Laparoscopic Suturing: Practical Tips
for Needle Management, Knot Tying and
Suture Use (Simulation Lab)
PROGRAM CHAIR
Aarathi Cholkeri-Singh, MD
PROGRAM CO-CHAIR
Joseph (Jay) L. Hudgens, MD
Angela Chaudhari, MD
Larry R. Glazerman, MD
Mark R. Hoffman, MD
Kathy Huang, MD
Hye-Chun Hur, MD
Gretchen E.H. Makai, MD
Nash S. Moawad, MD
Angela M. Pratt, MD
Sangeeta Senapati, MD
Jessica A. Shepherd, MD
Matthew T. Siedhoff, MD
Karen C. Wang, MD
AAGL acknowledges that it has received support in part by educational
grants and equipment (in-kind) from the following companies:
3-Dmed, Aesculap, Angiotech, CareFusion, Cook Medical, Covidien, Inc., CooperSurgical,
Ethicon Endo-Surgery, Inc., Ethicon Women’s Health & Urology, Karl Storz Endoscopy-America, Inc.,
Stryker Endoscopy, Richard Wolf Medical Instruments Corporation
Sponsored by
AAGL
Advancing Minimally Invasive Gynecology Worldwide
Professional Education Information Target Audience Educational activities are developed to meet the needs of surgical gynecologists in practice and in training, as well as, other allied healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME. Table of Contents Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 3 Port Placement, Needle Loading and Tissue Re‐approximation A. Cholkeri‐Singh .......................................................................................................................................... 5 Extracorporeal Knot Tying A. Cholkeri‐Singh .......................................................................................................................................... 9 Intracorporeal Knot Tying H.C. Hur ...................................................................................................................................................... 16 Suture Selection and Technologies Used in Gynecologic Laparoscopy K.C. Wang ................................................................................................................................................... 19 Cultural and Linguistics Competency ......................................................................................................... 24 PG 201
Laparoscopic Suturing: Practical Tips for Needle Management,
Knot Tying and Suture Use (Simulation Lab)
Aarathi Cholkeri-Singh, Chair
Joseph (Jay) L. Hudgens, Co-Chair
Faculty: Angela Chaudhari, Larry R. Glazerman, Mark R. Hoffman, Kathy Huang, Hye-Chun Hur,
Gretchen E.H. Makai, Nash S. Moawad, Angela M. Pratt, Sangeeta Senapati, Jessica A. Shepherd,
Matthew T. Siedhoff, Karen C. Wang
Course Description
This workshop provides an overview of laparoscopic suturing and knot tying techniques, which will
include both intracorporeal and extracorporeal knots. The course will offer hands-on suturing simulation
where experienced faculty will actively guide participants through the training steps. Various
applications for different suture materials and technologies utilized in gynecologic laparoscopy will also
be reviewed. The course is designed for gynecologists in practice who want to develop or improve their
suturing skills for immediate application in their surgical practice.
Course Objectives
At the conclusion of this course, the participant will be able to: 1) Manipulate and load a needle
laparoscopically for tissue reapproximation; 2) perform extracorporeal knots; 3) perform intracorporeal
knots; 4) outline the advantages, disadvantages, and clinical applications for extracorporeal versus
intracorporeal knots; 5) distinguish advantages and disadvantages of various suture materials, including
barbed suture; and 6) distinguish advantages and disadvantages of suturing technologies used in
