ergonomics in laparoscopic suturing

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tricks for laparoscopic suturing

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Laparoscopic Tissue approximation:

Laparoscopic Tissue approximation Dr.S.Easwaramoorthy MS FRCS(England) FRCS (Glasgow) FRCS (Edinburgh) Head of Dept of Minimal Access Surgery Examiner, RCS of Edinburgh Executive Member, South Zone IAGES

Slide2:

2 D Image No depth Perception No tactile feedback

Slide3:

It is both humiliating and frustrating to be observed by every one in OR when you take more than 15 min just to do a one square knot! Dr. Nathaneil Soper Surgical Clinics of North America Oct - 92

Learning Objectives:

Learning Objectives Working knowledge of Suturing Equipments Ergonomics for Suturing Tissue approximation Intra corporeal Suturing Extra corporeal Suturing Staplers in Laparoscopy

Slide5:

Practice, Practice, Practice

Laparoscopic Suturing Equipments:

Laparoscopic Suturing Equipments Needle Holders Knot pushers Suture Materials Part I HD Camera 30 degree telescope Good Assistants

Invest on Good Needle Holders:

Invest on Good Needle Holders Tip Tungsten carbide Diamond coating Straight/Curved

Needle holders:

Needle holders Active hand Needle holder Assisting hand Needle grasper

Knot Pushers:

Knot Pushers

Welcome Additions…:

Welcome Additions… Endo Stitch Self righting Needle holder Repair of Hiatus with Endostitch

Suture Material:

Suture Material Before selecting, Consider following qualities Absorbability/ Strength/tissue reaction Handling characteristics and visibility Favoured suture materials Absorbable Vicryl , Catgut, PDS Non absorbable Ethibond,Prolene Length of Suture Material Intra corporeal suture: 10-12cm Extra corporeal suture: 70cm

Suture needles:

Suture needles Straight Needle Ski Needle Curved Needle 25mm ½ circle

Learning Objectives:

Learning Objectives Working knowledge of Suturing Equipments Ergonomics for Suturing Tissue approximation Intra corporeal Suturing Extra corporeal Suturing Staplers in Laparoscopy

Different Ball Game!:

Different Ball Game! Open Surgery suturing Fast Ergonomics: Optional Laparoscopic Suturing Slow and steady Magnification effect Choreographic movements Ergonomics: Vital Triangulation Manipulation angle

Ergonomics:

Ergonomics Straight Line principle Triangulation Manipulation angle Elevation angle Low lying table Gaze down view

Base Ball Diamond Concept & Triangulation :

Base Ball Diamond Concept & Triangulation Monitor S C R L P

Manipulation angle:

Manipulation angle Azimuth Angle Manipulation Angle 30-45 degree 60-90 degree

Ergonomics of Hand Instruments:

Ergonomics of Hand Instruments Tip Range of movements Conventional Vs Robotic instrument: 4: 7

Slide19:

Da Vinci Robot Wrist like action Precision

Ergonomics of Hand Instruments:

Ergonomics of Hand Instruments Tip Range of movements Conventional Vs Robotic instrument Length of the shaft

Fulcrum Effect of Hand Instruments:

Fulcrum Effect of Hand Instruments 1: 1

Ergonomics of Hand Instruments:

Ergonomics of Hand Instruments Tip Range of movements Conventional Vs Robotic instrument Length of the shaft Handle design

Ergonomic handles…:

Ergonomic handles…

Surgeon’s Stance:

Surgeon’s Stance Ideal relaxed stature Tiring

Ideal Relaxed Position:

Ideal Relaxed Position -straight head, in the axis of the trunk, without rotation or extension of the cervical spine; - shoulders in a relaxed and neutral position; - arms alongside the body - elbows bent to 70 to 90 degrees - forearms in an horizontal or slightly descending axis- -hands pronated (physiological resting position); - hands and fingers lightly grip the handles/handpiece Waist line table Gaze down view of monitor Straight line principle Triangulation

Learning Objectives:

Learning Objectives Working knowledge of Suturing Equipments Ergonomics for Suturing Tissue approximation Intra corporeal Suturing Extra corporeal Suturing Staplers in Laparoscopy

Slide27:

I can recognize a good surgeon , not from how he cuts, but from how he sews! Johan Mikulicz Radecki 1850-1905

Critical Steps of Suturing:

Critical Steps of Suturing Introduction of Needle Grasping the Needle Tissue Penetration Knotting

Introduction of Needle:

Introduction of Needle Through 10mm port (with reducer) Non dominant hand port Hold the suture and not the needle Through 5mm port Through abdominal wall

Grasping the needle:

Grasping the needle Dominant hand port(right hand) Grasp with the tip of the needle holder Grasp at the ‘Sweet spot’ Deposit- Pick up technique Dangling needle technique Nudging

Needle discipline:

Needle discipline A held needle should always be in view. A trailing needle is a safe needle

Types of Knots:

Types of Knots Granny knot Square knot Slip knot to square knot Surgeon’s Knot Aberdeen knot Dundee Jamming Slip Knot

Surgeon’s Knot:

Surgeon’s Knot

Guidelines for Suturing:

Guidelines for Suturing The Passive and Active role of the holders The formation of the initial “C’ and a tail The use of the natural bias of the thread Choreographic movements with needle holders Economy of motion Execution of the knots near to the tissue surfaces Ambidexterity

Slip Knot to Square knot:

Slip Knot to Square knot

Continuous Suturing:

Continuous Suturing

Laparoscopic Bowel Anastomosis Key points:

Laparoscopic Bowel Anastomosis Key points Port positioning Good communications with your assistant Positioning of sutures, especially at the corners Spacing the sutures (remember the magnification) Tensioning of sutures

Learning Objectives:

Learning Objectives Working knowledge of Suturing Equipments Ergonomics for Suturing Tissue approximation Intra corporeal Suturing Extra corporeal Suturing Staplers in Laparoscopy

Extra corporeal knots:

Extra corporeal knots Roeder Knot Meltzer Knot Tayside knot

Roeder’s Knot:

Roeder’s Knot No 2 Chromic Catgut Eg: Appendix base

Extra corporeal Knotting:

Extra corporeal Knotting

Meltzer Knot:

Meltzer Knot 1-0 or 2-0 Vicryl Eg: Cystic duct

Tayside Knot:

Tayside Knot 1-0 or 2-0 PDS Eg: Azygos vein

Learning Objectives:

Learning Objectives Working knowledge of Suturing Equipments Ergonomics for Suturing Tissue approximation Intra corporeal Suturing Extra corporeal Suturing Staplers in Laparoscopy

Staplers: Types & Sizes:

Staplers : Types & Sizes Gastric Bypass Anterior Resection Types Linear staplers. Circular staplers. Color codes White - small gut. Blue / Gold - stomach (except pylorus). Green - pylorus / redo surgery.

Guidelines for Staple Anastomosis:

Guidelines for Staple Anastomosis Port positions for stapling Stay sutures for tensioning Enterotomy positioning and size Positioning and angulations of the stapler prior to closure Checking staple line Complete closure of residual opening

Slide47:

It is not practice that makes perfect It’s perfect practice that makes perfect! - Vince Lombardi, American Foot ball Coach, Green Bay, Wisconsin

Slide48:

Thank you…

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