Need for Laparoscopic Suturing1

Minimal access surgery poses a challenge to the surgeon right from the word go. It is in no way similar to the traditional laparotomic approach the students master at medical schools. The beginner first passes the hurdles of newer techniques, in the gyne endoscopic operation theater. It takes time to get used to the lack of depth perception as the procedure is viewed on a two-dimensional video screen, there is lack of direct tactile feel of the tissue. Those who are able to adjust to this newer way of working with long handled instruments looking at a video screen away from the surgical field, survive. The survivors then carry out simpler procedures, which may initially not require suturing, as it may sound quite intimidating in the beginning to introduce curved or straight needles in the abdominal cavity. But the followers of this unique modality of surgery, i.e. minimal access soon realize that without recourse to extracorporeal or intracorporeal suturing, they are left with very few surgical procedures in their armamentarium.

Certain procedures such as pelvic floor reconstruction and myomectomy, or the repair of lacerations of the bowel or bladder are still best accomplished by a suture-based approach. Prescient pioneers such as Courtney Clarke of Canada and Kurt Semm of Germany demonstrated that, with creativity, practice and patience, most, if not all the techniques developed for “open” surgery could be applied to endoscopically directed procedures. Clarke, in 1972, first described his set of 2instruments and a technique that could be used to suture-ligate tissue and transfer standard knots created extracorporeally into the peritoneal cavity via endoscopic ports or cannulas.

Semm demonstrated that pre-tied knots and loops could be introduced, placed around defined pedicles for secure and hemostatic ligation. Although these techniques received scant attention when first introduced, in the late 1980s and early 1990s endoscopic suturing and knot tying was rediscovered by surgeons such as Reich, and Corfman. Other innovators have added to the currently available list of needle drivers, suture positioners, knot manipulators and techniques that collectively allow for the application of suturing techniques to virtually any procedure. While many of these techniques have been published, there exist a variety of effective nonpublished variations. After an early phase of mastering simpler procedures and having gained sufficient proficiency in basic laparoscopic skills, it is quite natural for the endoscopist to progress to more advanced procedures which demand suturing back, the intended or accidental incisions made in the body tissue.

In laparoscopic surgery, innovators tried hard to bring in industry- based innovations to replace the traditional laparotomic suturing. Earlier innovations like clips, staples, Endo GI fires, fibrin glue, tackers, etc. were all directed towards a simpler shortcut to suturing. But in any modality of surgery and especially more so in gynecology, certain procedures like Myomectomy, pelvic floor repair and tubal recanalization cannot be carried out utilizing the above. Also the invariable risk of injury to bladder, bowel and ureter must be tackled only by suturing. So, this poses a challenge to progressive endoscopists and they have to embrace the fascinating world of laparoscopic suturing.

The art and science of laparoscopic suturing is neither too complex to understand, nor too difficult to master. Most critical to the successful use of the suturing techniques in laparoscopy is appropriate training at a dedicated training facility. It implies a long learning curve more so, because initially the techniques are required less frequently.

Laparoscopic surgeons often avoid suturing laparoscopically. They complain that laparoscopic suturing is cumbersome and too difficult to learn. Now that laparoscopic gynecologic surgery is an accepted method for treatment, there is a greater need for laparoscopic suturing skills. Just as one must be able to suture proficiently to perform open gynecologic surgeries, one must also be able to suture effectively when undertaking laparoscopic cases such as hysterectomy, prolapse repair, advanced endometriosis and other advanced endoscopic procedures.3

Endoscopic surgery is speedily being a well-known option to traditional procedures for variety of diseases and many of these procedures may need the employment of laparoscopic suturing. Laparoscopic ligation and suturing can be used for approximation of tissues and it is also an effective way of delivering hemostasis. The adaptation of tissue and suturing for hemostasis and reformation of anatomic components has been considered probably the most demanding of endoscopic technical skills. Endoscopic procedures are performed by taking a look at a 2-dimensional TV screen with as many as 6 times magnification, eliminating depth perception and the tactile feeling of the tissues; this involves significant hand - eye coordination. The state-of-the-art endoscopic procedures demand the laparoscopic surgeon to master suturing. Each and every surgeon performing laparoscopic procedures ought to be extensively acquainted with basic principles of knotting and suturing.

So, earlier attempts at applying these techniques in the operating room will be inappropriate, inefficient and at worst, unsafe. When the trainee tries doing all this instantly in the patient, it could wreak havoc and dampen his morale for another couple of months. So, it is highly recommended that the prospective laparoscopist who contemplates suturing, master his skills on a pelvic trainer. The most rudimentary trainer could be made using a cardboard box with a video camera attached to a color television. This gives the trainee ample opportunity to master the suturing skills within a home setting. Another trainer could be made utilizing a simple inexpensive small, sting camera worth 10 dollars, which transfers the images to the TV monitor. This obviates the need of telescope, light cable and a light source making it versatile to be used anywhere. Capturing images by computer software and videos during surgery and reviewing them later in the evening also adds a great deal to discover the shortcomings and improvising steps of improving them. Another versatile tissue for practicing suturing after one has acquired reasonable skills in introducing needles into the peritoneal cavity and learnt to grab the needle in the correct fashion is to practice the intracorporeal or extracorporeal knots on the round ligament. In the female pelvis, it is the best form of surgical tissue where one or two knots can be practiced as it is anterior, no danger of any important viscera close to it, does not bleed on passage of needle and lastly after the knot is done at the end of the procedure, the knot can be undone. Many times in simpler infertility evaluations when one gets time this could be easily accomplished. The author has learnt all newer knots and tried new needle holders on the round ligament itself. It is far safer to do a couple of knots on the round ligament rather than to jump on to a myomectomy 4and be unable to complete it. Therefore, a realistic progression from pelvic trainers and virtual simulators to relaxed suturing on the round ligament and then finally to an intended or accidental surgical tissue approximation by suturing should be attempted. At least, the author has herself learnt and mastered suturing this way.