laparoscopy.
Course Outline (SAME for AM and PM sessions)
8:00 Welcome, Introductions and Course Overview
A. Cholkeri-Singh
8:05 Port Placement, Needle Loading and Tissue Re-approximation
A. Cholkeri-Singh
8:20 Hands-on Training – Needle Loading and Needle Manipulation
All Faculty
9:00 Extracorporeal Knot Tying
A. Cholkeri-Singh
9:15 Hands-on Training – Extracorporeal Knot Tying
All Faculty
9:45 Questions & Answers
All Faculty
9:55 Break
10:10 Intracorporeal Knot Tying
H.C. Hur
1
10:25 Hands-on Training – Intracorporeal Knot Tying
All Faculty
11:05 Suture Selection and Technologies Used in Gynecologic Laparoscopy
K.C. Wang
11:20 Hands-on Training – Barbed Suture and Suturing Devices
All Faculty
11:50 Questions & Answers
All Faculty
12:00 Course Evaluation
CM
2
PLANNER DISCLOSURE
The following members of AAGL have been involved in the educational planning of this workshop and
have no conflict of interest to disclose (in alphabetical order by last name).
Art Arellano, Professional Education Manager, AAGL*
Viviane F. Connor
Consultant: Conceptus Incorporated
Frank D. Loffer, Executive Vice President/Medical Director, AAGL*
Linda Michels, Executive Director, AAGL*
Jonathan Solnik
Other: Lecturer - Olympus, Lecturer - Karl Storz Endoscopy-America
SCIENTIFIC PROGRAM COMMITTEE
Arnold P. Advincula
Consultant: CooperSurgical, Ethicon Women's Health & Urology, Intuitve Surgical
Other: Royalties - CooperSurgical
Linda Bradley
Grants/Research Support: Elsevier
Consultant: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharmaceuticals
Speaker's Bureau: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharm
Keith Isaacson
Consultant: Karl Storz Endoscopy
Rosanne M. Kho
Other: Honorarium - Ethicon Endo-Surgery
C.Y. Liu*
Javier Magrina*
Ceana H. Nezhat
Consultant: Intuitve Surgical, Lumenis, Karl Storz Endoscopy-America
Speaker's Bureau: Conceptus Incorporated, Ethicon Women's Health & Urology
William H. Parker
Grants/Research Support: Ethicon Women's Health & Urology
Consultant: Ethicon Women's Health & Urology
Craig J. Sobolewski
Consultant: Covidien, CareFusion, TransEnterix
Stock Shareholder: TransEnterix
Speaker's Bureau: Covidien, Abbott Laboratories
Other: Proctor - Intuitve Surgical
FACULTY DISCLOSURE
The following have agreed to provide verbal disclosure of their relationships prior to
their presentations. They have also agreed to support their presentations and clinical
recommendations with the “best available evidence” from medical literature (in
alphabetical order by last name).
Aarathi Cholkeri-Singh*
Joseph L. Hudgens
Consultant: Karl Storz Endoscopy-America
Angela Chaudhari*
Mark R. Hoffman*
Jian Qun (Kathy) Huang
3
Speaker's Bureau: Intuitve Surgical
Hye-Chun Hur*
Gretchen E.H. Makai
Other: Honorarium - Intuitve Surgical
Nash S. Moawad*
Angela M. Pratt*
Sangeeta Senapati*
Jessica A. Shepherd*
Matthew T. Siedhoff*
Karen C. Wang*
Asterisk (*) denotes no financial relationships to disclose.
4
Presented by:
Port Placement, Needle Loading,
& Tissue Re-approximation
Aarathi Cholkeri-Singh, M.D., FACOG
Jay L. Hudgens, M.D.
Center for Women’s Health
Owensboro, KY
Gratis Faculty University of Louisville
Department of Obstetrics, Gynecology, & Women’s Health
Disclosures
Objectives
Jay Hudgens, M.D.
Aarathi Cholkeri-Singh, M.D., FACOG
1. Present the different port placements
used in laparoscopic suturing
We have no financial relationships to disclose
2. Present a system for setting the needle
3. Discuss strategies for tissue reapproximation
System
Ipsilateral
1. Set the Needle
• Ergonomics
2. Reapproximate
• Assistant
3. Knot Tying
• One Sided

