State-of-the-Art Atlas and Textbook of Laparoscopic Suturing in Gynecology Nutan Jain
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1State-of-the-Art Atlas and Textbook of Laparoscopic Suturing in Gynecology2
3State-of-the-Art Atlas and Textbook of Laparoscopic Suturing in Gynecology
Second Edition
Edited by NUTAN JAIN MBBS MS (Obs & Gyne) FICOG FICMCH Endoscopic Surgeon and Infertility Specialist Vardhman Infertility and Endoscopy Centre Muzaffarnagar, Uttar Pradesh, India Forewords Victor Gomel Charles Edward Miller Ceana Nezhat Robert D Moore
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State-of-the-Art Atlas and Textbook of Laparoscopic Suturing in Gynecology
First Edition: 2006
Reprint: 2013
Second Edition: 2015
9789351524779
Printed at
5Dedicated to
Mrs Bhagwati Gada
My God Mother
Who has motivated and inspired me by her untenable spirit in her lifetime.
Her memories will always be my greatest treasure.
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7Contributors 11Foreword
After her successful multiauthor books Atlas of Endoscopic Surgery in Infertility and Gynecology and mini atlas Laparoscopic Surgery in Infertility and Gynecology, Dr Nutan Jain has led the production of this new interesting and useful text: State-of-the-Art Atlas and Textbook of Laparoscopic Suturing in Gynecology.
Suturing and sutures have been an integral part of surgery since its inception. Suturing via laparoscopic access poses challenges; it is certainly more difficult and time consuming to acquire proficiency in laparoscopic suturing compared to suturing by open access. But, acquiring such proficiency empowers the laparoscopic surgeon to perform more advanced and demanding procedures efficiently, and to deal with most complications that may ensue.
The book covers various modes of laparoscopic suturing and suturing instruments, comprehensively in superbly illustrated chapters. Included are detailed chapters on extracorporeal and intracorporeal suturing, sliding knots, use of barbed sutures, and microsurgical, single port and robotic suturing; chapters on equipment, needle holders, knot pushers, and on pelvic trainers and simulators for teaching endoscopic suturing.
Yet, this book is much more than a book on laparoscopic suturing. Many of the chapters dealing with suturing include detailed description of techniques of specific surgical procedures. The book also contains excellent chapters on: dedicated endoscopic operating room, myomectomy, repair of ureter and bladder injury, appendectomy, chapters dealing with genital prolapse, and a chapter describing three different techniques of posterior colpotomy, etc.
This book is much more than a book on laparoscopic suturing. The book has 25 chapters authored by internationally recognized experts. Dr Nutan Jain, who has authored 8 of these chapters, must be congratulated for being able to bring together such an impressive cadre of authors. This book will certainly cover a void on an important aspect of laparoscopic surgery: suturing.
Victor Gomel md frcsc
Department of Obstetrics and Gynecology
University of British Columbia
Vancouver, BC, Canada
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13Foreword
“Oh, the Places You'll Go”—so is the title of the ever-popular children's book by Dr Seuss. Well, thankfully, the second edition State-of-the-Art Atlas and Textbook of Laparoscopic Suturing in Gynecology, edited by Dr Nutan Jain comprehensively and contemporarily takes the reader through the ever-expanding field of minimally invasive gynecologic surgery. In so doing, this up-to-date atlas and textbook certainly will become a reference for both experts as well as novices in endoscopic surgery. To make this possible, Dr Jain has assembled a veritable “Who's Who” list of two generations of internationally recognized thought leaders in minimally invasive gynecologic surgery. Interestingly, many of the suturing techniques, both conventional and robotic, are discussed from the view of multiple authors, thus, providing even greater depth of information for the reader. To coincide with the myriad of chapters involving surgical discussion.
This up-to-date atlas and textbook certainly will become a reference for both experts as well as novices in endoscopic surgery. One quickly realizes that the second edition State-of-the-Art Atlas and Textbook of Laparoscopic Suturing in Gynecology is not only well written and edited, but is simply beautiful as well.
