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Sponsored by
AAGLAdvancing Minimally Invasive Gynecology Worldwide
Laparoscopic Suturing: Practical Tips
for Needle Management, Knot Tying and
Suture Use (Simulation Lab)
PROGRAM CHAIR
Aarathi Cholkeri-Singh, MD
PROGRAM CO-CHAIR
Joseph (Jay) L. Hudgens, MD
Angela Chaudhari, MDKathy Huang, MD
Nash S. Moawad, MDJessica A. Shepherd, MD
Larry R. Glazerman, MDHye-Chun Hur, MDAngela M. Pratt, MD
Matthew T. Siedhoff, MD
Mark R. Hoffman, MDGretchen E.H. Makai, MDSangeeta Senapati, MD
Karen C. Wang, MD
AAGL acknowledges that it has received support in part by educational grants and equipment (in-kind) from the following companies:
3-Dmed, Aesculap, Angiotech, CareFusion, Cook Medical, Covidien, Inc., CooperSurgical, Ethicon Endo-Surgery, Inc., Ethicon Women’s Health & Urology, Karl Storz Endoscopy-America, Inc.,
Stryker Endoscopy, Richard Wolf Medical Instruments Corporation
Professional Education Information Target Audience Educational activities are developed to meet the needs of surgical gynecologists in practice and in training, as well as, other allied healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.
Table of Contents
Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 3 Port Placement, Needle Loading and Tissue Re‐approximation A. Cholkeri‐Singh .......................................................................................................................................... 5 Extracorporeal Knot Tying A. Cholkeri‐Singh .......................................................................................................................................... 9 Intracorporeal Knot Tying H.C. Hur ...................................................................................................................................................... 16 Suture Selection and Technologies Used in Gynecologic Laparoscopy K.C. Wang ................................................................................................................................................... 19 Cultural and Linguistics Competency ......................................................................................................... 24
PG 201 Laparoscopic Suturing: Practical Tips for Needle Management,
Knot Tying and Suture Use (Simulation Lab)
Aarathi Cholkeri-Singh, Chair Joseph (Jay) L. Hudgens, Co-Chair
Faculty: Angela Chaudhari, Larry R. Glazerman, Mark R. Hoffman, Kathy Huang, Hye-Chun Hur,
Gretchen E.H. Makai, Nash S. Moawad, Angela M. Pratt, Sangeeta Senapati, Jessica A. Shepherd, Matthew T. Siedhoff, Karen C. Wang
Course Description This workshop provides an overview of laparoscopic suturing and knot tying techniques, which will include both intracorporeal and extracorporeal knots. The course will offer hands-on suturing simulation where experienced faculty will actively guide participants through the training steps. Various applications for different suture materials and technologies utilized in gynecologic laparoscopy will also be reviewed. The course is designed for gynecologists in practice who want to develop or improve their suturing skills for immediate application in their surgical practice.
Course Objectives At the conclusion of this course, the participant will be able to: 1) Manipulate and load a needle laparoscopically for tissue reapproximation; 2) perform extracorporeal knots; 3) perform intracorporeal knots; 4) outline the advantages, disadvantages, and clinical applications for extracorporeal versus intracorporeal knots; 5) distinguish advantages and disadvantages of various suture materials, including barbed suture; and 6) distinguish advantages and disadvantages of suturing technologies used in laparoscopy.