5

Contralateral
Suprapubic
• Ideal Triangulation
• Gravity
• Poor Ergonomics?
• Ergonomics?
• No Assistant
• Two Sided




Needle Holders
Straight Needle Holder
• Straight
• Curved
– For desired needle angles >135o
• Self-Righting
• Endo Wrist Articulating
– Hand-held
– Da Vinci Robot
Curved Needle Holder
Self-Righting Needle Holder
6
Endowrist Needle Holder
System
1. Set the Needle
2. Re-approximate
3. Knot Tying
Laparoscopic
Robotic
Needle Entry
System
• Set (perpendicular)
• Parallel ((tissue))
• Rotate (key)
Tie Knot
• Direct-trocar
• 5mm…..Backload
• Backloaded
• 8mm…..SH-1
8mm SH-1
• Abdominal Wall
• 10mm…CT-2 & CT-1
• 12mm…CT
• Reset
Setting the Needle
Setting the Needle
A-B-C
“A” = 2cm
from Swedge
“B” = 1/3
from Point
7
“C” = 1/3
from
Swedge
Setting the Needle
A-B-C
Right Hand
Left Hand
Right Hand Motion
System
• Set (perpendicular)
Novice
• Parallel ((tissue))
• Rotate (key)
Expert
Tie Knot
• Reset
Hiemstra et al JMIG 2011 vol. 18, pgs 494-499
What is the most important factor in
reproducible tissue re-approximation?
References
1. Joseph L. Hudgens, RP Pasic. Geometrically
Efficient Laparoscopic Suturing. 40th Global
Congress AAGL, 2011
A. Port placement.
B. Understanding the relationship between the
tissue, camera, and ports.
2 Resad P.
2.
P Pasic,
Pasic RL Levine.
Levine A Practical
Manual of Laparoscopy 2nd Edition. New
York: The Parthenon Publishing Group 2002
C. Use of mechanical suturing device to improve
efficiency and accuracy.
D. The type of suture and needle used.
3. Charles H. Koh. Laparoscopic Suturing in
the Vertical Zone. Endo Press 2008:
Tuttlingen, Germany
E. Not applicable to my practice.
8
Disclosures
 I have no financial relationships to disclose.
Aarathi Cholkeri‐Singh, M.D., FACOG
Clinical Assistant Professor of Obstetrics and Gynecology at UIC
Associate Director of Minimally Invasive Gynecologic Surgery
Director of Gynecologic Surgical Education at ALGH
Objectives
“… an unreliable suture knot can spoil the outcomes of an otherwise beautifully p
performed surgical procedure.”
g
p
 Review principles of knot security  Overview of applications of Extracorporeal Knots  Understand Extracorporeal Knot tying technique
p
y g
q
 Extracorporeal knot troubleshooting
‐ unknown author
 Video demonstrations of extracorporeal knot use in gynecologic surgery
Role of extracorporeal knots in laparoscopic surgery. www.laparoscopyhospital.com
Principles of Knot Security
1.
Suture Material
Type of Suture
2. Type of Knot
3. Surgical Technique
 Natural vs. Synthetic
 Natural i.e. Chromic
GOAL = tissue is approximated and secured