Gynecological endoscopists are required to put their suturing skills to test while carrying out a myomectomy. Earlier limitations of myoma no more than 5 cm made way for extracorporeal knot tying. But now, as endoscopic myomectomy knows no boundaries, the only limitation is the surgeons suturing capability. A 10 cm deep myoma would require extensive suturing of the myoma bed preferably in two or three layers. Here's where the real need for suturing in a more advanced manner arises. Laparoscopically assisted vaginal hysterectomy (LAVH) was the beginning towards offering the benefits of minimally invasive surgery and was quickly embraced by gynecologists all over. But soon the limitations of hybrid surgery, having three distinct steps of laparoscopic, vaginal and then final laparoscopic route made it rather cumbersome. Total laparoscopic hysterectomy wherein all steps of hysterectomy are done by the laparoscopic route, started gaining more popularity. It also became more versatile as pelvic reconstruction could be done at the same time and bigger uteri could be dealt with by laparoscopy. But transition from LAVH to TLH (Total laparoscopic hysterectomy) is possible only if one has adequate suturing skills. So once again there is need to learn intra- or extracorporeal suturing to effectively tackle the uterine arteries and laparoscopic closure of vaginal vault with vault suspension.

Laparoscopic microsurgery is another exciting field which puts the in vitro fertilization (IVF) specialist at bay and can empower the endoscopist to accomplish the same microsurgical feats as the open microsurgeon. Without recourse to operating microscope, laparoscopic microsurgery easily carries out tubo-tubal reanastomosis, tubo-cornual implantation, eversion of fimbria at neosalpingostomy and many other procedures. With the use of specially designed, dedicated instruments outstanding surgeries can be carried out. However, the bottom line remains acquiring proficiency in suturing. Deft intraoperative recognition and management of bladder, bowel and ureteric injuries is imperative for safe outcome of the procedure, avoidance of prolonged morbidity or even mortality and future litigations.

A deft endoscopist is not adjudged by surgical dexterity alone but rather by promptness to recognize intraoperative visceral injury and steadily asking for reparative procedure either himself or a colleague like a urologist or colorectal surgeon. In the face of a surgical disaster to gather one's wits and carry out necessary repair with the help of a 5specialist goes a long way in avoidance of medicolegal complications. Needless to say, this is a situation where the guts and skills of a laparoscopist are put to test. The more proficient one is in suturing, the more easily the complication is tidied over. So, if, the surgical team is efficient to do the required bowel and bladder repair the surgical morbidity does not alter much. The experienced surgeon you summon then, remains on observer and sort of just approves of your surgical procedure, rather than doing it himself. This is more of a medicolegal drill which is good to be followed. The literature is full of several case reports of bladder, bowel, and ureteric injury repair. They should only act as a stimulus to learn suturing and be able to tide a similar situation comfortably rather than scare an endoscopist. As the world's female population is living longer so are the problems of pelvic floor defects surfacing in larger proportions. Increasing awareness that these defects like stress urinary incontinence, pelvic organ prolapse viz. cystocele, rectocele, posthysterectomy vault prolapse can be repaired laparoscopically, a gyne endoscopist is repeatedly approached by patients concerning them. The most efficient way of treating them is, a thorough knowledge of surgical anatomy of the pelvic floor and then higher level of suturing abilities.

There is no shortcut except to be a master of laparoscopic suturing to be able to give equal or better results than vaginal or abdominal route. For the general surgeons, laparoscopic cholecystectomy becomes a surgery, which they can easily embrace. This is simply due to the fact that it can be performed without a single tie or suture. However, if one wishes to perform anything other than cholecystectomy, it is then imperative that the methods of securing knots, placing sutures and approximating tissues be learnt. Laparoscopic hernia repair, other bowel and bladder surgeries all require suturing skills.

This introduction to the historical development of suturing skills and their applications in the modern day endoscopic practice should be a starting point for understanding, learning and then mastering the skills of laparoscopic suturing. The only ingredients to success appear to be a passion for endoscopic surgery, ability to dedicate sufficient time for practicing on pelvic trainers and a sustained morale to overcome initial failures. A drive for learning supported by perseverance and diligence will definitely transform an average endoscopist to an endosuturing wizard.

Of the suturing and knot tying methods adopted for laparoscopic surgery, the intracorporeal method remains the most difficult to master. Performing extracorporeal knot is easy, however if delicate tissue like rectum, bladder and ureter is to be sutured than extracorporeal knot 6tying may lead to tearing of tissue. So, it is important to perform intracorporeal knot tying.

Complications can occur during any form of surgery. When it occurs during laparotomy, the injury can easily be repaired and no one will know about the complication. However, when it occurs during laparoscopy the inability to repair the injury laparoscopically will lead to laparotomy. Therefore, all laparoscopic surgeons should be familiar with laparoscopic suturing and with both intracorporeal and extracorporeal knot tying. These techniques are useful for ligating blood vessels, approximating tissue planes or creating anastomoses. The ability to suture laparoscopically opens the door to performing more complex surgical procedures. This means that many operations that have traditionally been performed at laparotomy may now be accomplished laparoscopically.