The timeliest new chapter, given the recent concern raised due to the inadvertent spread of sarcomatosis tissue at the time of electromechanical morcellation, is devoted to keeping tissue extraction safe—posterior colpotomy and morcellation in a bag.
In my mind, it is only a matter of time for the second edition State-of-the-Art Atlas and Textbook of Laparoscopic Suturing in Gynecology to become a definitive work in our field.
Charles Edward Miller md
Charles E Miller MD and Associates
120 Osler Drive, Suite 100, USA
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15Foreword
Dr Nutan Jain has brought together a knowledgeable and diverse group of experts in assembling the second edition State-of-the-Art Atlas and Textbook of Laparoscopic Suturing in Gynecology. The text is filled with theory, understanding and experience. The drawings and illustrations are based on a complete understanding of the subject by leading authorities in their field.
In the last 30 years, minimally invasive surgery has evolved exponentially. Complex conditions, previously managed by laparotomy, are possible using a minimally invasive approach with similar or better results. Advancement in instrumentation has taken us from the traditional large incision with cutting and sewing to the miniature incision utilizing different energy sources. Improved visualization results in identification of subtle pathology and precise diagnosis and management of disease involving multiple organs.
The primary focus of the atlas is placed on the step-by-step technical aspects affording the reader the necessary skills and knowledge to offer minimally invasive treatment options to patients, resulting in higher quality of care. Accompanied by advances in instrumentation, new methods of training have been developed, furthering the adoption of minimally invasive surgery. Furthermore, suturing has become a mandatory skill for the minimally invasive surgeon to perform successful advanced surgeries. With the use of simulators in training, the learning curve has decreased and safety has improved. Simulation practice prior to training in the operating room has been shown to reduce patient complications, save lives, and improve outcomes in all endoscopic surgical disciplines. Technology has evolved to the point where ample training can occur before a surgeon steps foot in the operating room, thus removing the patient from the learning process.
This atlas provides a descriptive and detailed stepwise approach and is an excellent addition to any personal or reference library. It provides a comprehensive instruction from experts to assist future minimally invasive surgeons to excel in their practice and naturally provide better care to patients. A product of the wisdom of Dr Nutan Jain, this work represents a passage of knowledge from advanced laparoscopic surgeons from around the world to current and future generations of minimally invasive surgeons.
Ceana Nezhat md facs facog
Director
Nezhat Medical Center
Adjunct Clinical Professor
Stanford University
California, USA
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17Foreword
It is with great pleasure and honor to write the foreword for Dr Nutan Jain's second edition of State-of-the-Art Atlas and Textbook of Laparoscopic Suturing in Gynecology. Dr Jain needs to be congratulated on the second edition of her landmark initial textbook on the subject of laparoscopic suturing in the field of gynecologic surgery. To make it to a second edition demonstrates the quality and the success of the initial edition, with the current edition adding even more quality and relevance in the field of gynecologic laparoscopic suturing. Textbooks abound in our field of minimally invasive gynecologic surgery, however, Dr Jain's forward vision of publishing a novel textbook concentrating on the actual techniques of laparoscopic suturing to help surgeons achieve success in accomplishing succsessful surgical options throughout all of the fields of gynecologic surgery and its subspecialties is truly unique and groundbreaking.
Robotic surgery has recently come to the forefront of our field, however, one must ask the question “Why?” or “Why the Robotic approach and not just a straight laparoscopic approach?”. After all, robotic surgery really is classified as “Robotic Assisted Laparoscopic Surgery”…or as my partner Dr John R Miklos (a pioneer himself in Laparoscopic Pelvic Reconstruction Surgery) would say robotic surgery is “Laparoscopic surgery with training wheels”. We must ask ourselves why use the robotic approach when in the majority of our gynecologic surgeries it has not been shown to have any benefit at all over the traditional laparoscopic approach. Robotic surgery takes significantly longer, costs significantly more and offers no bettter visualization or better outcomes compared to traditional laparoscopic surgery. Many young surgeons will say that it is easier to learn how to suture with the robot, however, if this is the limiting factor, we would argue that with the appropriate motivation, dedication, time and practice, suturing laparoscopically can be accomplished just as easily and definitively more simply with a traditional laparoscopic approach.
