a commonly used technique and depends
on the size of the needle and the diameter of the
trocar. With an appropriate diameter of the trocar,
the needle is grasped on its suture 1–2cm from the
suture swedge and inserted into the abdomen
through the selected trocar. For this type of entry,
the needle diameter should be smaller than the trocar diameter. Most curved needles used for laparoscopic suturing can easily be introduced using this
technique through a standard 10-mm trocar.
be used in women with a thin abdominal wall or
where there is a requirement for traction
sutures. Both curved and straight needles can
be used.
Through the Open Vagina Cuff
Following a total laparoscopic hysterectomy, the
suture could be introduced into the abdominal
cavity through the open vaginal cuff for vault closure (see Fig.6).
Back Loading
The back loading technique is another option for
introducing the suture into the abdominal cavity.
It is usually employed when the curved needle
diameter is larger than the trocar diameter, for
example, when introducing the suture through a
5-mm trocar port site (see Fig.5).
Back loading involves the following steps:
• Remove the trocar from the abdomen and pass
the needle holder through the trocar.
• Grasp the tail of the suture and pull it through
the trocar.
• The needle will now be at the intra-abdominal
end of the trocar.
• Grasp the suture 1–2cm from its swedge with
the needle holder.
• Then, reinsert the needle holder with the held
suture into the abdomen through the port site
under laparoscopic vision.
• Finally, slide the trocar back into place.
Directly through the Abdominal Wall
The needle could also be introduced directly
through the abdominal wall. This option could
Fig. 5 Needle holder grasping the suture about 2cm from
the swedge and introduced into the abdomen through a
5-mm trocar port site. Images courtesy of Dr. Uche
A.Menakaya and JUNIC Laparoscopy, Australia
Fig. 6 0 Monocryl suture introduced into the abdominal
cavity through the open vaginal vault during a total laparoscopic hysterectomy. Images courtesy of Dr. Uche
A.Menakaya and JUNIC Laparoscopy, Australia
140
swedge and now ready to go through tissue
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U. A. Menakaya and H. Olalere
3.2.2 Loading theNeedle
ontheDriver
The goal of this step in laparoscopic suturing is to
orient the body of the needle to lie perpendicular
to the needle driver. With the suture now introduced into the abdominal cavity, the steps will
include the following (see Fig.7):
Step 1: Needle driver holding the suture
1-2cm from the suture swedge
1. Pick up the suture with the needle holder,
holding the suture about 1–2 cm from the
suture swedge.
2. With the needle receiver in the other hand, grasp
the body of the needle about a third of the way
from the tip of the needle to stabilize the needle
in the direction required to pass through tissue.
Step 2: needle receiver on the other hand grasping
the body of the needle. Then use push and pull
technique to orient the needle appropriately.
Step 3: Sharp reflection of light from needle
Suggesting appropriate set up for needle loading.
Fig. 7 Steps to successful loading of the needle. Step 1:
Needle driver holding the suture 1–2cm from the suture
swedge. Step 2: The needle receiver on the other hand
grasping the body of the needle. Then use the push and
pull technique to orient the needle appropriately. Step 3:
Sharp reection of light from the needle suggesting
Step 4: needle driver grasping the body of the
needle about a third of the way from the suture
appropriate set-up for needle loading. Step 4: The needle
driver grasping the body of the needle about a third of the
way from the suture swedge and now ready to go through
tissue. Images courtesy of Dr. Uche A. Menakaya and
JUNIC Laparoscopy, Australia
suture through the tissue
of the vault)
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141
3. With the needle receiver holding rmly
onto the body of the needle, use the needle
holder (holding the suture 1–2cm from the
swedge) to orient the needle until it is perpendicular to the endoscope (using the
push-pull technique). This geometry is usually suggested when the body of the needle
sharply reects the light from the
endoscope.
4. Using the needle holder, grasp the body of the
needle about a third of the way from the suture
swedge.
3.2.3 Going through Tissue (Fig.8)
3.2.4 Preparing forKnot Tying
This is a critical part of laparoscopic suturing.
For beginners, it is important to use the needle as
Step 1: Position the tissue of interest parallel to
the shaft of the needle driver using the needle
receiver.
