Suturing and Tissue Approximation Shawn M. Garber

During the early stages of a surgeon's education, the techniques of tying knots and suturing and anastomosing tissue occupy a great deal of time and effort. Indeed, progress from assistant to surgeon is predicated upon one's ability to smoothly and reli­ ably perform these tasks. The initial enthusiasm for minimally invasive surgery was engendered by the devel­ opment of laparoscopic cholecystectomy, an operation that could be performed with­ out a single intracorporeal tie or suture. If one wishes to tackle anything other than cholecystectomy, then it is imperative that the methods of securing knots, placing sutures, and approximating tissue be learned. Indeed, it is also true that such skills may be germane to gallbladder surgery­ how else might one seal a rent in the gallbladder or close a dilated cystic duct? There are many differences between laparoscopic and open suturing. The apprecia­ tion of these differences allows surgeons to learn to adapt to the laparoscopic operat­ ing environment. The first difference is the lack of depth perception in laparoscopy, as the procedure is viewed on a two-dimensional video screen. Secondly, there is a lack of direct manual contact with the tissue. The remote technique of handling needle and thread with two instruments is considerably hampered by the length and rigidity of the instruments. It is difficult to achieve the correct needle position in the jaws of the needle holder or to drive it through the tissue in any desired direction, and it is chal­ lenging to maintain adequate suture tension. Restricted instrument mobility in laparo­ scopic surgery is another obstacle; for example, when passing a needle through tissue, the surgeon is confined by the cannula placement to a single arc of rotation perpen­ dicular to the axis of the instrument. Finally, the laparoscopic view is limited to a por­ tion of the body cavity and it is critical that instruments and needle always be followed to prevent iatrogenic injury. The best method of tissue approximation is determined by the type of procedure being performed and the technical skills of the surgeon. These methods include intra­ corporeal suturing, extracorporeal knotting, endoscopic staplers, endoscopic clips, automatic suturing devices, fibrin glue, and the biofragmentable anastomosis ring.