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Laparoscopic
Tissue approximation
Dr.S.Easwaramoorthy
MS FRCS(England) FRCS (Glasgow) FRCS (Edinburgh)
Head of Dept of Min...
2 D Image
No depth Perception
No tactile feedback
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 s...
Learning Objectives
• Working knowledge of Suturing Equipments
• Ergonomics for Suturing
• Tissue approximation
– Intra co...
Laparoscopic Suturing
Equipments
• Needle Holders
• Knot pushers
• Suture Materials
HD Camera
30 degree telescope Good Ass...
Invest on Good Needle Holders
Tip
Tungsten carbide
Diamond coating
Straight/Curved
Needle holders
Active hand Needle holder
Assisting hand Needle grasper
Knot Pushers
Welcome Additions…
Endo Stitch
Self righting Needle holder
Repair of Hiatus with Endostitch
Suture Material
• Before selecting, Consider following qualities
– Absorbability/ Strength/tissue reaction
– Handling char...
Suture needles
Straight Needle
Ski Needle
Curved Needle
25mm
½ circle
Learning Objectives
• Working knowledge of Suturing Equipments
• Ergonomics for Suturing
• Tissue approximation
– Intra co...
Different Ball Game!
Open Surgery suturing
 Fast
 Ergonomics: Optional
Laparoscopic Suturing
 Slow and steady
 Magnifi...
Ergonomics
• Straight Line principle
• Triangulation
• Manipulation angle
• Elevation angle
• Low lying table
• Gaze down ...
Base Ball Diamond Concept
& Triangulation
Monitor
S
C
R
L
P
Manipulation angle
Azimuth Angle
Manipulation Angle
30-45 degree
60-90 degree
Ergonomics of Hand Instruments
• Tip
– Range of movements
• Conventional Vs Robotic instrument: 4: 7
Da Vinci Robot
Wrist like action
PrecisionPrecision
Ergonomics of Hand Instruments
• Tip
– Range of movements
• Conventional Vs Robotic instrument
• Length of the shaft
Fulcrum Effect of Hand Instruments
1: 1
Ergonomics of Hand Instruments
• Tip
– Range of movements
• Conventional Vs Robotic instrument
• Length of the shaft
• Han...
Ergonomic handles…
Surgeon’s Stance
Ideal relaxed stature Tiring
Ideal Relaxed Position
-straight head, in the axis of the trunk,
without rotation or extension of the cervical spine;
- sh...
Learning Objectives
• Working knowledge of Suturing Equipments
• Ergonomics for Suturing
• Tissue approximation
– Intra co...
I can recognize a good surgeon ,
not from how he cuts,
but
from how he sews!
Johan Mikulicz Radecki
1850-1905
Critical Steps of Suturing
1. Introduction of Needle
2. Grasping the Needle
3. Tissue Penetration
4. Knotting
Introduction of Needle
• Through 10mm port (with reducer)
– Non dominant hand port
– Hold the suture and not the needle
• ...
Grasping the needle
• Dominant hand port(right hand)
• Grasp with the tip of the needle holder
• Grasp at the ‘Sweet spot’...
Needle discipline
•A held needle should always be in view.
•A trailing needle is a safe needle
Types of Knots
• Granny knot
• Square knot
• Slip knot to square knot
• Surgeon’s Knot
• Aberdeen knot
• Dundee Jamming Sl...
Surgeon’s Knot
Guidelines for Suturing
• The Passive and Active role of the holders
• The formation of the initial “C’ and a tail
• The u...
Slip Knot to Square knot
Continuous Suturing
Laparoscopic Bowel Anastomosis
Key points
• Port positioning
• Good communications with your assistant
• Positioning of su...
Learning Objectives
• Working knowledge of Suturing Equipments
• Ergonomics for Suturing
• Tissue approximation
– Intra co...
Extra corporeal knots
• Roeder Knot
• Meltzer Knot
• Tayside knot
Roeder’s Knot
No 2 Chromic Catgut
Eg: Appendix base
Extra corporeal Knotting
Meltzer Knot
1-0 or 2-0 Vicryl
Eg: Cystic duct
Tayside Knot
1-0 or 2-0 PDS
Eg: Azygos vein
Learning Objectives
• Working knowledge of Suturing Equipments
• Ergonomics for Suturing
• Tissue approximation
– Intra co...
Staplers: Types & Sizes
Gastric Bypass
Anterior Resection
Types
Linear staplers.
Circular staplers.
Color codes
White - sm...
Guidelines for Staple Anastomosis
•Port positions for stapling
•Stay sutures for tensioning
•Enterotomy positioning and si...
It is not practice that makes perfect
It’s perfect practice that makes perfect!
- Vince Lombardi,
American Foot ball Coach...
laparoscopic suturing
laparoscopic suturing
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laparoscopic suturing

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ergonomics and tricks of the trade in laparoscopic tissue approximation

