Laparoscopic Suturing: Practical Tips For Needle .

Type of knotSuture LengthIntracorporeal Single‐use suture, minimum length of suture shouldbe 27 inches (70 cm) – standard lengthExtracorporealSliding knot Coefficient of friction notequally distributedbetween suture ends Each end of suture entersand leaves knot in samedirection One axial strand is heldunder tension as the otherties around itSquare knot Coefficient of frictionequally distributedbetween suture ends Each end of suture entersand leaves knot in oppositedirection Multiple‐use or purse‐string suture, recommendlength of suture to be minimum 48 inches (122 cm)Schubert DC, Unger JB, Mukherjee D, et al. Mechanical performance of knots using braided and monofilament absorbable sutures. Am J Obstet Gynecol.2002;187(6):1438‐42.Amortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐1602.Laparoscopic KnotsLaparoscopic Knots Amortegui et al, Surg Endosc 2002 1 surgeon, 7 types of knots 140 knots conventional vs. 140 knots laparoscopic 2‐0 braided polyester 4‐6 throws Knots measured for breaks using tensiometer and knotslips 3mmS1 or 2X //#Sliding Knotindicates number of flat square knotsthrow in opposite direction from previousthrow in same direction as previouschange of axial strand and next throw turns in same direction as previouschange of axial strand and next throw turns in opposite direction from previousAmortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐1602.Amortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐1602.Laparoscopic KnotsLaparoscopic KnotsIntracorporeal SquareKnots Goldenberg et al, JSLS 2009Extracorporeal SlidingKnot 3 surgeons, 100 knots, 2‐0 silk,4 throws measured for knotslips and breaks usingtensiometerExtracorporeal square knotsvs.Intracorporeal slip‐squarevs.Intracorporeal flat‐square These configurations had superior tensile strength toothers tested in laparoscopic group (p 0.05)Figure 2. A graphical representation of the Knot Quality Score(KQS). It is based on the quartiles of the variable. The rectangularbox corresponds to the lower quartile and the upperquartile. The line in the middle is the median. No significant difference between these 3 configurationsAmortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐1602.Goldenberg EA, Chatterjee A. Towards a better laparoscopic knot: using knot quality scores to evaluate three laparoscopic knot‐tying techniques. JSLS2009;13(3):416‐9.13

Extracorporeal KnotsRobot‐assisted Laparoscopic Knots Decrease operative time Easy to perform Quicker to tie than intracorporeal knots Larger variability inthe strength of theknots made usingthe robot, whichcorresponded tohigher percentage ofunraveling knots Tensile strength comparable to intracorporeal knotsMuffly T, McCormick TC, Dean J, et al. An evaluation of knot integrity when tied robotically and conventionally. Am J Obstet Gynecol 2009;e18‐20.Sharp HT, Dorsey JH, Chovan JD, et al. The effect of knot geometry on the strength of laparoscopic slipknots. Obstet Gynecol 1996;88:408‐11.Reynisson P, Shokri E, Bendahl P, et al. Tensile strength of surgical knots performed with the da Vinci surgical robot. JMIG 2010;17(3):365‐70.Surgical Technique ofExtracorporeal KnotsApplications General GYN Ovarian reconstruction Vaginal cuff closure Cervical stump closure Myomectomy In lieu of additional portand grasper Repairs Bladder Bowel Uterine Perforation UroGyn Sacrocolpopexy/Sacrocer‐vicopexy Paravaginal defect repair Burch McCall’s CuldoplastyInterrupted or purse‐string stitch placed in tissueBoth ends of suture outside of laparoscopic portKnot formed outside of abdominal cavityLaparoscopic knot pusher mounted adjacent to knotTension placed on both ends of suture as laparoscopicknot pusher cinches down and secures each knot totissue6. Release knot pusher from suture7. Repeat throws (steps 2‐6)1.2.3.4.5. REI Cuff tuboplasty Tubal ReanastomosisUseful for any interruptedor purse‐string suturingGoldenberg EA, Chatterjee A. Towards a better laparoscopic knot: using knot quality scores to evaluate three laparoscopic knot‐tyingtechniques. JSLS 2009;13(3):416‐9.Inoue H, Kumagai Y, Nishikage T, et al. A simple technique of using novel thread‐holding and knot‐pushing forceps for extracorporeal knot‐tying. Surg Today 2000;30:571‐3.Behm T, Unger JB, Ivy JJ, et al. Flat square knots: are 3 throws enough? Am J Obstet Gynecol. 2007;197:172.e1‐3.Amortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐1602.Laparoscopic Knot Pushers14

