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In laparoscopic and thoracoscopic surgery, suturing and knot tying are considered difficult skills, leading to billions of dollars of technology development to make suturing easier for the surgeon. The primary problem begging solution is the loss of the wrist in laparoscopic instruments. The only technology to have adequately solved this engineering problem is the surgical robot, but this multimillion-dollar solution is unnecessary for the bulk of suturing tasks encountered in minimally invasive surgery. Simple suturing and knot tying without robots, articulated needle holders, or “instant” knots can be learned in a simulator with the investment of a few hours. Mastery of these techniques may take more time, so practice in a simulator or box trainer is advised. It is preferable to ascend the suturing and knotting learning curve in a simulator, rather than wasting valuable time in the operating room. No professional athlete, pilot, or concert musician learns their skill without hours of practice “off stage.” As surgeons, our obligation to our patient requires similar practice outside of the operating room. By convention, descriptions in this section are written for the right-hand-dominant surgeon.
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INTRODUCING AND REMOVING THE NEEDLE
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For laparoscopic suturing, the needle cannot be introduced on the needle holder, as the trocar is not wide enough. The suture is grasped with the needle holder adjacent to the needle and passed through the trocar (Figure 1). Clearly quick release (pop-off) needles cannot be used. A 10-mm trocar is needed, at a minimum, to introduce the needle.
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Positioning the needle in the needle holder is one of the more difficult tasks for the beginner. This becomes a one-handed task for the expert, but for the beginner, the simplest way to do this is to pick up the suture 1 or 2 centimeters above the needle, allowing the tip of the needle to dangle (Figure 2A). The needle is then lowered so the tip touches the tissue. Moving the left hand around causes the needle to pivot on its tip, allowing almost any position desired by the surgeon. Generally a position that will allow a 90-degree angle between needle holder and needle is desirable (Figure 2B). Once this position is achieved, the right hand is brought into view, and the needle grasped in the middle of its arc or several degrees toward the tail with a specialized laparoscopic needle holder (Figure 2C). The convex surface of the needle holder is aligned with the tip of the needle, to allow angulation of the needle (if desired) and to keep the tip of the needle holder from digging into tissue as it is rotated. With certain suturing tasks, the needle may need to be angled 100 to 120 degrees away from the needle holder (e.g., ...