Course Outline (SAME for AM and PM sessions) 8:00 Welcome, Introductions and Course Overview A. Cholkeri-Singh 8:05 Port Placement, Needle Loading and Tissue Re-approximation A. Cholkeri-Singh 8:20 Hands-on Training – Needle Loading and Needle Manipulation All Faculty 9:00 Extracorporeal Knot Tying A. Cholkeri-Singh 9:15 Hands-on Training – Extracorporeal Knot Tying All Faculty 9:45 Questions & Answers All Faculty 9:55 Break 10:10 Intracorporeal Knot Tying H.C. Hur
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10:25 Hands-on Training – Intracorporeal Knot Tying All Faculty 11:05 Suture Selection and Technologies Used in Gynecologic Laparoscopy K.C. Wang 11:20 Hands-on Training – Barbed Suture and Suturing Devices All Faculty 11:50 Questions & Answers All Faculty 12:00 Course Evaluation CM
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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor Consultant: Conceptus Incorporated Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Jonathan Solnik Other: Lecturer - Olympus, Lecturer - Karl Storz Endoscopy-America SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: CooperSurgical, Ethicon Women's Health & Urology, Intuitve Surgical Other: Royalties - CooperSurgical Linda Bradley Grants/Research Support: Elsevier Consultant: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharmaceuticals Speaker's Bureau: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharm Keith Isaacson Consultant: Karl Storz Endoscopy Rosanne M. Kho Other: Honorarium - Ethicon Endo-Surgery C.Y. Liu* Javier Magrina* Ceana H. Nezhat Consultant: Intuitve Surgical, Lumenis, Karl Storz Endoscopy-America Speaker's Bureau: Conceptus Incorporated, Ethicon Women's Health & Urology William H. Parker Grants/Research Support: Ethicon Women's Health & Urology Consultant: Ethicon Women's Health & Urology Craig J. Sobolewski Consultant: Covidien, CareFusion, TransEnterix Stock Shareholder: TransEnterix Speaker's Bureau: Covidien, Abbott Laboratories Other: Proctor - Intuitve Surgical FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Aarathi Cholkeri-Singh* Joseph L. Hudgens Consultant: Karl Storz Endoscopy-America Angela Chaudhari* Mark R. Hoffman* Jian Qun (Kathy) Huang
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Speaker's Bureau: Intuitve Surgical Hye-Chun Hur* Gretchen E.H. Makai Other: Honorarium - Intuitve Surgical Nash S. Moawad* Angela M. Pratt* Sangeeta Senapati* Jessica A. Shepherd* Matthew T. Siedhoff* Karen C. Wang* Asterisk (*) denotes no financial relationships to disclose.
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Port Placement, Needle Loading, & Tissue Re-approximation
Jay L. Hudgens, M.D.Center for Women’s Health
Owensboro, KY
Gratis Faculty University of LouisvilleDepartment of Obstetrics, Gynecology, & Women’s Health
Presented by:
Aarathi Cholkeri-Singh, M.D., FACOG
Disclosures
Jay Hudgens, M.D.Aarathi Cholkeri-Singh, M.D., FACOG
We have no financial relationships to disclose
Objectives
1. Present the different port placementsused in laparoscopic suturing
2. Present a system for setting the needle
3. Discuss strategies for tissue re-approximation
System
1. Set the Needle
2. Reapproximate
3. Knot Tying
Ipsilateral
• Ergonomics
• Assistant
• One Sided
5
Contralateral
• Ideal Triangulation
• Poor Ergonomics?
• No Assistant
Suprapubic
• Gravity
• Ergonomics?
• Two Sided
Needle Holders
• Straight• Curved
– For desired needle angles >135o
• Self-Righting• Endo Wrist Articulating
– Hand-held– Da Vinci Robot
Straight Needle Holder
Curved Needle Holder Self-Righting Needle Holder
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Endowrist Needle Holder
Laparoscopic Robotic
System
1. Set the Needle
2. Re-approximate
3. Knot Tying
• Set (perpendicular)
• Parallel (tissue)
System
( )
• Rotate (key)
• Reset
Tie Knot
• Direct-trocar
• Backloaded
• 5mm…..Backload
• 8mm SH-1
Needle Entry
• Backloaded
• Abdominal Wall
• 8mm…..SH-1
• 10mm…CT-2 & CT-1
• 12mm…CT
Setting the Needle Setting the Needle
A-B-C“A” = 2cm
from Swedge
“C” = 1/3 from
Swedge
“B” = 1/3 from Point
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Setting the Needle
A-B-C
Left Hand Right Hand
Right Hand Motion
Novice
Hiemstra et al JMIG 2011 vol. 18, pgs 494-499
Expert
• Set (perpendicular)
• Parallel (tissue)
System
( )
• Rotate (key)
• Reset
Tie Knot
What is the most important factor in reproducible tissue re-approximation?