Tissue fluids alter ability to hold knot  Synthetic
 Multifilament
 Lie flat more readily secondary to less memory
 Monofilament
 Less tissue inflammation
 Slippage and weaken from surgical instruments
4. Length of cut end
 Friction is greater for braided multifilament than Sanz LE. Selecting the best suture material. Contemporary Ob/Gyn. 2001;57‐72.
Schubert DC, Unger JB, Mukherjee D, et al. Mechanical performance of knots using braided and monofilament absorbable sutures. Am J Obstet Gynecol. 2002;187(6):1438‐42.
monofilament suture
Goldenberg EA, Chatterjee A. Towards a better laparoscopic knot: using knot quality scores to evaluate three laparoscopic knot‐tying techniques. JSLS 2009;13(3):416‐9.
Sanz LE. Selecting the best suture material. Contemporary Ob/Gyn. 2001;57‐72.
.
Amortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐1602.
Role of extracorporeal knots in laparoscopic surgery. www.laparoscopyhospital.com
9
Type of knot
Suture Length
Intracorporeal
 Single‐use suture, minimum length of suture should be 27 inches (70 cm) – standard length
Extracorporeal
Sliding knot
•Coefficient of friction not q
y
equally distributed between suture ends
•Each end of suture enters and leaves knot in same direction
•One axial strand is held under tension as the other ties around it
Square knot
•Coefficient of friction equally distributed between suture ends
•Each end of suture enters and leaves knot in opposite direction
 Multiple‐use or purse‐string suture, recommend length of suture to be minimum 48 inches (122 cm)
Schubert DC, Unger JB, Mukherjee D, et al. Mechanical performance of knots using braided and monofilament absorbable sutures. Am J Obstet Gynecol. 2002;187(6):1438‐42.
Amortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐1602.
Laparoscopic Knots
Laparoscopic Knots
 Amortegui et al, Surg Endosc 2002
 1 surgeon, 7 types of knots
 140 knots conventional vs. 140 knots laparoscopic
 2‐0 braided polyester
b id d l
 4‐6 throws  Knots measured for breaks using tensiometer and knot slips >3mm S
Sliding Knot
1 or 2 indicates number of flat square knots
X
throw in opposite direction from previous
=
throw in same direction as previous
//
change of axial strand and next throw turns in same direction as previous
# change of axial strand and next throw turns in opposite direction from previous
Amortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐1602.
Amortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐1602.
Laparoscopic Knots
Laparoscopic Knots
Intracorporeal Square Knots
 Goldenberg et al, JSLS 2009
Extracorporeal Sliding Knot