Dr Jain's atlas and textbook on laparoscopic suturing makes achieving the goal of completing all surgeries via a minimally invasive approach that much easier. Current technology and new instrumentation are making laparoscopic suturing easier to learn and these are all highlighted in the new text. The textbook has a stepwise progression in all aspects of laparoscopic suturing including dedicated chapter on operating room set-up, the use of pelvic trainers and simulators, suturing equipment, basic fundamentals, different approaches to knot tying and then individual chapters on advanced gynecologic and urogynecologic procedures, and treatment of complications. The advent of Robotic Surgery has set the bar higher and surgeons and technology have answered and have shown that this can also be achieved via a more cost-effective laparoscopic approach. Over the last 8 years, there has been improvement in visualization technology with high-definition and 3D technology and this is throughout the text with higher-quality pictures. New technology has made laparoscopic suturing easier, less invasive and more efficient and Dr Jain demonstrates this with new chapters in second edition covering Single Port Suturing, the Use of Barbed Sutures in Gynecologic Surgery, Suturing in Extensive Endometriosis Cases, Microsurgical Laparoscopic Suturing Techniques and even a new chapter by CY Liu on Laparoscopic Appendectomy for the gynecologists.
Dr Nutan Jain deserves praise and congratulation for a textbook that stands well above most in our field. All possible applications of suturing have been covered with high-quality photographs and illustrations from experts in Global Endoscopy.
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Current controversies in our field are also covered in a timely and up-to-date manner with chapters on alternatives for power morcellation of fibroids and traditional non-mesh repairs for pelvic floor disorders. This book is a must for beginners to experts, from medical students to advanced laparoscopists. No matter what our level, we all need to continue to learn and pursue excellence.
Robert D Moore facog facs fpmrs
Director
Advanced Pelvic Surgery
International Urogynecology Associates of Atlanta and Beverly Hills
Atlanta Center of Laparoscopic Urogynecology
Adjunct Professor
Department of Obstetrics and Gynecology
Emory University School of Medicine
Atlanta, GA, USA
19Preface to the Second Edition
The first edition of the book was brought out in 2006 and was largely welcomed by endoscopic community as a much-needed text on comprehensive approach to laparoscopic suturing. It was highly acclaimed and was nominated by British Medical Journal (BMJ) as the “Book of the Year”. It was translated in Spanish and Chinese to reach a large number of physicians around the world.
Having served the noble cause of safe propagation of laparoscopic suturing for over a decade, there was a need to update chapters with newer techniques, high-quality pictures and add topics according to contemporary medical practice. Robotics was just establishing then and today it is very much a routine in many hospitals. Single port surgery has made its mark and is very much part of the surgical armamentarium so chapters to include both have been added.
Endometriosis, especially deep infiltrating endometriosis, has become so often diagnosed and treated, hence we have added an entirely new chapter to include various suturing applications when dealing with bowel, bladder and rectovaginal endometriosis.
With a shadow cast on laparoscopic morcellation, endoscopists need to be well versed with exact and different techniques of posterior colpotomy and suturing of the colpotomy site. A new chapter dedicated exclusively to posterior colpotomy addresses the present need.
With controversies regarding use of mesh, full chapter on ‘non-mesh’ conventional pelvic floor repair makes the text very update as of today's need.
Barb sutures have had a great impact on laparoscopic suturing. They have made it easier and rather more efficient, hence we have put in a whole new chapter to amply emphasize its role in modern-day laparoscopy.