A. Port placement.
B. Understanding the relationship between the tissue, camera, and ports.
C. Use of mechanical suturing device to improve efficiency and accuracy.
D. The type of suture and needle used.
E. Not applicable to my practice.
References
1. Joseph L. Hudgens, RP Pasic. Geometrically Efficient Laparoscopic Suturing. 40th Global Congress AAGL, 2011
2 Resad P Pasic RL Levine A Practical 2. Resad P. Pasic, RL Levine. A Practical Manual of Laparoscopy 2nd Edition. New York: The Parthenon Publishing Group 2002
3. Charles H. Koh. Laparoscopic Suturing in the Vertical Zone. Endo Press 2008: Tuttlingen, Germany
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Aarathi Cholkeri‐Singh, M.D., FACOG
Clinical Assistant Professor of Obstetrics and Gynecology at UIC
Associate Director of Minimally Invasive Gynecologic Surgery
Director of Gynecologic Surgical Education at ALGH
Disclosures I have no financial relationships to disclose.
Objectives Review principles of knot security
Overview of applications of Extracorporeal Knots
Understand Extracorporeal Knot tying techniquep y g q
Extracorporeal knot troubleshooting
Video demonstrations of extracorporeal knot use in gynecologic surgery
“… an unreliable suture knot can spoil the outcomes of an otherwise beautifully
performed surgical procedure.”p g p
‐ unknown author
Role of extracorporeal knots in laparoscopic surgery. www.laparoscopyhospital.com
Principles of Knot Security1. Type of Suture
2. Type of Knot GOAL = tissue is approximated and
3. Surgical Technique
4. Length of cut end
approximated and secured
Sanz 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 braided and monofilament absorbable sutures. Am J Obstet Gynecol. 2002;187(6):1438‐42.
Goldenberg EA, Chatterjee A. Towards a better laparoscopic knot: using knot quality scores to 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..
Suture Material Natural vs. Synthetic
Natural i.e. Chromic Tissue fluids alter ability to hold knot
Synthetic Multifilament
Lie flat more readily secondary to less memory
Monofilament
Less tissue inflammation
Slippage and weaken from surgical instruments
Friction is greater for braided multifilament than monofilament suture
Sanz LE. Selecting the best suture material. Contemporary Ob/Gyn. 2001;57‐72.
Role of extracorporeal knots in laparoscopic surgery. www.laparoscopyhospital.com
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Suture Length
Single‐use suture, minimum length of suture should be 27 inches (70 cm) – standard length
Multiple‐use or purse‐string suture, recommend length of suture to be minimum 48 inches (122 cm)
Type of knot
Square knot•Coefficient of friction equally distributed
Sliding knot•Coefficient of friction not equally distributed
Intracorporeal Extracorporeal
equally distributed between suture ends•Each end of suture enters and leaves knot in opposite direction
q ybetween suture ends•Each end of suture enters and leaves knot in same direction•One axial strand is held under tension as the other ties around it
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 Knots Amortegui et al, Surg Endosc 2002
1 surgeon, 7 types of knots
140 knots conventional vs. 140 knots laparoscopic
b id d l 2‐0 braided polyester
4‐6 throws
Knots measured for breaks using tensiometer and knot slips >3mm
Amortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐1602.
Laparoscopic Knots
Amortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐1602.
S Sliding Knot1 or 2 indicates number of flat square knotsX throw in opposite direction from previous= throw in same direction as previous// change of axial strand and next throw turns in same direction as previous# change of axial strand and next throw turns in opposite direction from previous
Laparoscopic KnotsIntracorporeal Square
KnotsExtracorporeal Sliding
Knot
These configurations had superior tensile strength to others tested in laparoscopic group (p<0.05)
No significant difference between these 3 configurationsAmortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐1602.
Laparoscopic Knots Goldenberg et al, JSLS 2009
3 surgeons, 100 knots, 2‐0 silk, 4 throws measured for knot slips and breaks using tensiometer
Extracorporeal square knotsvs.
Intracorporeal slip‐square vs.
Intracorporeal flat‐square
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.
Goldenberg EA, Chatterjee A. Towards a better laparoscopic knot: using knot quality scores to evaluate three laparoscopic knot‐tying techniques. JSLS 2009;13(3):416‐9.
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Robot‐assisted Laparoscopic Knots
•Larger variability in the strength of the knots made using the robot, which corresponded to higher percentage of unraveling knots
Muffly T, McCormick TC, Dean J, et al. An evaluation of knot integrity when tied robotically and conventionally. Am J Obstet Gynecol 2009;e18‐20.