3 surgeons, 100 knots, 2‐0 silk, 4 throws measured for knot slips and breaks using tensiometer
Extracorporeal square knots
vs. Intracorporeal slip‐square vs. Intracorporeal flat‐square  These configurations had superior tensile strength to others tested in laparoscopic group (p<0.05)
Figure 2. A graphical representation of the Knot Quality Score
(KQS). It is based on the quartiles of the variable. The rectangular
box corresponds to the lower quartile and the upper
quartile. The line in the middle is the median.
 No significant difference between these 3 configurations
Amortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐1602.
Goldenberg EA, Chatterjee A. Towards a better laparoscopic knot: using knot quality scores to evaluate three laparoscopic knot‐tying techniques. JSLS 2009;13(3):416‐9.
10
Extracorporeal Knots
Robot‐assisted Laparoscopic Knots
 Decrease operative time
 Easy to perform
 Quicker to tie than intracorporeal knots
Q
p
•Larger variability in the strength of the knots made using the robot, which corresponded to higher percentage of unraveling knots
 Tensile strength comparable to intracorporeal knots
Muffly T, McCormick TC, Dean J, et al. An evaluation of knot integrity when tied robotically and conventionally. Am J Obstet Gynecol 2009;e18‐20.
Sharp HT, Dorsey JH, Chovan JD, et al. The effect of knot geometry on the strength of laparoscopic slipknots. Obstet Gynecol 1996;88:408‐11.
Reynisson P, Shokri E, Bendahl P, et al. Tensile strength of surgical knots performed with the da Vinci surgical robot. JMIG 2010;17(3):365‐70.
Surgical Technique of Extracorporeal Knots
Applications
 General GYN
 Ovarian reconstruction
 Vaginal cuff closure
 Cervical stump closure
 Myomectomy
 In lieu of additional port and grasper
 Repairs
 Bladder  Bowel  Uterine Perforation
 UroGyn
 Sacrocolpopexy/Sacrocer‐
vicopexy
 Paravaginal defect repair
 Burch
 McCall
McCall’s Culdoplasty
s Culdoplasty
Interrupted or purse‐string stitch placed in tissue
Both ends of suture outside of laparoscopic port
Knot formed outside of abdominal cavity
Laparoscopic knot pusher mounted adjacent to knot
Tension placed on both ends of suture as laparoscopic knot pusher cinches down and secures each knot to tissue
6. Release knot pusher from suture
7. Repeat throws (steps 2‐6)
1.
2.
3.
4
4.
5.
 REI
 Cuff tuboplasty
 Tubal Reanastomosis
Useful for any interrupted or purse‐string suturing
Goldenberg EA, Chatterjee A. Towards a better laparoscopic knot: using knot quality scores to evaluate three laparoscopic knot‐tying techniques. JSLS 2009;13(3):416‐9.
Inoue H, Kumagai Y, Nishikage T, et al. A simple technique of using novel thread‐holding and knot‐pushing forceps for extracorporeal knot‐
tying. Surg Today 2000;30:571‐3.
Behm T, Unger JB, Ivy JJ, et al. Flat square knots: are 3 throws enough? Am J Obstet Gynecol. 2007;197:172.e1‐3.
Amortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐1602.
Laparoscopic Knot Pushers
11
Extracorporeal Knot
The American College of Obstetricians and Gynecologists (Obstetrics and Gynecology, 1992, 79: 143‐147.)
Extracorporeal Knot Video
Suture Tail
 Cutting tail of knot too short compromises knot integrity as it can easily unravel
Troubleshooting
 Suture too short
g 5
p
 Needle through 5 mm port
 Suture twisting
 Open knot pusher released early
12
Short Suture
Needle Back‐loading
Needle Back‐loading
Untwisting Suture
Replacing Knot Pusher
Replacing Knot Pusher
13
Laparoscopic Babcock
Vaginal Cuff Repair
Uterosacral Suspension
Ovarian Reconstruction
Oophoropexy
14
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Question
Role of extracorporeal knots in laparoscopic surgery. www.laparoscopyhospital.com
Sanz LE. Selecting the best suture material. Contemporary Ob/Gyn. 2001;57‐72.
Schubert DC, Unger JB, Mukherjee D, et al. Mechanical performance of knots using braided and monofilament absorbable sutures. Am J Obstet Gynecol. 2002;187(6):1438‐42.
Goldenberg EA, Chatterjee A. Towards a better laparoscopic knot: using knot quality scores to evaluate three laparoscopic knot‐tying techniques. JSLS 2009;13(3):416‐9.
Amortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐
1602.
6