Extracorporeal KnotThe American College of Obstetricians and Gynecologists (Obstetrics and Gynecology, 1992, 79: 143‐147.)Extracorporeal Knot VideoSuture Tail Cutting tail of knot too short compromises knotintegrity as it can easily unravelClosed Knot pusher15

Short SutureTroubleshooting Suture too short Needle through 5 mm port Suture twisting Open knot pusher released earlyNeedle Back‐loadingNeedle Back‐loadingUntwisting SutureReplacing Knot Pusher16

Replacing Knot PusherLaparoscopic BabcockVaginal Cuff RepairUterosacral SuspensionOvarian Reconstruction17

e of extracorporeal knots in laparoscopic surgery. www.laparoscopyhospital.comSanz LE. Selecting the best suture material. Contemporary Ob/Gyn. 2001;57‐72.Schubert DC, Unger JB, Mukherjee D, et al. Mechanical performance of knots using braidedand monofilament absorbable sutures. Am J Obstet Gynecol. 2002;187(6):1438‐42.Goldenberg EA, Chatterjee A. Towards a better laparoscopic knot: using knot quality scoresto evaluate three laparoscopic knot‐tying techniques. JSLS 2009;13(3):416‐9.Amortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐1602.Sharp HT, Dorsey JH, Chovan JD, et al. The effect of knot geometry on the strength oflaparoscopic slipknots. Obstet Gynecol 1996;88:408‐11.Inoue H, Kumagai Y, Nishikage T, et al. A simple technique of using novel thread‐holdingand knot‐pushing forceps for extracorporeal knot‐tying. Surg Today 2000;30:571‐3.Behm T, Unger JB, Ivy JJ, et al. Flat square knots: are 3 throws enough? Am J Obstet Gynecol.2007;197:172.e1‐3.The American College of Obstetricians and Gynecologists (Obstetrics and Gynecology, 1992,79: 143‐147.)Muffly T, McCormick TC, Dean J, et al. An evaluation of knot integrity when tied roboticallyand conventionally. Am J Obstet Gynecol 2009;e18‐20.Reynisson P, Shokri E, Bendahl P, et al. Tensile strength of surgical knots performed with theda Vinci surgical robot. JMIG 2010;17(3):365‐70.

DisclosuresIntracorporeal Knot Tying Other: Author: UpToDate Other: Received travel expenses todiscuss residency robotic trainingcurriculum: Intuitive SurgicalHye‐Chun Hur, MDDirector, Minimally Invasive Gynecologic SurgeryBeth Israel Deaconess Medical CenterAssistant Professor, Harvard Medical SchoolIndicationsObjectives– Indications for intracorporeal knot tying– Basic equipment– Technique breakdown of steps helpful tips video demoGeneral:any indication forextracorporeal knot tyingcan be applied tointracorporeal knot tying vaginal cuff closurelaparoscopic myomectomyoophoropexysuturing for retraction (e.g.ovary, bowel, uterus)Specific:more delicate suturing,tying knots off tension bowel repairbladder repairperitoneal closures (e.g.sacrocolpopexy)continuous suture knot pusher unavailableIndication: Bowel SuturingEquipment Laparoscopic Needle Driver (curved, locking) Laparoscopic Needle Grasper (straight) Laparoscopic Scissors Suture, cut 6‐8 inches (interrupted vs figure ofeight sutures) 10 mm trocar (direct delivery of needle) 5 mm trocar (back load needle)19