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.
Extracorporeal Knots
Decrease operative time
Easy to perform
Quicker to tie than intracorporeal knotsQ p
Tensile strength comparable to intracorporeal knots
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.
Applications General GYN
Ovarian reconstruction Vaginal cuff closure Cervical stump closure Myomectomy In lieu of additional port
UroGyn Sacrocolpopexy/Sacrocer‐vicopexy
Paravaginal defect repair Burch McCall’s Culdoplasty In lieu of additional port
and grasper
Repairs Bladder Bowel Uterine Perforation
McCall s Culdoplasty
REI Cuff tuboplasty Tubal Reanastomosis
Useful for any interrupted or purse‐string suturing
Surgical Technique of Extracorporeal Knots
1. Interrupted or purse‐string stitch placed in tissue2. Both ends of suture outside of laparoscopic port3. Knot formed outside of abdominal cavity4 Laparoscopic knot pusher mounted adjacent to knot4. Laparoscopic knot pusher mounted adjacent to knot5. Tension placed on both ends of suture as laparoscopic
knot pusher cinches down and secures each knot to tissue
6. Release knot pusher from suture7. Repeat throws (steps 2‐6)
Goldenberg EA, Chatterjee A. Towards a better laparoscopic knot: using knot quality scores to evaluate three laparoscopic knot‐tying techniques. 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 Pushers
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Extracorporeal Knot
The American College of Obstetricians and Gynecologists (Obstetrics and Gynecology, 1992, 79: 143‐147.)
Suture Tail Cutting tail of knot too short compromises knot integrity as it can easily unravel
Extracorporeal Knot Video
Troubleshooting
Suture too short
Needle through 5 mm portg 5 p
Suture twisting
Open knot pusher released early
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Short Suture Needle Back‐loading
Needle Back‐loading Untwisting Suture
Replacing Knot Pusher Replacing Knot Pusher
13
Laparoscopic Babcock
Vaginal Cuff Repair Uterosacral Suspension
Ovarian Reconstruction Oophoropexy
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References1. Role of extracorporeal knots in laparoscopic surgery. www.laparoscopyhospital.com2. Sanz LE. Selecting the best suture material. Contemporary Ob/Gyn. 2001;57‐72.3. 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):1438‐42.4. Goldenberg EA, Chatterjee A. Towards a better laparoscopic knot: using knot quality scores
to evaluate three laparoscopic knot‐tying techniques. JSLS 2009;13(3):416‐9.5. Amortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐
61602.6. Sharp HT, Dorsey JH, Chovan JD, et al. The effect of knot geometry on the strength of
laparoscopic slipknots. Obstet Gynecol 1996;88:408‐11.7. 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;30:571‐3.8. Behm T, Unger JB, Ivy JJ, et al. Flat square knots: are 3 throws enough? Am J Obstet Gynecol.
2007;197:172.e1‐3.9. The American College of Obstetricians and Gynecologists (Obstetrics and Gynecology, 1992,
79: 143‐147.)10. Muffly T, McCormick TC, Dean J, et al. An evaluation of knot integrity when tied robotically
and conventionally. Am J Obstet Gynecol 2009;e18‐20.11. 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.
Question A 34‐year‐old woman who desires pregnancy has had 18 months
without conception. She has been found to have a right hydrosalpinxand is opting to undergo laparoscopic tubaplasty for treatment. Upon insertion of the uterine manipulator, the uterine fundus is perforated and actively bleeding.
What is the best step in maintaining hemostasis at the site of the uterine perforation?A. Dessicate the area B. Place surgical hemostatic agentC. Place an interrupted sutureD. No treatment necessaryE. Not applicable to my area of practice
Correct Answer: C
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Intracorporeal Knot Tying
Hye‐Chun Hur, MDBeth Israel Deaconess Medical Center
Director, Minimally Invasive Gynecologic SurgeryAssistant Professor, Harvard Medical School
Disclosures
I have no financial relationships to disclose.
