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2 Minimally Invasive Suturing Techniques
Boel A. Fransson and Kyle W. Martin
Key Points
Laparoscopic suturing requires simulator training until the motion is fluent and automatic. There will be added challenges in the operating room (OR), and if the skill is not fluent in the simulator, clinical hand suturing will be near impossible.
Sutures longer than 30 cm (12 in.) are extremely challenging for intracorporeal suturing and knot tying and 6 in. is preferred.
For intracorporeal continuous suturing, barbed sutures are outstanding.
Automated suturing devices, including the Endo Stitch and the SILS (single incision laparoscopic surgery) Stitch device, are preferred by many surgeons.
Introduction to Laparoscopic Suturing
In the early years of minimally invasive surgery (MIS), controversy existed regarding the need for suturing skills. Many practicing surgeons thought that laparoscopic suturing was too difficult to ever be considered a realistic requirement [1]. However, in the early 1990s, a consensus was built: laparoscopic surgeons had to learn and apply basic suturing skills unless the development of laparoscopic surgery was to be impeded. [2] As laparoscopic techniques advanced from ablative to reconstructive procedures, suturing skills became increasingly important [3]. Soon it was recognized that these complex skills had to be practiced with other methods than the classical “see one, do one, teach one” paradigm of conventional residency training. As a result, simulation training became a requirement. Despite an intense technological advancement, intracorporeal suturing remains of paramount importance to MIS surgeons to this day. Robotic technology has not circumvented the need for suturing. However, robotic wrist‐action and 3D vision have made suturing more intuitive to learn [4].
Currently, veterinary medicine is facing a similar dilemma. The introduction of MIS into small animal surgery has resulted in MIS technology being available at most specialized and many nonspecialized practices. For progressive evolution of small animal MIS, we need to embrace suturing techniques. Because of the challenge of suturing, many replacement devices have been introduced, but most are expensive and not always as versatile or secure as desired. With suturing skills, many open surgical techniques can be replaced with minimally invasive counterparts for the benefit of our patients. Having suturing skills also increases the surgeon's confidence to deal with emergent situations during a surgical procedure without the need for conversion to open surgery.
This chapter is intended to give novice laparoscopic surgeons a foundation, enabling them to start practicing suturing in a simulator in preparation for clinical application. With suturing skills developed in the simulator, we have found that the step to intracorporeal clinical suturing is small for most trainees.
Needle Holders for Laparoscopic Suturing
Conventional laparoscopic needle holders differ from most other laparoscopic instruments in that they do not rotate around the axis of the instruments in order to provide stability. Articulating and rotating needle drivers have been introduced but have been criticized for creating imprecision in needle exit and for being more difficult to learn to use than conventional needle drivers [5].
The handles are often of a straight axial design, placing the needle in line with the surgeon's hands to allow greater maneuverability and more natural motion of the wrist when suturing. The jaws are often single action and are usually operated by means of an ergonomic spring‐loaded palm grip on the handle.
Several handle types are available, and the efficacies of four of them were compared. [6] It was found that a pistol grip (Figure 2.1) was superior for experienced operators but not for novices, who preferred a palmed straight grip. Neither experienced or novice users performed well nor preferred a thumb–ring finger grip (Figure 2.2) [6].
For novice laparoscopic surgeons, we recommend a needle driver that is sturdy, with straight handle, a ribbed grip, and a conveniently located needle release button on the grip (Figure 2.3). Hand size differs among surgeons; therefore, the preferred position of the release button may differ. When the release button is placed in the axis of the instrument, it can be used with either hand.
Needle driver jaws may be straight, curved left, or curved right (Figure 2.4). They can also be self-righting. Straight jaws are this author's (BAF) preference because they can be used in both left and right positions. The jaws are designed for a particular range of needle sizes, which is important to note before purchase. Self-righting needle drivers force the needle into a fixed position, usually at 90° angle to the instrument shaft. The limitations of self-righting needle drivers is that they should not be used to grasp the suture because they may damage or weaken the material. In addition, they reduce the surgeon's freedom to position the needle in different angles.
Figure 2.1 Pistol grip laparoscopic needle driver.
Source: © 2014 Photo courtesy of KARL STORZ GmbH & Co. KG.
Figure 2.2 Needle driver with handle designed for thumb–ring finger grip. These did not perform as well as other designs.
Source: © 2014 Photo courtesy of KARL STORZ GmbH & Co. KG.
Figure 2.3 For novice laparoscopic surgeons, we recommend needle drivers that are sturdy, with straight handles, ribbed grips, and conveniently located needle release buttons on the grips.
Source: © 2014 Photo courtesy of KARL STORZ GmbH & Co. KG.
