Laparoscopic Skills: Suturing 101

Welcome to our tutorial on the basics of laparoscopic suturing. Begin by loading the suture in the driver of your dominant hand, grasping the suture about 2 centimeters from the swedge to pass through the trocar without getting stuck. It helps to visualize both tips of your driver to avoid fumbling. Once inside, you should rest the needle on the tissue. It's easier to pick up something stationary. Close the jaws gently to allow rotation of the needle, and repositioning so that you can orient the needle parallel to the line of tension you're hoping to create in the tissue. Grasp the needle approximately 1/3 of the way from the swedge for maximum tissue penetration without undue torque on the needle. Next, you want to distract the tissue to give yourself a clear visual of where you're coming out in the tissue. Enter at a right angle, supinating to follow the curve of the needle just like you would outside the body. It's important to keep your instruments in view at all times and minimize needle handling if possible. Trust the needle left in the tissue. Bring the needle through by supinating your right hand. Make a fulcrum with your left hand to avoid traumatizing tissue as you pull through. Gather the suture where you have the most room on your screen, either above or below the equator. This sort of equator later determines the most efficient way to throw your knots. Keeping short tail allows for economy of motion and material. When working laparoscopically, you should be using all your degrees of freedom to make your life easier. In addition to moving your instruments in and out and pivoting at the port, it's important to supinate and pronate to create the biggest loop through which your left hand can travel. If you weigh the suture above the equator as we have here, your tying instrument should begin tying the knot by going below the loop. This avoids the potential complication of trapping the needle end of your suture within the knot. Working directly over the knot also increases your length of working suture. Rotate the loop by supinating. Now you want to rotate the loop back down toward the tissue by pronating, and this will create your first throw. Repeat the exercise to create a surgeon's knot. Grasp the tail with your hand pronated so that if your tail gets stuck in the knot, you can supinate your hand to flip the tail out. Begin snugging down the knot by pulling only with the needle end. This ensures your tail stays short. Be deliberate in placing your tail where it will be easy to find later, because we're going below the loop to make our tie, our tying instrument will end up below our grasping instrument, and so the tail should be placed down so that our grasping instrument doesn't get in the way. Here you can see how you should be setting up for tying when the needle end of your suture is below the equator. You'll start with your tying instrument above the loop. Throw the surgeon's knot in the same way as before, supinating and pronating to make your loops. Here's what happens when you tie on the wrong side of the loop. Each time you regrass the suture to change hands, make a conscious decision to either grass it on the knot side of the driver to shorten your loop, or on the needle side of the driver to lengthen it. A short loop facilitates snugging down the knot in one motion rather than multiple. Square knots require that you snug your knot down in the tissue plane, parallel to the axis of the knot.