Notes on Laparoscopic Suturing and Extracorporeal Knots

1. Port positioning
a. Operating Suprapubic port (midway symphysis and umbilicus) and high
lateral ports
b. Two Ipsilateral port and one contralateral port
2. Determine the size of needle required (10-36mm)
a. Pathology
b. Procedure
3. Determine the length of suture required
a. Full length (75 -90cm) for extracorporeal tie
b. Short length (8 to 12cm) for intracorporeal tie
4. Choice of an appropriate needle holder (or two), and the type of grasping
forceps
5. Extracorporeal ties
a. Weston knot requires locking with single intracorporeal tie
b. Modified Roeders knot requires knot pusher
c. Using knot pusher
Practice at open with rope
Practice with different suture materials eg. Ethibond, Prolene,
Vicryl etc.
Practice tying with gloves on
d. Practice tying with sutures coming through the port
Shorter suture ends make tying more difficult
Beware of the possibility that twists form inside the port which
may
1. prevent knot from slipping down properly
2. prevent knot from being secured squarely
6. Introducing needle inside the abdomen
a. Direct loading through 10-mm port
b. Back loading through 5-mm port
7. Grasping and loading needle onto needle driver/holder
a. Grasp suture 0.5 to 1 cm from swag
b. Introduce needle through port into abdomen
c. Follow and position camera and telescope
d. Keep needle in the safest and largest part of the operating field away
from dangerous structures avoid trauma to bowels, blood vessels
e. Gently grasp the needle tip with grasping forceps
f. Grasp suture close to swag
g. Jiggle needle tip into the correct position with the combination of
rotation with the left grasper and the in/out movement of the right
grasper.
h. Load needle with needle holder
i. Wrist rotation to present the needle: supinate / pronate

j. Rotate fingers or wrist to check that needle is loaded at correct angle

k. Check correct loading of needle using light reflection off needle
l. Now youre ready to suture
8. How to reverse direction of needle
a. Using one needle holder though the same port
b. Using a second needle holder through the ispilateral port
c. Using the same steps as above
9. Position the needle at the target organ / tissue
10. Drive the needle by wrist pronation till 2/3 of the needle is passed through the
tissue
11. Grasp the needle with the grasping forceps approximately 1/3 from the needle
tip
12. Pull the remainder of needle through the tissue by pronating the grasping
forceps
13. Grasp the suture 1 cm from the swag and pull the suture gently out through
the same port for extracorporeal tie
14. Remove the needle
15. Tie extracorporeal knot and pull slip knot back inside the abdomen or use knot
pusher
16. How to do intracorporeal knot tying
a. Complete the passage of the needle through the tissue by grasping the
needle with grasping forceps in the left hand
b. Pass suture needle back to the needle holder in the right hand
c. In doing so one completes the C loop over the short end
d. Point the grasping forceps / needle holder in the left hand at the short
end
e. Wrap a double loop around the tip of the grasping forceps / needle
holder in the left hand
f. The secret is to keep the left hand absolutely still until the double loops
have been wrapped around the tip of the grasping forceps
g. Move left hand forward to grasp the short end
h. Pull the short end through to complete the knot
i. At the same time pull the long end with the attached needle to the
opposite side
j. Lay the knot down horizontally square to the target
k. Pass the long end from the needle holder (in the right hand) to the
grasping forceps (in the left hand)
l. Bring the long end over the short end, by doing so a reverse C loop is
formed
m. Point the needle holder (in the right hand) at the short end
n. Wrap a loop around the needle holder
o. Grasp the short end with the needle holder, pull through to complete
the surgeons knot
p. Cut and trim the knot to the desired length