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Laparoscopic Tissue

Approxima tion
Equipment and instrumentation Ergonomics and handling of camera Passage of needle into abdominal cavity Loading of needle by needle
holder Handling of needle

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INTRODUCTION

Tissue approximation in laparoscopy can be performed by a wide range of techniques like extracorpo real
knotting, loop ligatures, intracorporeal suturing and knotting and also with the help ofvari ous suture assist
devices, Knowledge of endosuturing provides a great sense of confidence to reconstruct a vital organ, to repair an
inadvertent injury or to control bleeding after other methods are unsuccessful or inappropriate. The surgeon faces
the technical challenge to perform intra corporeal maneuvers under video guidance with a less than ideal visual
image with limited movements. These challenges can be overcome by following a mental choreography of step-
by-step maneuvers and by repeated training to master this skill.
A skilled laparoscopic surgeon must be able to perform laparoscopic suturing and knotting to make

Extracorporeal knots
Intracorporeal suturing and knotting Laparoscopic assisted mechanical stapling techniques Endostitch
Conclusion

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advanced, complex procedures more perfect and safe. The mechanical stapling devices also form an essential part
of the laparoscopic surgeon's armamentarium. Though intra corporeal suturing and knotting is preferred to
staplers due to its adaptability and cost effectiveness, mechanical staplers have sev eral advantages in certain
situations. This chapter will discuss about the various types of tissue approximation and the methods of extra
corporeal and intra corporeal knots and sutures, suture assist devices and also about the mechanical stapling
devices. Initially, the basics of equipments needed for endosuturing and the ergonomics of endosuturing will be
discussed
followed by detailed description of creation of endoloops, square knots and practical tips on endosuturing.
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General Laparoscopy

EQUIPMENT AND INSTRUMENTATION 1. Video Equipment

High standard resolution imaging system is important since greater visual acuity is necessary for accurate tissue
approximation.

2. Instrumentation
Usually a pair of needle holder and grasper is used. The active hand (Right) holds the needle holder and the
passive hand (left) holds the grasper. Various types of needle holders are available and the surgeon should opt for
one pair of needle holder and grasper and continue to practice with the same rather than changing the instruments
frequently. With practice, the surgeon becomes accustomed to the instruments and starts using it as an extension
of his hands
The needle holder should have a coaxial handle with a locking mechanism. It should be strong with a heavy
handle. The tip is usually tapered either with straight or curved tip with a single moving jaw. The coaxial needle
holders are better than the pistol type holder as it associated with less strain, greater maneuverability and rotation,
which is essential requirement for endosuturing. Various types of needle holders with different handgrip designs
have been tested. I The pistol type limits the rotatory movements of hand and might lead to compression nerve
damage due to the awkward position.
The assisting grasper held by the non-dominant hand is used to assist the right hand in handling the needle and
sutures and providing counter traction during suturing. It should have a short straight and rounded tip with
minimal serrations in order to avoid crushing effect on thread while tying the knot. The conventional Smm
atraumatic grasper without ratchet will be an ideal left hand instrument during suturing.

3. Trocars
The tip of the trocars should be kept as short as possible inside the peritoneal cavity. Trocars that are too long
interfere with the movement of instruments and also prevent adequate opening of the jaws of the needle holder.

4. Suture material
The conventional suture material with the needles can be used in laparoscopy and there is no need for any
specialized needles and sutures. The surgeon should be familiar with the characteristics of the su ture material.
Approximately 8 -1 0 cms of suture length is needed for first suture with additional 2 cm for each suture. An
incision that requires 6 sutures will approximately need 20 cm {I 0 + (5x2)} length of suture material.
Manipulation of longer threads is cumbersome and frustrating especially in the learning period. Selection of
suture material should be based upon the tissue response and the handling characteristics of the suture material.

For example a slipknot requires fewer loops, if the material is chromic catgut as in Roeder's knot. If it is PDS or
polypropylene, it needs additional throws or different looping system. The ideal suture material for easy handling
and knotting is vicryl. Silk has good pliability but also has sticking and fraying tendency. PDS sutures can be used
for mesh fixation in hernia surgery and for approximation of crura in hiatal hernia repair. For intestinal
anastomosis, the use of2-0 vicryl and 2-0 silk is preferred. For anastomosis involving delicate tissues like
choledochojejunal anastomosis or CBD suturing after 'T' tube placement, 4-0 vicryl is preferable.
5. Needles
In choosing a needle, apart from strength and sharpness, visibility and curvature are important in laparoscopic
suturing. The early pioneers used straight needles because curved needles could not be taken into the peritoneal
cavity through the ports. Later ski needle (curved tip, with straight shaft) that were easy to pass through the
trocars were introduced.2 Many surgeons prefer curved needles due to the familiarity in using these needles in
conventional surgeries and for good tissue pick up.
But, in practice all conventional needles can be used in laparoscopic surgery. The needles can be straightened just
to the extent that is needed for it to pass through the reducing sleeve. The needles are taken inside the peritoneal
cavity as described below. Non swedged needle should not be used, because of the danger of loss of the needle in
the peritoneal cavity.