Sharp HT, Dorsey JH, Chovan JD, et al. The effect of knot geometry on the strength of laparoscopic slipknots. Obstet Gynecol 1996;88:408‐11.
Inoue H, Kumagai Y, Nishikage T, et al. A simple technique of using novel thread‐holding and knot‐pushing forceps for extracorporeal knot‐tying. Surg Today 2000;30:571‐3.
Behm T, Unger JB, Ivy JJ, et al. Flat square knots: are 3 throws enough? Am J Obstet Gynecol. 2007;197:172.e1‐3.
The American College of Obstetricians and Gynecologists (Obstetrics and Gynecology, 1992, 79: 143‐147.)
Muffly T, McCormick TC, Dean J, et al. An evaluation of knot integrity when tied robotically and conventionally. Am J Obstet Gynecol 2009;e18‐20.
Reynisson P, Shokri E, Bendahl P, et al. Tensile strength of surgical knots performed with the da Vinci surgical robot. JMIG 2010;17(3):365‐70.
 A 34‐year‐old woman who desires pregnancy has had 18 months without conception. She has been found to have a right hydrosalpinx
and is opting to undergo laparoscopic tubaplasty for treatment. Upon insertion of the uterine manipulator, the uterine fundus is perforated and actively bleeding.
What is the best step in maintaining hemostasis at the site of the uterine perforation?
A. Dessicate the area B. Place surgical hemostatic agent
C. Place an interrupted suture
D. No treatment necessary
E. Not applicable to my area of practice
Correct Answer: C
15
Disclosures
Intracorporeal Knot Tying
I have no financial relationships to disclose.
Hye‐Chun Hur, MD
Beth Israel Deaconess Medical Center
Director, Minimally Invasive Gynecologic Surgery
Assistant Professor, Harvard Medical School
Indications
Objectives
– Indications for intracorporeal knot tying
– Basic equipment
– Technique
• breakdown of steps
• helpful tips • video demo
General:
any indication for
extracorporeal knot tying
can be applied to
intracorporeal
p
knot tying
y g
•
•
•
•
vaginal cuff closure
laparoscopic myomectomy
oophoropexy
suturing for retraction (e.g.
ovary,
y, bowel,, uterus))
Specific:
more delicate suturing,
tying knots off tension
•
•
•
bowel repair
bladder repair
peritoneal closures (e.g.
sacrocolpopexy)
knot pusher unavailable
Equipment
• Laparoscopic Needle Driver (curved, locking)
• Laparoscopic Needle Grasper (straight)
• Laparoscopic Scissors
• Suture, cut 6‐8 inches (interrupted vs figure of eight sutures)
• 10 mm trocar (direct delivery of needle)
• 5 mm trocar (back load needle)
16
Breakdown of Steps
Tips: Intracorporeal Knot Tying
1. Select appropriate trocar size for needle delivery.
2. Cut suture in advance.
1. Select appropriate trocar size for needle delivery
• Interrupted suture  6 inches • Figure of eight suture  8 inches
• Continuous running suture  12 inches
2. Cut suture in advance (6-8 inches)
3. Place suture (use locking needle driver)
TIP: Leave free end ((tail)) short
3. Place suture.
3
Place suture
4. Throw 4‐6 square knots (opposite direction).
4. Throw 4-6 square knots (opposite direction)
TIP: Keep heel of needle in-line with needle grasper
TIP: Pull ends so the free end stays short
• Vicryl  4 throws
• PDS  6 throws
5. Cut suture, remove needle under direct visualization.
5. Cut suture and remove needle under direct visualization
Replicate an instrument tie.
Interrupted Suture
Important Tips
Figure of Eight Suture
Take Home Points
Think ahead
• select appropriate trocar size (10 vs 5mm)
• cut suture in advance (6-8 inches)
Suturing & Intracorporeal Knot Tying
• Leave free end (tail) short
• Keep heel of needle in-line with needle grasper
• Pull ends so the free end stays short
17
Conclusion
If you can do an instrument tie, you
can do intracorporeal knot tying.
Questions?
Laparoscopic suturing and intracorporeal knot tying is a skill that anyone can learn and master in the dry lab setting.
Continuous Running Suture
18
Disclosures
Alternative Suture and
Technologies used in
Gynecologic
y
g Laparoscopy
p
py
 I have no financial relationships to
disclose.
Karen C. Wang, MD
Associate Director MIGS, Fellowship Director
Brigham and Women’s Hospital
Instructor, Harvard Medical School
AAGL November 6, 2012
1
2
Objectives
Laparoscopic suturing
 Introduce alternative suture material and
devices utilized in gynecologic
laparoscopic surgery





