Laparoscopic Continuous Suturing
It is common practice to start a continuous suture with a Dundee Jamming Slip Knot. An equally acceptable alternative is an internally tied knot if the surgeon is proficient. A continuous suture can be finished in a number of ways. We recommend the Aberdeen termination, an internal tie to a convenient tailor a slipping loop tied to itself.
Dundee Jamming Slip Knot
This is a recommended way of starting a continuous suture. This knot has an external component but is completed, once inside the body cavity, after the first bite of tissue has been taken.
The external component has the following steps:
• A simple slipping loop
• Passage of the tail through the first loop
• Creating a second loop
• Tensioning of the second loop.
The second loop should slip only from the tail, the knot should not be tightened at this stage and the length of both the loop and of the tail should be at least 1 cm. Once inside, the knot is locked by the passage of the standing part of the suture through the loop, which is then slipped to lock the knot.
Starting a Continuous Suture
• Tie the external component of the Dundee jamming slip knot at the end of an atraumatic suture or start with and intracorporeal surgeons knot.
• Pass an atraumatic grasper through an introducer tube.
• Pick up the suture at a point midway from the tail of the suture to the needle tip.
• Draw suture and needle completely inside the introducer tube, being careful not to slip the Dundee jamming slip knot.
• Pass the introducer through the 11 mm cannula.
• Extrude the suture and deposit it on a safe surface (e.g. the anterior surface of the stomach).
• Pick up the needle and take the first bite of the tissue or tissues to be sutured.
• Pull the thread through until the Dundee jamming slip knot just impinges on the tissue.
• Pass the needle holder carefully through the loop of the Dundee jamming slip knot and pick up the thread attached to the needle at a point near to its exit from the tissues.
• Pull the needle holder and thread with the trailing needle back through the loop.
• Next take hold of the tail of the loop and the standing part of the thread and pull first on the tail and then on the standing part, locking the knot.
• Trim the tail. You are now ready to start your continuous suture.
Applications
It is used in any continuous suture, e.g. closure of viscerotomies following stapled anastomosis, sutured anastomosis such as cholecystojejunostomy, gastrojejunostomy, etc. It can also be used as an interrupted suture when adding one or two hitches are advised for security (in our practice an internally tied knot would be used in preference for an interrupted suture).
Aberdeen Termination
This is an adaptation of a termination commonly used in abdominal closure following open surgery. The continuous suture is finished by the formation of three interlocking loops. In order to simplify the maintenance of tension in the suture line, the penultimate stitch can be locked. A further bite is then taken and the suture pulled through, though not completely. A small loop of suture is left, enough that the needle holder can be passed through it to pick up the standing part of the suture. A loop of this is then drawn through the first loop, which is tightened down onto the tissues. The needle holder is then passed through the new loop to repeat the maneuver three times. It is important that each loop is tightened as you proceed. To do this, tension must be applied to the leg of the loop, which exits, from the tissues or the preceding loop. The standing part and needle are delivered completely through the last loop. The standing part is held up and the suture tensioned with counter pressure from the jaws of the needle holder placed on either side of the suture. The suture is cut off leaving a reasonable length (approximately
1 cm).
Interrupted Knots
Dundee jamming loop knot is used to create interrupted sutures. For additional safety, a further hitch or two is recommended if it is to be used as an interrupted suture. More commonly interrupted intracorporeal sutures are made by the use of the surgeon's or the tumbled square knots.
Applications of Interrupted Sutures
Interrupted sutures have a multitude of uses. Simple examples are the closure of the common bile duct after exploration and fundoplication.
Stapled Anastomosis
The use of disposable stapling guns has simplified a number of endoscopic procedures such as the division of vascular pedicles and gut anastomosis.
The following important points are emphasized:
• Port positions for stapling
• Stay sutures for tensioning
• Enterotomy positioning and size
• Positioning and angulations of the instrument prior to closure
• Checking suture line
• Complete closure of the residual opening
• End to end anastomosis can also be carried out by stapling closed bowel ends side by side.
Clinical Applications
An anterior or posterior, side to side anastomosis of stomach and jejunum did laparoscopically be a satisfactory palliative procedure. Likewise, a laparoscopic cholecystojejunostomy may be performed with a stapler to relieve jaundice and itching in patients with inoperable pancreatic cancer.
Sutured Anastomosis
The sutured anastomosis can be carried out endoscopically, although the process is demanding in terms of skill and time. However, it is pertinent to note that staplers may not always be available, or appropriate, and even if a stapler is used, you require the skills to perform a sutured closure if the stapled anastomosis is not perfect.
Important points to remember are:
• Port positioning
• Use of communication with your assistant
• Positioning of sutures, especially at the corners
• Spacing the sutures (remember the magnification)
• Tensioning of sutures.
Direction of Suturing
It is important that you suture at the right height, ideally, your elbows should be held adducted and at right angles. Keep your wrists loose and remember that you have two hands that must manipulate to help each other. The choreography is as follows:
• The suturing line is started with a 'starter knot' (surgeons or tumbled square knot).
• The two-needle holders must be kept in view and used in concert with each other.
• Passage from right to left through the tissue edges (bites consisting of entry and exit points with the dominant needle holder.
• The needle is picked up from the exit point by the passive needle holder (NH).
• It is transferred to the dominant needle holder for the next bite if the orientation is correct. Otherwise, it is dropped and reorientated in the needle holder. Once the suture has passed through the two edges, the thread is pulled through, handing the suture one needle holder to the other.
• The distance between the suture bites must be approximately equal to the depth of the bites.