Introducing, for the first time, is a new concept of “Chair Laparoscopy”. To tide over long suturing spells as in multiple myomas, suturing by a sitting surgeon has been technically discussed.
All other chapters on Hysterectomy, Myomectomy, Pelvic Floor Repair, Appendectomy and Microsurgical Suturing have been revised and retained with new pictures.
Suturing for bowel and bladder has been updated. With contents covering all possible aspects of gynecological laparoscopy, we have tried to give a most comprehensive text.
It has been our endeavor to clearly explain the knick-knacks of suturing in all possible ways and means.
With great hope and enthusiasm, we have brought out this second edition. I am confident that the second edition is a much more comprehensive text and will be a boon for enthusiast of learning endosuturing.
I am filled with a deep sense of fulfillment at the completion of this task and thank all my team mates for having put in their very best to bring out this book.
Nutan Jain
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21Preface to the First Edition
Today, minimally invasive surgery is a highly-acclaimed surgical modality amongst both patients and medical practitioners. It appears that laparoscopy is applicable in almost every clinical situation, be it a huge myoma, multiple laparotomies, extensive endometriosis or pelvic floor repair. Laparoscopic surgery is the answer to all of the above situations. This sea change from laparoscopy in “Challenging Situations” to laparoscopy becoming commonplace has been brought about exclusively by the increased manual dexterity in laparoscopic suturing. The approach is much bolder now, laparoscopic complications which occur in situations like bladder, bowel, ureter or vascular injury can now be managed in the same laparoscopic procedure without conversion to laparotomy. An average endoscopist can be transformed into an advanced endoscopic surgeon by acquiring proficiency in suturing. Anybody can do an LAVH (laparoscopically assisted vaginal hysterectomy) but the ones skilled in the art of endosuturing would gladly take a total laparoscopic hysterectomy and offer a Hi-McCall culdoplasty or a Burch colposuspension at the time. So, it can be aptly said “SUTURE IS FUTURE”.
This book has been crafted keeping in mind the indispensable need of every endoscopist, i.e. enabling or enhancing the suturing skills of laparoscopic surgeons. A group of dedicated endoscopic surgeons have toiled together to compile this textbook-cum-atlas, which covers each and every aspect of suturing. All possible know-how that a surgeon needs to have before starting and then mastering endosuturing is present within a single textbook. Not only has the text been written by the world's leading experts, the surgical techniques too are shown through high-quality pictures from actual surgeries.
The introduction emphasizes to the reader the need for effective suturing skills. The subsequent chapter deals with the required surgical armamentarium and operation theater facilities. In order to enable the surgeon to be more precise with what is needed for a particular surgery, separate chapter has been included which elaborates upon the appropriate choice of suture materials, needles and needle holders. The need and application of pelvic trainers and virtual simulators has been dealt with in exquisite detail. There are separate chapters to explain extracorporeal and intracorporeal suturing. Specific applications like sliding knots have been covered in an entirely different chapter. So the basics of endosuturing have been discussed in great detail and presented in a manner that is easy to understand and apply.
Pioneered by Dr Charles H Koh is the concept of ipsilateral suturing which is a major breakthrough in learning stress free, precise, targeted and prolonged suturing. An entire chapter has been dedicated to this concept and its clinical applications. This promises to take the reader through a complete journey of all the applications of laparoscopic suturing.
Hysterectomy, the most common surgical procedure can be more complete if the vault closure is done with a reinforcing Hi-McCall culdoplasty. The exact technique for this procedure has been described by the pioneer of this technique.
The section on laparoscopic management of myomas by laparoscopy and laparoscopic-assisted minilap (LAM) are duly covered in two separate chapters. Most challenging situation is suturing of deep multiple myomas and the exact technique has been dealt with very well.