 Demonstrate utility of these alternatives
to facilitate laparoscopic suturing
Technically challenging
Diminished tactile feedback
Lack of depth perception
Tremor amplification
Limited instrument mobility
3
4
Solution?
Barbed Suture
 QuillTM
 FDA approved 2004
 Initiallyy used byy Plastics
 Barbed suture
 V LocTM
 FDA approved 2009
 Automated suturing devices
Greenberg et al. 2008 JMIG
5
6
19
QuillTM




V LocTM 90 and 180




Angiotech
Bidirectional
Helical pattern
Anchors every 1mm
Covidien
Unidirectional barbed suture
20 barbs/cm
Spiral configuration of barbs
7
8
V LocTM 90 and 180
Advantages of Barbed Suture
 V LocTM 90
 No knot tying required
 Equally distributed tension throughout
suture
 Enables continuous suturing without
backsliding
 Provides hemostatic closure of
myometrium during myomectomy
 Similar to Monocryl
 V LocTM 180
 Similar to PDS, Maxon
 Suture lengths: 6, 9, 12, and 18 inches
 Suture size: 33-0, 22-0
9
10
V-LocTM vs continuous
suture in lsc myomectomy
Advantages of Barbed Suture
 Barbed suture associated with
significantly shorter suturing times for
laparoscopic myomectomy compared to
traditional sutures.
 N = 19
 Solitary intramural fibroids 33-5 cm
V-loc 90
Conventional
P
113.7 + 74.1 ml
168.6 + 75.1 ml
0.0076
Operative time
(total)
51 + 18.1 min
58 + 17.8 min
0.0616
Suturing time
9.9 + 4.3 min
15.8 + 4.7 min
0.0004
EBL
Alessandri et al. 2010 JMIG
Einarsson et al. 2011. JMIG
Angioli et al. 2012. IJGO
11
20
12
Downside of Barbed Suture
Advantages of Barbed Suture
 Does barbed suture reduce the risk of
vaginal cuff dehiscence?
 Does barbed suture increase the risk of
adhesion formation?
 Unidirectional barbed suture
 Retrospective study N = 387, Jan 20072007- Jan 2010
 149 Barbed suture vs. 229 with Vicryl or Endostitch
 Mean time dehiscence 45 days
 13 canine enterotomy model
 No
N significant
i ifi
t diff
difference in
i adhesion
dh i scores att 21
days
Miller et al. 2012 J Invest Surg
 Two layer closure 00-PDO Quill 14 x 14 cm
No. Dehiscence
Quill (149)
Vicryl or Endostitch or
Monofilament suture
 Bidirectional barbed suture
Length of followfollow-up (days)
0
96
10 (4.2%)
281
 23 non
non--pregnant ewes
 Necropsy at 3 months
 12 horns (52.2%) with barbed suturesuture-adhesions
 10 horns (43.5%) with Vicryl closure
closure--adhesions
Einarsson et al. 2011 JMIG
14
13
Siedoff et al. 2011. JMIG
Downside of Barbed Suture
Downside of Barbed Suture





 “His” pareunia





Limited data
117 TLH, 82 completed
p
q
questionnaires
5 reported persistent dyspareunia (6.8%) at
6 months postpost-op
6 reported “his”pareunia (8.2%)
Case report
Bowel obstruction after TLH
0-PDO 14 x 14 cm Quill with Lapra Ty
Presented POD #30
On laparoscopylaparoscopy-tail of left end of barbed suture
(4cm) found as cause of point of volvulus
Einarsson et al. 2010 JSLS
Donnellan et al. 2011, JMIG
16
15
QuillTM Suturing Video:
Myomectomy Closure
V-LocTM Suturing Video:
Vaginal Cuff Closure
17
18
21
RD 180TM and TK®
Automated Suture Devices
 “Running Device”
 RD 180TM and TK®





 5 or 10 mm
LSI Solutions
Single use
First used for heart valve surgery
Vaginal cuff closure
 “Titanium Knot”
 Trims suture
 Secures suture
 Permanent clips
EndostitchTM
 Covidien
 Single use
 Vaginal cuff closure
19
20
EndostitchTM
RD 180TM and TK® Video
 10 mm
 Shuttle needle
 Option articulating tip
 Intracorporeal knot tying 18 cm
 Extracorporeal knot tying 120 cm
21
EndostitchTM
22
EndostitchTM Video
 Comparative study of pyeloplasties and
bladder neck suspension
 Automated intracorporeal suturing versus
conventional
ti
l suturing
t i
Endostitch
Conventional
P
Stitch placement
43 + 27 sec
151 + 24 sec
<0.0001
Knot tying
74 + 50 sec
197 + 70 sec
<0.0001
Adams et al. 1995. Urology
23
24
22
EndostitchTM with Barbed
Suture
Suture Comparison
Suture
 0, 22-0, 33-0 VV-Loc
 10,15,20 cm lengths
Name, Size
Type
Polydioxanone
Monofilament
Complete by 180 days
80% at 14 days
80% at 28 days
V Loc
V-LocTM 90
V-LocTM 180
Monofilament
Complete 9090-110 days
C
Complete
l t b
by 180 d
days
75% at 14 days
65% at 21 days
RD 180
Strongsorb 2
2--0
Monoglide 22-0
Monoglide 0
Multifilament
Monofilament
Monofilament
Complete 6060-110 days
Complete < 110 days
Complete < 110 days
49% at 21 days
77% at 21 days
77% at 21 days
Endostitch
Polysorb3
Polysorb3--0
Polysorb 2
2--0
Poysorb 0
Multifilament
Complete 5656-70 days
30% at 21 days
26
Cost $$$
References

