laparoscopic suturing
TRANSCRIPT
Laparoscopic Tissue approximation
Dr.S.EaswaramoorthyMS FRCS(England) FRCS (Glasgow) FRCS (Edinburgh)
Head of Dept of Minimal Access SurgeryExaminer, RCS of Edinburgh
Executive Member, South Zone IAGES
2 D ImageNo depth PerceptionNo tactile feedback
It is both humiliating and frustrating to be observed by every one in OR when you take more than 15 min just to do a one square knot!
Dr. Nathaneil Soper Surgical Clinics of North America Oct - 92
Learning Objectives
• Working knowledge of Suturing Equipments• Ergonomics for Suturing• Tissue approximation
– Intra corporeal Suturing– Extra corporeal Suturing– Staplers in Laparoscopy
Laparoscopic Suturing Equipments
• Needle Holders• Knot pushers• Suture Materials
HD Camera30 degree telescope Good Assistants
Invest on Good Needle Holders
TipTungsten carbideDiamond coatingStraight/Curved
Needle holders
Active hand Needle holderAssisting hand Needle grasper
Knot Pushers
Welcome Additions…
Endo Stitch
Self righting Needle holder
Repair of Hiatus with Endostitch
Suture Material
• Before selecting, Consider following qualities– Absorbability/ Strength/tissue reaction– Handling characteristics and visibility
• Favoured suture materials– Absorbable
• Vicryl, Catgut, PDS– Non absorbable
• Ethibond,Prolene• Length of Suture Material
– Intra corporeal suture: 10-12cm– Extra corporeal suture: 70cm
Suture needles
Straight NeedleSki NeedleCurved Needle
25mm½ circle
Learning Objectives
• Working knowledge of Suturing Equipments• Ergonomics for Suturing• Tissue approximation
– Intra corporeal Suturing– Extra corporeal Suturing– Staplers in Laparoscopy
Different Ball Game!
Open Surgery suturing Fast Ergonomics: Optional
Laparoscopic Suturing Slow and steady
Magnification effect Choreographic
movements Ergonomics: Vital
Triangulation Manipulation angle
Ergonomics• Straight Line principle• Triangulation• Manipulation angle• Elevation angle• Low lying table• Gaze down view
Base Ball Diamond Concept& Triangulation
Monitor
S
C
R
L
P
Manipulation angle
Azimuth Angle Manipulation Angle
30-45 degree 60-90 degree
Ergonomics of Hand Instruments
• Tip– Range of movements
• Conventional Vs Robotic instrument: 4: 7
Da Vinci Robot
Wrist like action
PrecisionPrecision
Ergonomics of Hand Instruments
• Tip– Range of movements
• Conventional Vs Robotic instrument
• Length of the shaft
Fulcrum Effect of Hand Instruments
1: 1
Ergonomics of Hand Instruments
• Tip– Range of movements
• Conventional Vs Robotic instrument
• Length of the shaft• Handle design
Ergonomic handles…
Surgeon’s Stance
Ideal relaxed stature Tiring
Ideal Relaxed Position
-straight head, in the axis of the trunk, without rotation or extension of the cervical spine;- shoulders in a relaxed and neutral position;- arms alongside the body- elbows bent to 70 to 90 degrees- forearms in an horizontal or slightly descending axis- -hands pronated (physiological resting position);- hands and fingers lightly grip the handles/handpiece
•Waist line table•Gaze down view of monitor•Straight line principle•Triangulation
Learning Objectives
• Working knowledge of Suturing Equipments• Ergonomics for Suturing• Tissue approximation
– Intra corporeal Suturing– Extra corporeal Suturing– Staplers in Laparoscopy
I can recognize a good surgeon ,not from how he cuts, but from how he sews!
Johan Mikulicz Radecki 1850-1905
Critical Steps of Suturing
1. Introduction of Needle2. Grasping the Needle3. Tissue Penetration4. Knotting
Introduction of Needle• Through 10mm port (with reducer)
– Non dominant hand port– Hold the suture and not the needle
• Through 5mm port• Through abdominal wall
Grasping the needle
• Dominant hand port(right hand)• Grasp with the tip of the needle holder• Grasp at the ‘Sweet spot’
– Deposit- Pick up technique– Dangling needle technique– Nudging
Needle discipline
•A held needle should always be in view.•A trailing needle is a safe needle
Types of Knots• Granny knot• Square knot• Slip knot to square knot• Surgeon’s Knot• Aberdeen knot• Dundee Jamming Slip Knot
Surgeon’s Knot
Guidelines for Suturing• The Passive and Active role of the holders• The formation of the initial “C’ and a tail• The use of the natural bias of the thread• Choreographic movements with needle holders• Economy of motion• Execution of the knots near to the tissue surfaces• Ambidexterity
Slip Knot to Square knot
Continuous Suturing
Laparoscopic Bowel AnastomosisKey points
• Port positioning• Good communications with your assistant• Positioning of sutures, especially at the
corners• Spacing the sutures (remember the
magnification)• Tensioning of sutures
Learning Objectives
• Working knowledge of Suturing Equipments• Ergonomics for Suturing• Tissue approximation
– Intra corporeal Suturing– Extra corporeal Suturing– Staplers in Laparoscopy
Extra corporeal knots
• Roeder Knot• Meltzer Knot• Tayside knot
Roeder’s Knot
No 2 Chromic CatgutEg: Appendix base
Extra corporeal Knotting
Meltzer Knot
1-0 or 2-0 VicrylEg: Cystic duct
Tayside Knot1-0 or 2-0 PDSEg: Azygos vein
Learning Objectives
• Working knowledge of Suturing Equipments• Ergonomics for Suturing• Tissue approximation
– Intra corporeal Suturing– Extra corporeal Suturing– Staplers in Laparoscopy
Staplers: Types & SizesGastric Bypass
Anterior Resection
TypesLinear staplers.Circular staplers.
Color codesWhite - small gut.Blue / Gold - stomach (except pylorus).Green - pylorus / redo surgery.
Guidelines for Staple Anastomosis
•Port positions for stapling•Stay sutures for tensioning•Enterotomy positioning and size•Positioning and angulations of the stapler prior to closure•Checking staple line•Complete closure of residual opening
It is not practice that makes perfect
It’s perfect practice that makes perfect!
- Vince Lombardi, American Foot ball Coach, Green Bay, Wisconsin