Objectives
– Indications for intracorporeal knot tying
– Basic equipment
– Technique• breakdown of steps• helpful tips • video demo
Indications
General:any indication for extracorporeal knot tying can be applied to intracorporeal knot tying
• vaginal cuff closure• laparoscopic myomectomy• oophoropexy• suturing for retraction (e.g.
ovary, bowel, uterus)p y g
knot pusher unavailable
y, , )
• bowel repair• bladder repair• peritoneal closures (e.g.
sacrocolpopexy)
Specific: more delicate suturing, tying knots off tension
Equipment
• Laparoscopic Needle Driver (curved, locking)• Laparoscopic Needle Grasper (straight)• Laparoscopic Scissors
• Suture, cut 6‐8 inches (interrupted vs figure of eight sutures)
• 10 mm trocar (direct delivery of needle)• 5 mm trocar (back load needle)
16
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 inches
3 Place suture3. Place suture.
4. Throw 4‐6 square knots (opposite direction).• Vicryl 4 throws• PDS 6 throws
5. Cut suture, remove needle under direct visualization.
Replicate an instrument tie.
Intracorporeal Knot Tying
1. Select appropriate trocar size for needle delivery
2. Cut suture in advance (6-8 inches)
3. Place suture (use locking needle driver)TIP: Leave free end (tail) short
Tips:
4. Throw 4-6 square knots (opposite direction)
5. Cut suture and remove needle under direct visualization
TIP: Pull ends so the free end stays short
TIP: Keep heel of needle in-line with needle grasper
( )
Important TipsInterrupted Suture
Figure of Eight SutureTake Home Points
Think 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• Pull ends so the free end stays short
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If you can do an instrument tie, you can do intracorporeal knot tying.
Conclusion
Laparoscopic suturing and intracorporeal knot tying is a skill that anyone can learn
and master in the dry lab setting.
Questions?
Continuous Running Suture
18
Alternative Suture and Alternative Suture and Technologies used in Technologies used in Gynecologic LaparoscopyGynecologic Laparoscopy
11
y g p pyy g p py
Karen C. Wang, MDKaren C. Wang, MDAssociate Director MIGS, Fellowship DirectorAssociate Director MIGS, Fellowship DirectorBrigham and Women’s HospitalBrigham and Women’s HospitalInstructor, Harvard Medical SchoolInstructor, Harvard Medical SchoolAAGL November 6, 2012AAGL November 6, 2012
DisclosuresDisclosures
22
I have no financial relationships to I have no financial relationships to disclose.disclose.
ObjectivesObjectives
Introduce alternative suture material and Introduce alternative suture material and devices utilized in gynecologic devices utilized in gynecologic laparoscopic surgerylaparoscopic surgery
33
Demonstrate utility of these alternatives Demonstrate utility of these alternatives to facilitate laparoscopic suturingto facilitate laparoscopic suturing
Laparoscopic suturingLaparoscopic suturing
Technically challengingTechnically challenging
Diminished tactile feedbackDiminished tactile feedback
44
Diminished tactile feedbackDiminished tactile feedback
Lack of depth perceptionLack of depth perception
Tremor amplificationTremor amplification
Limited instrument mobilityLimited instrument mobility
44
Solution?Solution?
55
Barbed sutureBarbed suture
Automated suturing devicesAutomated suturing devices
55
Barbed SutureBarbed Suture
QuillQuillTMTM
FDA approved 2004 FDA approved 2004
Initially used by PlasticsInitially used by Plastics
66
y yy y
V LocV LocTMTM
FDA approved 2009FDA approved 2009
Greenberg et al. 2008 JMIG
19
QuillQuillTMTM
AngiotechAngiotech
BidirectionalBidirectional
Helical patternHelical pattern
77
Anchors every 1mmAnchors every 1mm
V LocV LocTM TM 90 and 18090 and 180
CovidienCovidien
Unidirectional barbed sutureUnidirectional barbed suture
20 barbs/cm20 barbs/cm
88
Spiral configuration of barbsSpiral configuration of barbs
V LocV LocTMTM 9090 Similar to MonocrylSimilar to Monocryl
V LocV LocTMTM 90 and 18090 and 180
99
V LocV LocTMTM 180180 Similar to PDS, MaxonSimilar to PDS, Maxon
Suture lengths: 6, 9, 12, and 18 inchesSuture lengths: 6, 9, 12, and 18 inches Suture size: 3Suture size: 3--0, 20, 2--00
Advantages of Barbed SutureAdvantages of Barbed Suture
No knot tying requiredNo knot tying required
Equally distributed tension throughout Equally distributed tension throughout suturesuture
1010
suturesuture
Enables continuous suturing without Enables continuous suturing without backslidingbacksliding
Provides hemostatic closure of Provides hemostatic closure of myometrium during myomectomymyometrium during myomectomy
Barbed suture associated with Barbed suture associated with significantly shorter suturing times for significantly shorter suturing times for laparoscopic myomectomy compared to laparoscopic myomectomy compared to
Advantages of Barbed SutureAdvantages of Barbed Suture
1111
traditional sutures. traditional sutures.