It is common practice to start a continuous suture with a Dundee Jamming Slip Knot. An equally acceptable alternative is an internally tied knot if the surgeon is proficient. A continuous suture can be finished in a number of ways. We recommend the Aberdeen termination, an internal tie to a convenient tailor a slipping loop tied to itself.
Dundee Jamming Slip Knot
This is a recommended way of starting a continuous suture. This knot has an external component but is completed, once inside the body cavity, after the first bite of tissue has been taken.
The external component has the following steps:
• A simple slipping loop
• Passage of the tail through the first loop
• Creating a second loop
• Tensioning of the second loop.
The second loop should slip only from the tail, the knot should not be tightened at this stage and the length of both the loop and of the tail should be at least 1 cm. Once inside, the knot is locked by the passage of the standing part of the suture through the loop, which is then slipped to lock the knot.
Starting a Continuous Suture
• Tie the external component of the Dundee jamming slip knot at the end of an atraumatic suture or start with and intracorporeal surgeons knot.
• Pass an atraumatic grasper through an introducer tube.
• Pick up the suture at a point midway from the tail of the suture to the needle tip.
• Draw suture and needle completely inside the introducer tube, being careful not to slip the Dundee jamming slip knot.
• Pass the introducer through the 11 mm cannula.
• Extrude the suture and deposit it on a safe surface (e.g. the anterior surface of the stomach).
• Pick up the needle and take the first bite of the tissue or tissues to be sutured.
• Pull the thread through until the Dundee jamming slip knot just impinges on the tissue.
• Pass the needle holder carefully through the loop of the Dundee jamming slip knot and pick up the thread attached to the needle at a point near to its exit from the tissues.
• Pull the needle holder and thread with the trailing needle back through the loop.
• Next take hold of the tail of the loop and the standing part of the thread and pull first on the tail and then on the standing part, locking the knot.
• Trim the tail. You are now ready to start your continuous suture.
Applications
It is used in any continuous suture, e.g. closure of viscerotomies following stapled anastomosis, sutured anastomosis such as cholecystojejunostomy, gastrojejunostomy, etc. It can also be used as an interrupted suture when adding one or two hitches are advised for security (in our practice an internally tied knot would be used in preference for an interrupted suture).
Aberdeen Termination
This is an adaptation of a termination commonly used in abdominal closure following open surgery. The continuous suture is finished by the formation of three interlocking loops. In order to simplify the maintenance of tension in the suture line, the penultimate stitch can be locked. A further bite is then taken and the suture pulled through, though not completely. A small loop of suture is left, enough that the needle holder can be passed through it to pick up the standing part of the suture. A loop of this is then drawn through the first loop, which is tightened down onto the tissues. The needle holder is then passed through the new loop to repeat the maneuver three times. It is important that each loop is tightened as you proceed. To do this, tension must be applied to the leg of the loop, which exits, from the tissues or the preceding loop. The standing part and needle are delivered completely through the last loop. The standing part is held up and the suture tensioned with counter pressure from the jaws of the needle holder placed on either side of the suture. The suture is cut off leaving a reasonable length (approximately
1 cm).
Interrupted Knots
Dundee jamming loop knot is used to create interrupted sutures. For additional safety, a further hitch or two is recommended if it is to be used as an interrupted suture. More commonly interrupted intracorporeal sutures are made by the use of the surgeon's or the tumbled square knots.
Applications of Interrupted Sutures
Interrupted sutures have a multitude of uses. Simple examples are the closure of the common bile duct after exploration and fundoplication.
Stapled Anastomosis
The use of disposable stapling guns has simplified a number of endoscopic procedures such as the division of vascular pedicles and gut anastomosis.
The following important points are emphasized:
• Port positions for stapling
• Stay sutures for tensioning
• Enterotomy positioning and size
• Positioning and angulations of the instrument prior to closure
• Checking suture line
• Complete closure of the residual opening
• End to end anastomosis can also be carried out by stapling closed bowel ends side by side.
Clinical Applications
An anterior or posterior, side to side anastomosis of stomach and jejunum did laparoscopically be a satisfactory palliative procedure. Likewise, a laparoscopic cholecystojejunostomy may be performed with a stapler to relieve jaundice and itching in patients with inoperable pancreatic cancer.
Sutured Anastomosis
The sutured anastomosis can be carried out endoscopically, although the process is demanding in terms of skill and time. However, it is pertinent to note that staplers may not always be available, or appropriate, and even if a stapler is used, you require the skills to perform a sutured closure if the stapled anastomosis is not perfect.
Important points to remember are:
• Port positioning
• Use of communication with your assistant
• Positioning of sutures, especially at the corners
• Spacing the sutures (remember the magnification)
• Tensioning of sutures.
Direction of Suturing
It is important that you suture at the right height, ideally, your elbows should be held adducted and at right angles. Keep your wrists loose and remember that you have two hands that must manipulate to help each other. The choreography is as follows:
• The suturing line is started with a 'starter knot' (surgeons or tumbled square knot).
• The two-needle holders must be kept in view and used in concert with each other.
• Passage from right to left through the tissue edges (bites consisting of entry and exit points with the dominant needle holder.
• The needle is picked up from the exit point by the passive needle holder (NH).
• It is transferred to the dominant needle holder for the next bite if the orientation is correct. Otherwise, it is dropped and reorientated in the needle holder. Once the suture has passed through the two edges, the thread is pulled through, handing the suture one needle holder to the other.
• The distance between the suture bites must be approximately equal to the depth of the bites.