Step 3: remove the needle from the tissue of
interest using the needle receiver and pull the
Fig. 8 Step 1: Position the tissue of interest parallel to the
shaft of the needle driver using the needle receiver. Step 2:
Push the needle tip through the tissue of interest. At the
start of this step, the wrist should be fully pronated and
then rotate to full supination going through the tissue of
interest. Step 3: Remove the needle from the tissue of
Step 2: Push the needle tip through the tissue of
interest. At the start of this step, the wrist should
be fully pronated and then rotate to full supination
on going through the tissue of interest
Step 4: An assistant stabilizes the suture as you pull
the needle out of the tissue of interest (posterior wall
interest using the needle receiver and pull the suture
through the tissue. Step 4: An assistant stabilizes the
suture as you pull the needle out of the tissue of interest
(posterior wall of the vault). Images courtesy of Dr. Uche
A.Menakaya and JUNIC Laparoscopy, Australia
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https://t.me/med1917
U. A. Menakaya and H. Olalere
3.2.5 Subsequent Knots
Subsequent knots are thrown by repetition of the
same process of prepare, throw and secure. For
subsequent knots, a single loop will sufce to
throw the knot. To secure the knot, tighten the
knot by pulling the short tail of the suture in alternating directions, e.g. North Pole and then South
Pole directions. For monolament sutures, up to
four subsequent throws may be required. For
multilament sutures up to two subsequent
throws may be required.
Fig. 9 The left hand with the needle receiver holding the
body of the needle in reverse C position with the swedge
directed towards you. The needle driver is then directed
between the suture thread and the concavity of the body of
the needle in its reverse C position to throw the rst knot.
Images courtesy of Dr. Uche A. Menakaya and JUNIC
Laparoscopy, Australia
your fulcrum for knot tying. To do this, the surgeon should manipulate the needle into a reverse
C position with the needle receiver grasping the
body of the needle and the suture swedge directed
towards you (see Fig.9).
Throwing the First Knot
To throw the rst knot, pass the needle driver
between the suture thread and the concavity of the
body of the needle in its reverse C position and
make a minimum of two loops as shown in Fig.10.
For a secure rst knot, you should make a
minimum of two loops as shown above.
Thereafter, the assistant presents the short tail of
the suture to the needle driver. The needle driver
should grasp the short tail of the suture and pull
it through the formed loops to create the rst
knot. To tighten the rst knot securely, you
should pull the short tail in an opposite direction
to where it was prior to going through the formed
suture loops. For example, if the short tail was
located at the South Pole when the assistant
presents it to you, tighten and secure the rst
knot by pulling the short end towards the North
Pole once it has passed through your formed
loops.
3.3 Removal ofNeedle
fromtheAbdomen
At the end of the suturing process, the needle is
cut off with laparoscopic scissors. It is important
to cut the needle with up to 1–2 cm of suture
length attached at the swedge. To remove the
needle, a number of techniques can be utilized.
3.3.1 Through a10-Mm-Sized Port
This is possible when a 10-mm-sized port is used
during the laparoscopic procedure. Most curved
needles used in laparoscopic suturing can be
removed through these 10-mm-sized ports. To do
this, insert the needle holder through the 10-mm
port and securely grasp the 1–2 cm remnant
thread holding the needle at the swedge. Then
pull the thread out of the port. This process
should be done under laparoscopic vision; thus,
you will need to insert the laparoscope through a
different port. It is important to remember not to
hold on the body of the curved needle for this
process as the needle will not be able to pass
through the port. Do not forget to remove all
suture remnants from the abdomen at the end of
your suturing.
3.3.2 Through a5-Mm-Sized Port
You can also remove the needle through a 5-mmsized port at the end of the laparoscopic procedure.
As the diameter of the curved needle is larger than a
5-mm-sized port, the rst step in this technique is to
straighten the curved needle. To do this:
Step 1: Making the first loop Step 2: Making the second loop
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143
Step 3: Pulling the short tail through the formed
loops for the first knot
Fig. 10 Step 1: Making the rst loop. Step 2: Making the
second loop. Step 3: Pulling the short tail through the
formed loops for the rst knot. Step 4: Pulling in opposite
• Grasp the body of the curved needle about
1cm from the needle tip as well as about 1cm
from the swedge with your needle holder and
the receiving grasper.
Step 4: Pulling in opposite directions to tighten
and secure the first knot
directions to tighten and secure the rst knot. Images
courtesy of Dr. Uche A. Menakaya and JUNIC
Laparoscopy, Australia
• Grasp the remnant suture attached to the needle about 1–2 cm from the swedge and pull
the needle through your 5-mm port (see
Fig.11).
• Straighten the curve needle by applying
appropriate pressure at both ends of the curved
needle with your laparoscopic instruments.
• Convert the curved needle to a straight
needle.