Quill
$20$20-60
V-Loc
V-Loc 90 $20
V-Loc 180 $23
Endostitch
Tensile
Strength
Quill
25
RD 180 + TK
Absorption Rate




RD 180 $175 each
TK Device $150 each
53” suture $32 each
Ti Knot clips $35 pack of 12


Device $140
$140--150
Suture $20
$20--28
V-Loc Suture $57


27
Adams JB, Shulam PG, Moore RG, Partin AW, and Kavoussi LR. New Laparoscopic Suturing
Device: Initial Clinical Experience. Urology 1995;46(2):2421995;46(2):242-245.
Alessandri F, Remorgida V, Venturini PL, and Ferrero S. Unidirectional barbed suture versus
continuous suture with intracorporeal knots in laparoscopic myomectomy: a randomized study.
JMIG 2010;17(6):7252010;17(6):725-9.
Angioli R, Plotti F, Montera R, Damiani P, Terranova C, Oronzi I, Luvero D, Scaletta G, Muzii
L, and Panici PB. A new type of absorable barbed suture for use in laparoscopic myomectomy.
Int J Gynecol Obstet. 2012;117:2202012;117:220-223.
Donnellan NM and Mansuria SM. Small bowel obstructing resulting from laparoscopic vaginal
cuff closure with a barbed suture. JMIG 2011;18(4):5282011;18(4):528-30.
Einarsson JI, Chavan NR, Suzuki Y. Use of bidirectional barbed suture in laparoscopic
myomectomy: an evaluation of perioperative outcomes, safety, and efficacy. 2011;18(1):922011;18(1):92-5.
Einarsson JI, GrazulGrazul-Bilska AT, and Vonnahme KA. Barbed vs standard suture:randomized
single--blinded comparison of adhesion formation and ease of use in an animal model. JMIG
single
2011;18(6):716--19.
2011;18(6):716
Greenberg JA, Einarsson JI. The use of bidirectional barbed suture in laparoscopic
myomectomy and total laparoscopic hysterectomy. JMIG 2008;15(5):621-3.
Miller J, Zaruby J, and Kaminskaya K. Evaluation of a barbed suture device versus
conventional suture in a canine enterotomy model. J Invest Surg 2012;25(2):107-11.
Siedhoff MT, Yunker AC, Steege JF. Decreased incidence of vaginal cuff dehiscence after
laparoscopic closure with bidirectional barbed suture. JMIG 2011;18(2):218-223.
28
23
CULTURAL AND LINGUISTIC COMPETENCY
Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as
the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians
(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights
Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which
recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English
proficiency (LEP).
US Population
Language Spoken at Home
California
Language Spoken at Home
Spanish
English
Spanish
Indo-Euro
Asian
Other
Indo-Euro
English
Asian
Other
19.7% of the US Population speaks a
language other than English at home
In California, this number is 42.5%
California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws
identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided
by the Institute for Medical Quality at http://www.imq.org
Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from
discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of
their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national
origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP
individuals in the eligible service population, the frequency with which they come into contact with the
program, the importance of the services, and the resources available to the recipient, including the mix of oral
and written language services. Additional details may be found in the Department of Justice Policy Guidance
Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.
Executive Order 13166,”Improving Access to Services for Persons with Limited English
Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the
genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,
including those which provide federal financial assistance, to examine the services they provide, identify any
need for services to LEP individuals, and develop and implement a system to provide those services so LEP
persons can have meaningful access.
Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every
California state agency which either provides information to, or has contact with, the public to provide bilingual
interpreters as well as translated materials explaining those services whenever the local agency serves LEP
members of a group whose numbers exceed 5% of the general population.
~
If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.
A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee
competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.
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