Breakdown of Steps1. Select appropriate trocar size for needle delivery.2. Cut suture in advance. Interrupted suture 6 inches Figure of eight suture 8 inches Continuous running suture 12 inches3. Place suture.4. Throw 4‐6 square knots (opposite direction). Vicryl 4 throws PDS 6 throws5. Cut suture, remove needle under direct visualization.Replicate an instrument tie.Important TipsTips: Intracorporeal Knot Tying1. Select appropriate trocar size for needle delivery2. Cut suture in advance (6-8 inches)3. Place suture (use locking needle driver)TIP #1: Leave free end (tail) short4. Throw 4-6 square knots (opposite direction)TIP #2: Keep heel of needle in-line with needle grasperTIP #3: Don’t drift from surgical field when suturingTIP #4: Pull ends so the free end stays short5. Cut suture and remove needle under direct visualizationInterrupted SutureCommon Mistakes to Avoid20

Figure of Eight SutureContinuous Running SutureImportant TipsTake Home PointsThink ahead select appropriate trocar size (10 vs 5mm) cut suture in advance (6-8 inches)Suturing & Intracorporeal Knot Tying Leave free end (tail) short Keep heel of needle in-line with needle grasper Don’t drift from surgical field when suturing Pull ends so the free end stays shortConclusionIf you can do an instrument tie, youcan do intracorporeal knot tying.Laparoscopic suturing and intracorporealknot tying is a skill that anyone can learnand master in the dry lab setting.21

DisclosureSuture Selection and TechnologiesUsed in Gynecologic LaparoscopyOther: Proctor: Intuitive SurgicalKathy Huang, M.D.Director of Gynecologic Robotic SurgeryAssistant ProfessorNew York University Langone Medical CenterObjectives Bi-directional barbed suture was introduced in January 2007and uni-directional barbed suture was approved shortly after Demonstrate proper suturing technique for both Bi-directional Barbed suture: EASE OF USEand Uni-directional Barbed Sutures Demonstrate proper technique for Endo-Stitch eliminates knot tying Describe the advantages as well as the disadvantages of achieves hemostasis without the use of locking andfigure of eightutilizing barbed suture/suturing devices decreases operative timeBi-Directional barbed suture Retrospective Cohort: TLH Bidirectional barbed (48) vs Traditional interrupted withpolycolic acid (40) Traditional laparoscopic suturing and knot tying requires a No difference in vaginal cuff dehiscence, major vaginalsteep learning curve and is often the rate-limiting step inperforming advance laparoscopic gynecologic surgicalprocedures.bleeding, infection significant reduction in operative time in bidirectional barbedsuture groupBogliolo S, Nadalini C, Iacobone AD, Musacchi V, Carus AP; Vaginal cuff closure with absorbablebidirectional barbed suture during TLH; Eur J Obstet Gynecol Reprod Biol. 2013 Aug;170(1):219-2122

OutcomeBi-directional Barbed Suture 10.4 vs 9.6 minutes, p 0.51 Cuff healing - similar 63 patients were randomized toQuill or Vicryl No difference in rates of dyspareunia, partner dyspareunia operative time for cuff closure Sexual function: similar sexual function questionnaire - Statistical power of 80% to detect of difference of 5 minpreop and 3 months postop Cuff closure time: attendings faster than residents/fellows 7.1 vs 12.8 minutes, p 0.0001Einarsson JI, Cohen SL et al, Barbed versus standard suture: A randomizedtrial for laparoscopic vaginal cuff closure J Minim Invasive Gynecol. 2013Jul-Aug;20(4):492-8.Unidirectional Barbed Suture Retrospective analysis: 138 consecutive laparoscopicmyomectomies by a single surgeon over a 3 year period Stratafix 31 Vicryl and 107 bidirectional barbed Barbed suture group: decreased operative time: 118 vs 162 min, p 0.05 reduced duration of hospital stay: 0.58 vs 0.97, p 0.05 V-loc 90 (4-0 to 2-0) No differences: perioperative complications, EBL, or # of V-loc 180 (4-0 to 0)myomas removed during surgeryEinarsson JI, Chavan NR, Suzuki Y, Jonsdottir G, Vellinga TT, Greenberg JA. Use of bidirectional barbedsuture in laparoscopic myomectomy: evaluation of perioperative outcomes, safety, and efficacy. J MinimInvasive Gynecol. 2011;18:92-95.V-LocProspective Study Women with single intramural myoma Retrospective Study from Feb 2008 to August 2012 V-Loc vs classic continuous suture with intracorporeal knots 202 TLH: Vloc 63 and PDS 139 Mean operative time was shorter in V-Loc; 51 vs 58 min Postop fever: higher in Vloc group suturing time: 9.9 vs 15.8, p 0.0004 similar operative time, blood loss and hospital stay decreased blood loss, p 0.0076 decreased drop in hemoglobin, p 0.0176Bassi A, Tolandi T, Evaluation of total laparoscopic hysterectomywith and without the use of barbed sutures. J Obstet GynaecolCan 2013 Aug; 35(8):718-22Angioli R, Plotti F, Montera R et al. A new type of absorbablebarbed suture for use in laparoscopic myomectomy. Int JGynaecol Obstet 2012;117 (3):220-22323