1111
Alessandri et al. 2010 JMIGEinarsson et al. 2011. JMIG
VV--LocLocTM TM vsvs continuous continuous suture in lsc myomectomysuture in lsc myomectomy
N = 19N = 19
Solitary intramural fibroids 3Solitary intramural fibroids 3--5 cm5 cm
12121212Angioli et al. 2012. IJGO
VV--loc 90loc 90 ConventionalConventional PPEBLEBL 113.7 113.7 ++ 74.1 ml74.1 ml 168.6 168.6 ++ 75.1 ml75.1 ml 0.00760.0076
Operative time Operative time (total)(total)
51 51 ++ 18.1 min18.1 min 58 58 ++ 17.8 min17.8 min 0.06160.0616
Suturing timeSuturing time 9.9 9.9 ++ 4.3 min4.3 min 15.8 15.8 ++ 4.7 min4.7 min 0.00040.0004
20
Advantages of Barbed SutureAdvantages of Barbed Suture Does barbed suture reduce the risk of Does barbed suture reduce the risk of
vaginal cuff dehiscence?vaginal cuff dehiscence? Retrospective study N = 387, Jan 2007Retrospective study N = 387, Jan 2007-- Jan 2010Jan 2010
149 Barbed suture vs. 229 with Vicryl or Endostitch149 Barbed suture vs. 229 with Vicryl or Endostitch
Mean time dehiscence 45 daysMean time dehiscence 45 days
1313
Two layer closure 0Two layer closure 0--PDO Quill 14 x 14 cmPDO Quill 14 x 14 cm
No. DehiscenceNo. Dehiscence Length of followLength of follow--up (days)up (days)
Quill (149)Quill (149) 00 9696
Vicryl or Endostitch or Vicryl or Endostitch or Monofilament sutureMonofilament suture
10 (4.2%)10 (4.2%) 281281
Siedoff et al. 2011. JMIG
Downside of Barbed SutureDownside of Barbed Suture
Does barbed suture increase the risk of Does barbed suture increase the risk of adhesion formation?adhesion formation? Unidirectional barbed sutureUnidirectional barbed suture 13 canine enterotomy model13 canine enterotomy model
N i ifi t diff i dh i t 21N i ifi t diff i dh i t 21
1414
No significant difference in adhesion scores at 21 No significant difference in adhesion scores at 21 days days Miller et al. 2012 J Invest SurgMiller et al. 2012 J Invest Surg
Bidirectional barbed sutureBidirectional barbed suture 23 non23 non--pregnant ewespregnant ewes Necropsy at 3 monthsNecropsy at 3 months 12 horns (52.2%) with barbed suture12 horns (52.2%) with barbed suture--adhesionsadhesions 10 horns (43.5%) with Vicryl closure10 horns (43.5%) with Vicryl closure--adhesionsadhesions
Einarsson et al. 2011 JMIGEinarsson et al. 2011 JMIG1414
Downside of Barbed SutureDownside of Barbed Suture
“His” pareunia“His” pareunia Limited dataLimited data
117 TLH, 82 completed questionnaires117 TLH, 82 completed questionnaires
1515
p qp q
5 reported persistent dyspareunia (6.8%) at 5 reported persistent dyspareunia (6.8%) at
6 months post6 months post--opop
6 reported “his”pareunia (8.2%)6 reported “his”pareunia (8.2%)
1515
Einarsson et al. 2010 JSLS
Downside of Barbed SutureDownside of Barbed Suture
Case report Case report
Bowel obstruction after TLHBowel obstruction after TLH
00--PDO 14 x 14 cm Quill with Lapra Ty PDO 14 x 14 cm Quill with Lapra Ty
1616
Presented POD #30Presented POD #30
On laparoscopyOn laparoscopy--tail of left end of barbed suture tail of left end of barbed suture (4cm) found as cause of point of volvulus(4cm) found as cause of point of volvulus
1616Donnellan et al. 2011, JMIG
QuillQuillTMTM Suturing Video: Suturing Video: Myomectomy ClosureMyomectomy Closure
17171717
VV--LocLocTMTM Suturing Video: Suturing Video: Vaginal Cuff ClosureVaginal Cuff Closure
18181818
21
Automated Suture DevicesAutomated Suture Devices
RD 180RD 180TMTM and TKand TK®®
LSI SolutionsLSI Solutions
Single useSingle use