Step 1: Showing the curved needle at the end
of procedure. Step 2: Grasping both ends of the
curved needle with your laparoscopic equipment.
Step 3: Straightening the curved needle by apply-
144
Step one: showing the curved needle at end of
Step two: Grasping both ends of the curved
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U. A. Menakaya and H. Olalere
of procedure
Step three: straightening the curved needle
by applying appropriate pressure with your
Laparoscopic instruments.
needle with your laparoscopic equipments
Step four: Removing the straightened
needle by grasping the remnant thread 1-2
cm from the swedge
Fig. 11 Techniques for straighening a curve needle prior to removal from a 5-mm port
ing appropriate pressure with your laparoscopic
instruments. Step 4: Removing the straightened
needle by grasping the remnant thread 1–2 cm
from the swedge. Images courtesy of Dr. Uche
A.Menakaya and JUNIC Laparoscopy, Australia.
References
1. Semm K.Tissue-puncher and loop-ligation. New aids
for surgical-therapeutic pelviscopy (laparoscopy).
Endoscopy. 1978;10(2):119–24.
2. Wang X, Li Y, Cai Y, Meng L, Cai H, Liu X, Peng
B. Laparoscopic suture training curricula and techniques. Ann Transl Med. 2018;6(11):215.
3. Olmi S, et al. Scissor-knot-pusher: an instrument
for simplied laparoscopic extracorporeal knotting.
JSLS. 2003;7:281–4.
4. Croce E, Olmi S.Intracorporeal knot-tying and suturing techniques in laparoscopic surgery: technical
details. JSLS. 2000;4(1):17–22.
5. Kothari R, Uday S, Sharma D, Thakur DS, Kumar
V. A simple and safe extracorporeal knotting technique. JSLS. 2012;16(2):280–2.
6. Al Fallouji M. Making loops in laparoscopic surgery: state of the art. Surg Laparosc Endosc.
1993;3(6):477–81.
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7. Akindele RA, Fasanu AO, Mondal SC, Komolafe JO,
Mishra RK.Comparing extracorporeal knots in laparoscopy using knot and loop securities. World J Lap
Surg. 2014;7(1):28–32.
8. Babettty Z, Sumer A, Altintas S. Knot properties of alternating sliding knots. J Am Coll Surg.
1998;186(4):485–9.
9. Khattab OS.Role of extracorporeal knots in laparoscopic surgery. http://www.laparoscopyhospital.
com/extracorporael_knot.html. Accessed 19 May
2021.
10. Mishra RK.Text book of practical laparoscopic surgery. New Delhi: Jaypee Brothers medical publishers
PVT Ltd; 2007. p.104–23.
11. Hudgens J, Pasic RP. Fundamentals of geometric
laparoscopy and suturing. 1st ed. GmbH: Endo press;
2015.
Laparoscopic Management
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ofBenign Ovarian Tumours
AdebiyiGbadeboAdesiyun, NkeirukaAmeh,
andHajaratuUmar-Sulayman
1 Introduction
The place and uniqueness of laparoscopy in the
management of benign ovarian tumour are not in
doubt. However, the task of the attending gynaecologic laparoscopic surgeon is proper case evaluation to ensure that the tumour is not malignant.
Intraoperative spill of tumour cells could lead to
spread of the tumour which may accelerate disease
progression resulting in poor prognostic outcome.
Laparoscopic surgery for benign ovarian tumour is
associated with reduction in surgical injury, postoperative complications (fever, urinary tract infection), post-operative pain, hospital stay and total
cost. Besides these known merits of laparoscopic
surgery, the attainment of normal fertility after
laparoscopic treatment for benign ovarian mass in
premenopausal women is impressive.
2 Types ofBenign Ovarian
Tumour
Benign ovarian tumours include functional ovarian cysts (follicular cysts and corpus luteum
cysts), epithelial cysts (serous cysts, mucinous
A. G. Adesiyun (*) · N. Ameh · H. Umar-Sulayman
Department of Obstetrics and Gynaecology, Ahmadu
Bello University/Ahmadu Bello University Teaching
Hospital, Zaria, Nigeria
cysts, endometrioma), germinal cysts (dermoid
cysts, ovarian stroma) and solid ovarian masses
(ovarian broma, benign Brenner tumour).