Endo StitchReferences Bogliolo S, Nadalini C, Iacobone AD, Musacchi V, Carus AP; Vaginal cuff closurewith absorbable bidirectional barbed suture during TLH; Eur J Obstet GynecolReprod Biol. 2013 Aug;170(1):219-21 Einarsson JI, Cohen SL et al, Barbed versus standard suture: A randomized trialfor laparoscopic vaginal cuff closure J Minim Invasive Gynecol. 2013 JulAug;20(4):492-8. Einarsson JI, Chavan NR, Suzuki Y, Jonsdottir G, Vellinga TT, Greenberg JA. Useof bidirectional barbed suture in laparoscopic myomectomy: evaluation ofperioperative outcomes, safety, and efficacy. J Minim Invasive Gynecol.2011;18:92-95. Bassi A, Tolandi T, Evaluation of total laparoscopic hysterectomy with and withoutthe use of barbed sutures. J Obstet Gynaecol Can 2013 Aug; 35(8):718-22 Angioli R, Plotti F, Montera R et al. A new type of absorbable barbed suture foruse in laparoscopic myomectomy. Int J Gynaecol Obstet 2012;117 (3):220-223 10mm disposable suturing device Allows for placement of multiple suturetypes during laparoscopic surgery andsimplifies knot tying SILS Stitch: added advantage of articulation up to75 degrees and rotation up to 360degrees24

CULTURAL AND LINGUISTIC COMPETENCYGovernor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such asthe AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil RightsAct of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of whichrecognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited Englishproficiency (LEP).US PopulationLanguage Spoken at HomeCaliforniaLanguage Spoken at uroEnglishAsianOther19.7% of the US Population speaks alanguage other than English at homeIn California, this number is 42.5%California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the lawsidentified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is providedby the Institute for Medical Quality at http://www.imq.orgTitle VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance fromdiscriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any oftheir activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of nationalorigin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEPindividuals in the eligible service population, the frequency with which they come into contact with theprogram, the importance of the services, and the resources available to the recipient, including the mix of oraland written language services. Additional details may be found in the Department of Justice Policy GuidanceDocument: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.Executive Order 13166,”Improving Access to Services for Persons with Limited EnglishProficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was thegenesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,including those which provide federal financial assistance, to examine the services they provide, identify anyneed for services to LEP individuals, and develop and implement a system to provide those services so LEPpersons can have meaningful access.Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires everyCalifornia state agency which either provides information to, or has contact with, the public to provide bilingualinterpreters as well as translated materials explaining those services whenever the local agency serves LEPmembers of a group whose numbers exceed 5% of the general population. If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guaranteecompetence as a medical interpreter. i?artid 2078538.25

Consultant: Ethicon Endo‐Surgery, Karl Storz Objectives Review principles of knot security Overview of applications of Extracorporeal Knots Understand Extracorporeal Knot tying technique Extracorporeal knot troubleshooting Video demonstrations of extracorporeal knot use in gynecologic surgery