Laparoscopic pelvic floor repair has been getting a lot of attention and is on its way to gaining the same acceptance as a laparoscopic hysterectomy. Gradually critics will be fewer and aspirants for learning to treat this day-to-day problem will be more as the proportion of elderly women in the world's population is increasing. Greater stress has been laid on elucidating the different techniques of suturing applications for stress incontinence, cystocele, rectocele, enterocele and posthysterectomy vault prolapse and nulliparous prolapse. There are several chapters describing the various ways of treating them like mesh and site-specific repair. This employs the use of both intracorporeal and extracorporeal suturing.
The next section deals with accidental or intentional repair of bowel, bladder and ureter. The dilemma of many before starting rectal mobilization for advanced endometriosis or hysterectomy with multiple cesarean sections. Once the surgeon is empowered to deal with hollow viscous injury, many surgical opportunities and challenges will lie ahead.
Applications in general surgery like hernia repair, gallbladder and appendectomy are all dealt with exclusively by experts in their field. It promises to be an equally beneficial atlas for the gynecologists and the general surgeons alike. All surgical procedures have been showcased through pictures.
Lastly, the latest and most advanced application of suturing, i.e. laparoscopic microsurgery has been extremely well elaborated and will instantly prompt the reader to venture into this new modality.
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Advances in Robotic suturing promise to make ‘endoscopic suturing wizards’ without the prerequisite for acquiring manual dexterity. The latest applications of robotic suturing have been amply highlighted by the pioneers in this field.
This atlas, with its unique theme and purpose, i.e. propagation of suturing applications, promises to be the most useful creation on laparoscopic suturing. The richness of text, references, and high-quality color photographs.
Nutan Jain
23Acknowledgments
It has been such a pleasure planning, working, executing and finally bringing out this State-of-the-Art Atlas and Textbook of Laparoscopic Suturing in Gynecology. Right from inception to the final completion, it has been a great learning experience. Though science knows no boundaries, interacting and working with so many renowned endoscopic surgeons from around the globe has been an memorable experience. It gave enormous insight into human behavior, differences in ethnic, linguistic and cultural practices, but the one thing that remained common was their commitment to endoscopic surgery. The keen desire to promote and propagate safe practices of endoscopic surgery was the common platform they shared, which brought them together. It was my endeavor to bring forth a book containing the best possible expertise from around the world on suturing.
I express my heartfelt gratitude to all contributing authors, pioneers in their specific fields who despite their busy schedules put in their best efforts to compile chapters of immense scientific value. Their valuable suggestions, constructive criticism and words of encouragement during the compilation of the book went a long way in keeping me motivated towards this task. Their valuable contributions collectively have taken the shape of a fine textbook and atlas which will enlighten gynecologists on laparoscopic suturing.
I profusely thank the Publishers M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India and especially Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President) and Mr Tarun Duneja (Director–Publishing), and their efficient team. They put in tremendous efforts to bring out this book timely and to give it excellent print and picture quality. It was a pleasant experience working with them.
My heart goes out to acknowledge all my friends and mentors who have nurtured my skills and enabled me to work for the cause of endoscopic surgery.
I would like to acknowledge the efforts of Dr Vandana Jain who has been very keen on this project and helped me a lot in the compilation of this book. Also, I would mention the efforts of my research fellows Dr Sonika Mann and Dr Swati Kanawa in helping me all through with the book chapters and pictures. Hope they have blooming careers in endoscopic surgery. I sincerely thank my own hospital staff especially Mr Ashish Jain and Mr Vishram Singh who have worked day and night for the compilation of this book. They deserve full credit for their excellent work and dedication.
I greatly appreciate the wholehearted support of all my family members. My husband, Dr Mukesh and children, Mansi, Amol, Anubhav and Vandana who have in their capacity been extremely caring and helpful and never complaining about the lesser time spent with them. Their unwavering support helped me tide over the difficult phases during the compilation of this book.
In the end, I would like to thank all my patients who have posed faith in me and the newer modality of endoscopic surgery. If I can assure safe propagation of more advanced endoscopic surgery by means of this atlas, which promises to sharpen the existing skills of endoscopists in suturing, it will be the ultimate fulfillment of a cherished dream.