First used for heart valve surgeryFirst used for heart valve surgery
1919
First used for heart valve surgeryFirst used for heart valve surgery
Vaginal cuff closureVaginal cuff closure
EndostitchEndostitchTMTM
CovidienCovidien
Single useSingle use
Vaginal cuff closureVaginal cuff closure
RD 180RD 180TMTM and TKand TK®®
“Running Device”“Running Device” 5 or 10 mm5 or 10 mm
2020
“Titanium Knot”“Titanium Knot” Trims sutureTrims suture
Secures sutureSecures suture
Permanent clipsPermanent clips
RD 180RD 180TMTM and TKand TK® ® VideoVideo
2121
EndostitchEndostitchTMTM
10 mm10 mm
Shuttle needleShuttle needle
Option articulating tipOption articulating tip
2222
Option articulating tipOption articulating tip
Intracorporeal knot tying 18 cmIntracorporeal knot tying 18 cm
Extracorporeal knot tying 120 cmExtracorporeal knot tying 120 cm
EndostitchEndostitchTMTM
Comparative study of pyeloplasties and Comparative study of pyeloplasties and bladder neck suspensionbladder neck suspension Automated intracorporeal suturing versus Automated intracorporeal suturing versus
ti l t iti l t i
2323
conventional suturingconventional suturing
2323
EndostitchEndostitch ConventionalConventional PP
Stitch placementStitch placement 43 43 ++ 27 sec27 sec 151 151 ++ 24 sec24 sec <0.0001<0.0001
Knot tyingKnot tying 74 74 ++ 50 sec50 sec 197 197 + + 70 sec70 sec <0.0001<0.0001
Adams et al. 1995. Urology
EndostitchEndostitchTM TM VideoVideo
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EndostitchEndostitchTMTM with Barbed with Barbed SutureSuture
2525
0, 20, 2--0, 30, 3--0 V0 V--LocLoc
10,15,20 cm lengths10,15,20 cm lengths
2525
Suture ComparisonSuture ComparisonSutureSuture Name, SizeName, Size TypeType Absorption RateAbsorption Rate Tensile Tensile
Strength Strength
QuillQuill PolydioxanonePolydioxanone MonofilamentMonofilament Complete by 180 daysComplete by 180 days 80% at 14 days80% at 14 days80% at 28 days80% at 28 days
V LocV Loc VV--LocLocTMTM 9090 MonofilamentMonofilament Complete 90Complete 90--110 days110 daysC l t b 180 dC l t b 180 d
75% at 14 days75% at 14 days
2626
VV--LocLocTMTM 180180 Complete by 180 daysComplete by 180 days 65% at 21 days65% at 21 days
RD 180RD 180 Strongsorb 2Strongsorb 2--00Monoglide 2Monoglide 2--00Monoglide 0Monoglide 0
MultifilamentMultifilamentMonofilament Monofilament MonofilamentMonofilament
Complete 60Complete 60--110 days110 daysComplete < 110 daysComplete < 110 daysComplete < 110 daysComplete < 110 days
49% at 21 days49% at 21 days77% at 21 days77% at 21 days77% at 21 days77% at 21 days
EndostitchEndostitch Polysorb3Polysorb3--00Polysorb 2Polysorb 2--00Poysorb 0Poysorb 0
MultifilamentMultifilament Complete 56Complete 56--70 days70 days 30% at 21 days30% at 21 days
Cost $$$Cost $$$
QuillQuill $20$20--60 60
VV--LocLoc VV--Loc 90 $20Loc 90 $20VV--Loc 180 $23Loc 180 $23
2727
VV Loc 180 $23Loc 180 $23
RD 180 + TKRD 180 + TK RD 180 $175 eachRD 180 $175 eachTK Device $150 eachTK Device $150 each53” suture $32 each53” suture $32 eachTi Knot clips $35 pack of 12Ti Knot clips $35 pack of 12
EndostitchEndostitch Device $140Device $140--150150Suture $20Suture $20--2828VV--Loc Suture $57Loc Suture $57
ReferencesReferences Adams JB, Shulam PG, Moore RG, Partin AW, and Kavoussi LR. New Laparoscopic Suturing Adams JB, Shulam PG, Moore RG, Partin AW, and Kavoussi LR. New Laparoscopic Suturing
Device: Initial Clinical Experience. Urology 1995;46(2):242Device: Initial Clinical Experience. Urology 1995;46(2):242--245.245.