3 Clinical Evaluation
A good assessment of patients with suspected
ovarian tumour is a pertinent step towards conrming that the mass is indeed benign. Firstly, it
is important to take into cognisance the menopausal status of the patient. Postmenopausal
patients are women that have not menstruated in
the last one year or patients aged 50 years and
above who have had hysterectomy. History to be
sought for include the following: irregularities in
menstruation, pelvic pain, urinary symptoms,
bowel symptoms, weight loss, abdominal fullness/swelling, easy satiety and family history of
ovarian, bowel and breast cancer.
Examination should include the general outlook of the patient for signs of chronic disease,
anaemia and leg oedema. Abdominal and pelvic
examination should be carried out to check for
abdominopelvic masses, hepatomegaly, splenomegaly, lymph node and ascites. The mass should
be characterized in size, consistency, regularity,
tenderness and mobility and if it is unilateral or
bilateral. Benign ovarian masses are usually unilateral, smooth surfaced and mobile. The sensitivity of clinical examination in detecting an
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
J. E. Okohue et al. (eds.), Gynaecological Endoscopic Surgery,
https://doi.org/10.1007/978-3-030-86768-3_14
147
148
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A. G. Adesiyun et al.
ovarian mass is as low as 15–51% which is based
on tenderness, mobility, nodularity of the mass
and demonstration of ascites. Malignant features
that may be detected clinically are masses that
are xed, irregular, nodular, bilateral and hard
with associated ascites.
4 Investigations
Specic investigations may include ultrasound
scan, colour Doppler, tumour markers, computerized tomography (CT), positron emission tomography (PET) and magnetic resonance imaging
(MRI). The relevance of these diagnostic methods will be discussed based on the menopausal
status of the patient. Ancillary investigations like
full blood count, liver function test and renal
function test are also important.
4.1 Investigation
ofthePremenopausal Patient
Ultrasonography: Transvaginal scan (TVS) is
most preferred in the evaluation of ovarian
masses; however, transabdominal scan (TAS)
may be complimentary in instances where the
mass is big and there is need to assess for disease
that may have gone beyond the ovary [1].
Employing colour Doppler has been found to be
of limited use because the accuracy of diagnosis
is not increased signicantly, though when the
mass is complex, there may be better accuracy
when combined with 3-D imaging [1].
It is important to ascertain the following features of an ovarian mass from an ultrasound scan:
unilocular or multilocular, evidence of solid
areas, evidence of metastasis, ascites, bilateral or
unilateral lesions. The International Ovarian
Tumour Analysis (IOTA) Group (Table 1) came
up with ultrasound ndings classied into B-rules
and M-rules, which are pointers to benign and
malignant lesions, respectively. The IOTA group
rules have sensitivity and specicity as high as
95% and 91%, respectively.
CA-125: The place of CA-125 in premenopausal women with ultrasound ndings of simple
ovarian cyst is limited [1]. CA-125 level of 35IU/
Table 1 IOTA group simple ultrasound rules
Types of
rules Ultrasound rule
B-rules Unilocular cyst, presence of solid
M-rules Irregular solid tumour, ascites, at least four
Table 2
S/N Causes
1 Pelvic inammatory disease
2 Uterine broid
3 Endometriosis
4 Adenomyosis
5 Torsion ovarian cyst
6 Haemorrhage into ovarian cyst
7 Irritation of peritoneum from non-
8 Irritation of peritoneum from primary
components with the largest less than
7mm, presence of acoustic shadowing,
smooth multilocular tumour with the
largest less than 100mm in diameter, no
blood ow on colour Doppler
papillary structures, irregular solid
multilocular tumour with the largest
diameter greater than 100mm, prominent
blood ow on colour Doppler
Causes of raised CA-125
gynaecological causes: Tuberculosis, liver
cirrhosis, hepatitis, pancreatitis, peritonitis,
pleuritis, ascites
tumour metastasis from breast, pancreas,
lung, colon
mL is the cut-off reference value used routinely.
When the ovarian cyst is not simple and the
serum CA-125 is high but less than 200IU/mL,
further assessment is advocated to rule other
pathologies that may cause raised CA-125 levels.
Other than ovarian tumour, CA-125 may be high
in premenopausal women because it is equally
secreted by pathologies like endometriosis, adenomyosis, broids, pelvic infections and conditions that cause peritoneal irritation whether from
benign non-gynaecological causes or primary
tumours with metastasis to the peritoneum
(Table2).
At the other end of the spectrum, low levels of
CA-125 are found in situations like smoking, caffeine intake and hysterectomy. This brings to the
fore that the interpretation of high and low levels
of CA-125 should be cautiously done. Serial measurement of CA-125 is suggested when the value
is raised but less than 200IU/mL and other causes
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