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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, MDKathy Huang, MD

Nash S. Moawad, MDJessica A. Shepherd, MD

Larry R. Glazerman, MDHye-Chun Hur, MDAngela M. Pratt, MD

Matthew T. Siedhoff, MD

Mark R. Hoffman, MDGretchen E.H. Makai, MDSangeeta Senapati, 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

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

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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

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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

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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.

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Port Placement, Needle Loading, & Tissue Re-approximation

Jay L. Hudgens, M.D.Center for Women’s Health

Owensboro, KY

Gratis Faculty University of LouisvilleDepartment of Obstetrics, Gynecology, & Women’s Health

Presented by:

Aarathi Cholkeri-Singh, M.D., FACOG

Disclosures

Jay Hudgens, M.D.Aarathi Cholkeri-Singh, M.D., FACOG

We have no financial relationships to disclose

Objectives

1. Present the different port placementsused in laparoscopic suturing

2. Present a system for setting the needle

3. Discuss strategies for tissue re-approximation

System

1. Set the Needle

2. Reapproximate

3. Knot Tying

Ipsilateral

• Ergonomics

• Assistant

• One Sided

5

Contralateral

• Ideal Triangulation

• Poor Ergonomics?

• No Assistant

Suprapubic

• Gravity

• Ergonomics?

• Two Sided

Needle Holders

• Straight• Curved

– For desired needle angles >135o

• Self-Righting• Endo Wrist Articulating

– Hand-held– Da Vinci Robot

Straight Needle Holder

Curved Needle Holder Self-Righting Needle Holder

6

Endowrist Needle Holder

Laparoscopic Robotic

System

1. Set the Needle

2. Re-approximate

3. Knot Tying

• Set (perpendicular)

• Parallel (tissue)

System

( )

• Rotate (key)

• Reset

Tie Knot

• Direct-trocar

• Backloaded

• 5mm…..Backload

• 8mm SH-1

Needle Entry

• Backloaded

• Abdominal Wall

• 8mm…..SH-1

• 10mm…CT-2 & CT-1

• 12mm…CT

Setting the Needle Setting the Needle

A-B-C“A” = 2cm

from Swedge

“C” = 1/3 from

Swedge

“B” = 1/3 from Point

7

Setting the Needle

A-B-C

Left Hand Right Hand

Right Hand Motion

Novice

Hiemstra et al JMIG 2011 vol. 18, pgs 494-499

Expert

• Set (perpendicular)

• Parallel (tissue)

System

( )

• Rotate (key)

• Reset

Tie Knot

What is the most important factor in reproducible tissue re-approximation?

A. Port placement.

B. Understanding the relationship between the tissue, camera, and ports.

C. Use of mechanical suturing device to improve efficiency and accuracy.

D. The type of suture and needle used.

E. Not applicable to my practice.

References

1. Joseph L. Hudgens, RP Pasic. Geometrically Efficient Laparoscopic Suturing. 40th Global Congress AAGL, 2011

2 Resad P Pasic RL Levine A Practical 2. Resad P. Pasic, RL Levine. A Practical Manual of Laparoscopy 2nd Edition. New York: The Parthenon Publishing Group 2002

3. Charles H. Koh. Laparoscopic Suturing in the Vertical Zone. Endo Press 2008: Tuttlingen, Germany

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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

Disclosures I have no financial relationships to disclose.

Objectives Review principles of knot security

Overview of applications of Extracorporeal Knots

Understand Extracorporeal Knot tying techniquep y g q

Extracorporeal knot troubleshooting

Video demonstrations of extracorporeal knot use in gynecologic surgery

“… an unreliable suture knot can spoil the outcomes of an otherwise beautifully

performed surgical procedure.”p g p

‐ unknown author

Role of extracorporeal knots in laparoscopic surgery. www.laparoscopyhospital.com

Principles of Knot Security1. Type of Suture

2. Type of Knot GOAL = tissue is approximated and

3. Surgical Technique

4. Length of cut end

approximated and secured

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..

Suture Material Natural vs. Synthetic

Natural i.e. Chromic 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

Friction is greater for braided multifilament than monofilament suture

Sanz LE. Selecting the best suture material. Contemporary Ob/Gyn. 2001;57‐72.

Role of extracorporeal knots in laparoscopic surgery. www.laparoscopyhospital.com

9

Suture Length

Single‐use suture, minimum length of suture should be 27 inches (70 cm) – standard length

Multiple‐use or purse‐string suture, recommend length of suture to be minimum 48 inches (122 cm)

Type of knot

Square knot•Coefficient of friction equally distributed

Sliding knot•Coefficient of friction not equally distributed

Intracorporeal Extracorporeal

equally distributed between suture ends•Each end of suture enters and leaves knot in opposite direction

q ybetween 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

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 Amortegui et al, Surg Endosc 2002

1 surgeon, 7 types of knots

140 knots conventional vs. 140 knots laparoscopic

b id d l 2‐0 braided polyester

4‐6 throws

Knots measured for breaks using tensiometer and knot slips >3mm


Laparoscopic Knots


S Sliding Knot1 or 2 indicates number of flat square knotsX 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

Laparoscopic KnotsIntracorporeal Square

KnotsExtracorporeal Sliding

Knot

These configurations had superior tensile strength to others tested in laparoscopic group (p<0.05)

No significant difference between these 3 configurationsAmortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐1602.