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laparoscopic suturing

  1. 1. Laparoscopic Tissue approximation Dr.S.Easwaramoorthy MS FRCS(England) FRCS (Glasgow) FRCS (Edinburgh) Head of Dept of Minimal Access Surgery Examiner, RCS of Edinburgh Executive Member, South Zone IAGES
  2. 2. 2 D Image No depth Perception No tactile feedback
  3. 3. 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
  4. 4. Learning Objectives • Working knowledge of Suturing Equipments • Ergonomics for Suturing • Tissue approximation – Intra corporeal Suturing – Extra corporeal Suturing – Staplers in Laparoscopy
  5. 5. Laparoscopic Suturing Equipments • Needle Holders • Knot pushers • Suture Materials HD Camera 30 degree telescope Good Assistants
  6. 6. Invest on Good Needle Holders Tip Tungsten carbide Diamond coating Straight/Curved
  7. 7. Needle holders Active hand Needle holder Assisting hand Needle grasper
  8. 8. Knot Pushers
  9. 9. Welcome Additions… Endo Stitch Self righting Needle holder Repair of Hiatus with Endostitch
  10. 10. 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
  11. 11. Suture needles Straight Needle Ski Needle Curved Needle 25mm ½ circle
  12. 12. Learning Objectives • Working knowledge of Suturing Equipments • Ergonomics for Suturing • Tissue approximation – Intra corporeal Suturing – Extra corporeal Suturing – Staplers in Laparoscopy
  13. 13. Different Ball Game! Open Surgery suturing  Fast  Ergonomics: Optional Laparoscopic Suturing  Slow and steady  Magnification effect  Choreographic movements  Ergonomics: Vital  Triangulation  Manipulation angle
  14. 14. Ergonomics • Straight Line principle • Triangulation • Manipulation angle • Elevation angle • Low lying table • Gaze down view
  15. 15. Base Ball Diamond Concept & Triangulation Monitor S C R L P
  16. 16. Manipulation angle Azimuth Angle Manipulation Angle 30-45 degree 60-90 degree
  17. 17. Ergonomics of Hand Instruments • Tip – Range of movements • Conventional Vs Robotic instrument: 4: 7
  18. 18. Da Vinci Robot Wrist like action PrecisionPrecision
  19. 19. Ergonomics of Hand Instruments • Tip – Range of movements • Conventional Vs Robotic instrument • Length of the shaft
  20. 20. Fulcrum Effect of Hand Instruments 1: 1
  21. 21. Ergonomics of Hand Instruments • Tip – Range of movements • Conventional Vs Robotic instrument • Length of the shaft • Handle design
  22. 22. Ergonomic handles…
  23. 23. Surgeon’s Stance Ideal relaxed stature Tiring
  24. 24. 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
  25. 25. Learning Objectives • Working knowledge of Suturing Equipments • Ergonomics for Suturing • Tissue approximation – Intra corporeal Suturing – Extra corporeal Suturing – Staplers in Laparoscopy
  26. 26. I can recognize a good surgeon , not from how he cuts, but from how he sews! Johan Mikulicz Radecki 1850-1905
  27. 27. Critical Steps of Suturing 1. Introduction of Needle 2. Grasping the Needle 3. Tissue Penetration 4. Knotting
  28. 28. 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
  29. 29. 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
  30. 30. Needle discipline •A held needle should always be in view. •A trailing needle is a safe needle
  31. 31. Types of Knots • Granny knot • Square knot • Slip knot to square knot • Surgeon’s Knot • Aberdeen knot • Dundee Jamming Slip Knot
  32. 32. Surgeon’s Knot
  33. 33. 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
  34. 34. Slip Knot to Square knot
  35. 35. Continuous Suturing
  36. 36. Laparoscopic Bowel Anastomosis Key points • Port positioning • Good communications with your assistant • Positioning of sutures, especially at the corners • Spacing the sutures (remember the magnification) • Tensioning of sutures
  37. 37. Learning Objectives • Working knowledge of Suturing Equipments • Ergonomics for Suturing • Tissue approximation – Intra corporeal Suturing – Extra corporeal Suturing – Staplers in Laparoscopy
  38. 38. Extra corporeal knots • Roeder Knot • Meltzer Knot • Tayside knot
  39. 39. Roeder’s Knot No 2 Chromic Catgut Eg: Appendix base
  40. 40. Extra corporeal Knotting
  41. 41. Meltzer Knot 1-0 or 2-0 Vicryl Eg: Cystic duct
  42. 42. Tayside Knot 1-0 or 2-0 PDS Eg: Azygos vein
  43. 43. Learning Objectives • Working knowledge of Suturing Equipments • Ergonomics for Suturing • Tissue approximation – Intra corporeal Suturing – Extra corporeal Suturing – Staplers in Laparoscopy
  44. 44. Staplers: Types & Sizes Gastric Bypass Anterior Resection Types Linear staplers. Circular staplers. Color codes White - small gut. Blue / Gold - stomach (except pylorus). Green - pylorus / redo surgery.
  45. 45. 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
  46. 46. 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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