缝合指引

When the needle is introduced into the body, the view of the surgical field should be wide. Once the surgeon prepares to load the needle holder with a needle the camera view should be zoomed in on the tip of the needle holder and the needle itself to allow identification of the finer details required to load and angle the needle correctly. After the needle is placed through the tissue, the camera view should again be focused on the needle in order for it to be grasped. Finally, the needle is reset and tying the knot can begin. While the knot is being tied, the camera angle should again alternate between focusing closely on angling the needle and a wider view of the surgical site.

All laparoscopic suturing requires the use of both hands. Both instruments must be working in a coordinated fashion during the entire process.In general, try to ensure that the arms and shoulders are relaxed and when performing suturing one should be aware of posture, instrument motion, etc.One hand should feed the other in order for both instruments to work in a coordinated manner.

Needle holders have a locking system. This ratchet mechanism is generally of two different types: either a graduated ratchet (for example Olympus) or an “all-or-none” type. The graduate mechanism allows the surgeon to control the amount of force holding the needle in place. Applying additional pressure will engage the ratchet further. One can hear and feel the clicks as the ratchet teeth engage each other. In this scenario there is little danger of inadvertently releasing the needle. The “all-or-none design” only completely fixes the needle when maximum pressure is applied to the mechanism. The graduated ratchet allows for easy manipulation of the needle within the jaws, even when the mechanism is partially engaged. The jaws can be either smooth or serrated to allow for a light or strong grip on the needle. The instrument tip can be straight or slightly curved (left and right handed).Self-aligning designs have a bottom lever that is U-shaped in a cross-section and a top lever which is a narrow bar. When the jaws are closed, they will become correctly aligned perpendicular to the line of the jaws even if the needle is placed in the jaws at an oblique angle.
This kind of needle holder is intended for laparoscopic beginners although it is also useful to support the experienced surgeon in time efficient suturing.

To insert (and remove) the suture and needle through the trocar the suture should not be held at the needle. This is different to open surgery. A loosened needle during insertion or removal
can cause serious problems and a
lost needle is difficult to find inside the abdominal cavity.
Using a reduction tube inside a 10 mm trocar to introduce a needle into the patient is common practice and recommended by many surgeons.

The different steps are as follows:

• The needle holder is inserted into the reduction tube.
• The needle holder will grasp the suture approximately 3 cm behind the  needle.
• The needle is pulled into the reduction tube smoothly until the needle is completely covered and protected inside the tube.
• he reduction tube with the needle holder inside is inserted into the 10 mm trocar and passed through the abdominal wall of the patient. This is done under visual guidance until the needle can be seen coming out of the reduction tube.
• The left-hand grasper or assistant needle holder picks up the needle, approximately in the middle of the needle, with the needle tip oriented towards the left.
• Needle correction: The needle needs to be corrected before the needle holder can grasp it in the optimal position for driving. This is attained by the needle holder grasping the suture approximately 2 cm from the swage end of the needle and twisting it into an upright position.
• After the needle is corrected on the grasper, the needle holder can now grasp the needle at a point two-thirds away from the tip (or one-third from the swaged end of the needle).
  The angle of the needle to the needle holder shaft is now accomplished.
• The removal of the suture is done the same way as during insertion by grasping the suture close behind the needle.
• The reduction tube remains in place during the whole procedure.

The needle holder and the reduction tube are removed from the trocar simultaneously. The trocar itself is fixed into position using the right hand in order to avoid any unintended movement out of position. Under visual control the 10 mm trocar is removed using slow rotating movements. Then the trocars (5 mm) are removed by slow rotation, also under visual control. Finally the telescope trocar is removed. Trocar incisions may be closed by suturing, depending on the amount of trocars and the diameter of the trocars used. It is recommended to close a fascial incision with a diameter more than 5 mm by using suture for example by using a fascial closure needle.

Drive the needle vertically into the tissue and follow the needle curvature.
Roll the needle through tissue without tearing through it. By following this guideline, the needle will not be damaged and tissue damage can be minimized accordingly.

Incorrect needle manipulation can result in abnormal needle bending, increased tissue trauma and breakage of the needle. This can happen when the needle is grasped at the very end, or the stitch is not performed in a direction perpendicular to the tissue, or the tissue passage is not in line with the needle geometry.

Laparoscopic intracorporeal suturing is a complex task involving several integrated skills including needle handling, suturing and knotting. Generally, the suture should be as short as possible for the given task at hand. If the suture is too long it is difficult to find the end of the suture and that can lead to entanglement. If the suture length is too short, the end can pull through tissue accidentally before it is tied or leaves the surgeon with suture ends too short for tying with ease.

Intracorporeal suturing with the single knot technique can be performed by using needles and sutures known from conventional surgery. The single and most important issue is the length of the suture and the ability of the needle to pass through the trocar and the reduction tube. Stitch the needle vertically, follow the needle curvature by “rolling through the tissue” without tearing through it. After tissue penetration, the needle is best grasped with the needle holder at a 90° angle and a surgical knot is performed. The free needle holder is passed at least twice around the assistant needle holder or grasper holding the suture. The short end of the suture is grasped and the first double knot is tightened.
As in open surgery, at least two additional single knots are placed to secure the knot and to avoid unintentional knot opening.
Single knot interrupted suturing results in a very good tissue approximation but it takes time to perform and is difficult to do with a laparoscopic approach. Continuous suturing is much quicker and much easier to perform especially in laparoscopy.