Alessandri F, Remorgida V, Venturini PL, and Ferrero S. Unidirectional barbed suture versus Alessandri F, Remorgida V, Venturini PL, and Ferrero S. Unidirectional barbed suture versus continuous suture with intracorporeal knots in laparoscopic myomectomy: a randomized study. continuous suture with intracorporeal knots in laparoscopic myomectomy: a randomized study. JMIG 2010;17(6):725JMIG 2010;17(6):725--9. 9.
Angioli R, Plotti F, Montera R, Damiani P, Terranova C, Oronzi I, Luvero D, Scaletta G, Muzii Angioli R, Plotti F, Montera R, Damiani P, Terranova C, Oronzi I, Luvero D, Scaletta G, Muzii L, and Panici PB. A new type of absorable barbed suture for use in laparoscopic myomectomy. L, and Panici PB. A new type of absorable barbed suture for use in laparoscopic myomectomy. Int J Gynecol Obstet. 2012;117:220Int J Gynecol Obstet. 2012;117:220--223.223.
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Donnellan NM and Mansuria SM. Small bowel obstructing resulting from laparoscopic vaginal Donnellan NM and Mansuria SM. Small bowel obstructing resulting from laparoscopic vaginal cuff closure with a barbed suture. JMIG 2011;18(4):528cuff closure with a barbed suture. JMIG 2011;18(4):528--30.30.
Einarsson JI, Chavan NR, Suzuki Y. Use of bidirectional barbed suture in laparoscopic Einarsson JI, Chavan NR, Suzuki Y. Use of bidirectional barbed suture in laparoscopic myomectomy: an evaluation of perioperative outcomes, safety, and efficacy. 2011;18(1):92myomectomy: an evaluation of perioperative outcomes, safety, and efficacy. 2011;18(1):92--5.5.
Einarsson JI, GrazulEinarsson JI, Grazul--Bilska AT, and Vonnahme KA. Barbed vs standard suture:randomized Bilska AT, and Vonnahme KA. Barbed vs standard suture:randomized singlesingle--blinded comparison of adhesion formation and ease of use in an animal model. JMIG blinded comparison of adhesion formation and ease of use in an animal model. JMIG 2011;18(6):7162011;18(6):716--19.19.
Greenberg JA, Einarsson JI. The use of bidirectional barbed suture in laparoscopic myomectomy and total laparoscopic hysterectomy. JMIG 2008;15(5):621-3.
Miller J, Zaruby J, and Kaminskaya K. Evaluation of a barbed suture device versus conventional suture in a canine enterotomy model. J Invest Surg 2012;25(2):107-11.
Siedhoff MT, Yunker AC, Steege JF. Decreased incidence of vaginal cuff dehiscence after laparoscopic closure with bidirectional barbed suture. JMIG 2011;18(2):218-223.
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CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as
the 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 Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which
recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).
California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws
identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org
Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from
discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national
origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the
program, the importance of the services, and the resources available to the recipient, including the mix of oral
and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: 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 English
Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis 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 any
need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.
Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every
California state agency which either provides information to, or has contact with, the public to provide bilingual
interpreters as well as translated materials explaining those services whenever the local agency serves LEP members 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 guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.
US Population
Language Spoken at Home
English
Spanish
AsianOther
Indo-Euro
California
Language Spoken at Home
Spanish
English
OtherAsianIndo-Euro
19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%
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