Download - laparoscopic suturing
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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
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2 D ImageNo depth PerceptionNo tactile feedback
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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
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Learning Objectives
• Working knowledge of Suturing Equipments• Ergonomics for Suturing• Tissue approximation
– Intra corporeal Suturing– Extra corporeal Suturing– Staplers in Laparoscopy
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Laparoscopic Suturing Equipments
• Needle Holders• Knot pushers• Suture Materials
HD Camera30 degree telescope Good Assistants
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Invest on Good Needle Holders
TipTungsten carbideDiamond coatingStraight/Curved
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Needle holders
Active hand Needle holderAssisting hand Needle grasper
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Knot Pushers
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Welcome Additions…
Endo Stitch
Self righting Needle holder
Repair of Hiatus with Endostitch
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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
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Suture needles
Straight NeedleSki NeedleCurved Needle
25mm½ circle
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Learning Objectives
• Working knowledge of Suturing Equipments• Ergonomics for Suturing• Tissue approximation
– Intra corporeal Suturing– Extra corporeal Suturing– Staplers in Laparoscopy
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Different Ball Game!
Open Surgery suturing Fast Ergonomics: Optional
Laparoscopic Suturing Slow and steady
Magnification effect Choreographic
movements Ergonomics: Vital
Triangulation Manipulation angle
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Ergonomics• Straight Line principle• Triangulation• Manipulation angle• Elevation angle• Low lying table• Gaze down view
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Base Ball Diamond Concept& Triangulation
Monitor
S
C
R
L
P
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Manipulation angle
Azimuth Angle Manipulation Angle
30-45 degree 60-90 degree
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Ergonomics of Hand Instruments
• Tip– Range of movements
• Conventional Vs Robotic instrument: 4: 7
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Da Vinci Robot
Wrist like action
PrecisionPrecision
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Ergonomics of Hand Instruments
• Tip– Range of movements
• Conventional Vs Robotic instrument
• Length of the shaft
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Fulcrum Effect of Hand Instruments
1: 1
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Ergonomics of Hand Instruments
• Tip– Range of movements
• Conventional Vs Robotic instrument
• Length of the shaft• Handle design
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Ergonomic handles…
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Surgeon’s Stance
Ideal relaxed stature Tiring
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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
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Learning Objectives
• Working knowledge of Suturing Equipments• Ergonomics for Suturing• Tissue approximation
– Intra corporeal Suturing– Extra corporeal Suturing– Staplers in Laparoscopy
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I can recognize a good surgeon ,not from how he cuts, but from how he sews!
Johan Mikulicz Radecki 1850-1905
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Critical Steps of Suturing
1. Introduction of Needle2. Grasping the Needle3. Tissue Penetration4. Knotting
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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
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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
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Needle discipline
•A held needle should always be in view.•A trailing needle is a safe needle
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Types of Knots• Granny knot• Square knot• Slip knot to square knot• Surgeon’s Knot• Aberdeen knot• Dundee Jamming Slip Knot
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Surgeon’s Knot
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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
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Slip Knot to Square knot
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Continuous Suturing
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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
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Learning Objectives
• Working knowledge of Suturing Equipments• Ergonomics for Suturing• Tissue approximation
– Intra corporeal Suturing– Extra corporeal Suturing– Staplers in Laparoscopy
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Extra corporeal knots
• Roeder Knot• Meltzer Knot• Tayside knot
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Roeder’s Knot
No 2 Chromic CatgutEg: Appendix base
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Extra corporeal Knotting
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Meltzer Knot
1-0 or 2-0 VicrylEg: Cystic duct
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Tayside Knot1-0 or 2-0 PDSEg: Azygos vein
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Learning Objectives
• Working knowledge of Suturing Equipments• Ergonomics for Suturing• Tissue approximation
– Intra corporeal Suturing– Extra corporeal Suturing– Staplers in Laparoscopy
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Staplers: Types & SizesGastric Bypass
Anterior Resection
TypesLinear staplers.Circular staplers.
Color codesWhite - small gut.Blue / Gold - stomach (except pylorus).Green - pylorus / redo surgery.
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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
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It is not practice that makes perfect
It’s perfect practice that makes perfect!
- Vince Lombardi, American Foot ball Coach, Green Bay, Wisconsin
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