Laparoscopic Skills: Suturing 101

The suture should be grasped about 2 centimeters from the swedge when loading in the driver to pass through the trocar without getting stuck.

It is easier to pick up a needle that is resting stationary on tissue than one that is moving.

The needle should be oriented parallel to the line of tension you are hoping to create in the tissue.

Grasping the needle approximately 1/3 of the way from the swedge provides maximum tissue penetration without undue torque on the needle.

Tissue should be entered at a right angle, supinating to follow the curve of the needle just like you would outside the body.

It is important to keep instruments in view at all times and minimize needle handling if possible during laparoscopic suturing.

Making a fulcrum with the left hand when bringing the needle through avoids traumatizing tissue as you pull through.

Suture should be gathered where you have the most room on your screen, either above or below the equator, and this equator position determines the most efficient way to throw knots.

Keeping a short tail allows for economy of motion and material during laparoscopic suturing.

When working laparoscopically, you should use all degrees of freedom including moving instruments in and out, pivoting at the port, and supinating and pronating to create the biggest loop through which the left hand can travel.

If you weigh the suture above the equator, your tying instrument should begin tying the knot by going below the loop to avoid trapping the needle end of the suture within the knot.

Working directly over the knot increases your length of working suture.

The loop is rotated by supinating, then rotated back down toward the tissue by pronating to create the first throw.

When grasping the tail with your hand pronated, if the 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 to ensure the tail stays short.

The tail should be placed deliberately where it will be easy to find later; when going below the loop to tie, the tail should be placed down so the grasping instrument does not get in the way.

When the needle end of the suture is below the equator, you start with your tying instrument above the loop.

Each time you regrasp the suture to change hands, make a conscious decision to either grasp it on the knot side of the driver to shorten your loop, or on the needle side to lengthen it.

A short loop facilitates snugging down the knot in one motion rather than multiple motions.

Square knots require that you snug your knot down in the tissue plane, parallel to the axis of the knot.