Laparoscopic Knots Goldenberg et al, JSLS 2009

3 surgeons, 100 knots, 2‐0 silk, 4 throws measured for knot slips and breaks using tensiometer

Extracorporeal square knotsvs.

Intracorporeal slip‐square vs.

Intracorporeal flat‐square

Figure 2. A graphical representation of the Knot Quality Score(KQS). It is based on the quartiles of the variable. The rectangularbox corresponds to the lower quartile and the upperquartile. The line in the middle is the median.


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Robot‐assisted Laparoscopic Knots

•Larger variability in the strength of the knots made using the robot, which corresponded to higher percentage of unraveling 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.

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.

Extracorporeal Knots

Decrease operative time

Easy to perform

Quicker to tie than intracorporeal knotsQ p

Tensile strength comparable to intracorporeal knots

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.

Applications General GYN

Ovarian reconstruction Vaginal cuff closure Cervical stump closure Myomectomy In lieu of additional port

UroGyn Sacrocolpopexy/Sacrocer‐vicopexy

Paravaginal defect repair Burch McCall’s Culdoplasty In lieu of additional port

and grasper

Repairs Bladder Bowel Uterine Perforation

McCall s Culdoplasty

REI Cuff tuboplasty Tubal Reanastomosis

Useful for any interrupted or purse‐string suturing

Surgical Technique of Extracorporeal Knots

1. Interrupted or purse‐string stitch placed in tissue2. Both ends of suture outside of laparoscopic port3. Knot formed outside of abdominal cavity4 Laparoscopic knot pusher mounted adjacent to knot4. Laparoscopic knot pusher mounted adjacent to knot5. Tension placed on both ends of suture as laparoscopic

knot pusher cinches down and secures each knot to tissue

6. Release knot pusher from suture7. Repeat throws (steps 2‐6)


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.


Laparoscopic Knot Pushers

11

Extracorporeal Knot

The American College of Obstetricians and Gynecologists (Obstetrics and Gynecology, 1992, 79: 143‐147.)

Suture Tail Cutting tail of knot too short compromises knot integrity as it can easily unravel

Extracorporeal Knot Video

Troubleshooting

Suture too short

Needle through 5 mm portg 5 p

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

References1. Role of extracorporeal knots in laparoscopic surgery. www.laparoscopyhospital.com2. Sanz LE. Selecting the best suture material. Contemporary Ob/Gyn. 2001;57‐72.3. 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):1438‐42.4. Goldenberg EA, Chatterjee A. Towards a better laparoscopic knot: using knot quality scores

to evaluate three laparoscopic knot‐tying techniques. JSLS 2009;13(3):416‐9.5. Amortegui JD, Restrepo H. Knot security in laparoscopic surgery. Surg Endosc. 2002;16:1598‐

61602.6. Sharp HT, Dorsey JH, Chovan JD, et al. The effect of knot geometry on the strength of

laparoscopic slipknots. Obstet Gynecol 1996;88:408‐11.7. 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;30:571‐3.8. Behm T, Unger JB, Ivy JJ, et al. Flat square knots: are 3 throws enough? Am J Obstet Gynecol.

2007;197:172.e1‐3.9. The American College of Obstetricians and Gynecologists (Obstetrics and Gynecology, 1992,

79: 143‐147.)10. Muffly T, McCormick TC, Dean J, et al. An evaluation of knot integrity when tied robotically

and conventionally. Am J Obstet Gynecol 2009;e18‐20.11. 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.

Question A 34‐year‐old woman who desires pregnancy has had 18 months

without conception. She has been found to have a right hydrosalpinxand 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 agentC. Place an interrupted sutureD. No treatment necessaryE. Not applicable to my area of practice

Correct Answer: C

15

Intracorporeal Knot Tying

Hye‐Chun Hur, MDBeth Israel Deaconess Medical Center

Director, Minimally Invasive Gynecologic SurgeryAssistant Professor, Harvard Medical School

Disclosures

I have no financial relationships to disclose.

Objectives

– Indications for intracorporeal knot tying

– Basic equipment

– Technique• breakdown of steps• helpful tips • video demo

Indications

General:any indication for extracorporeal knot tying can be applied to intracorporeal knot tying

• vaginal cuff closure• laparoscopic myomectomy• oophoropexy• suturing for retraction (e.g.

ovary, bowel, uterus)p y g

knot pusher unavailable

y, , )

• bowel repair• bladder repair• peritoneal closures (e.g.

sacrocolpopexy)

Specific: more delicate suturing, tying knots off tension

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 Steps1. Select appropriate trocar size for needle delivery.

2. Cut suture in advance.• Interrupted suture 6 inches • Figure of eight suture 8 inches• Continuous running suture 12 inches

3 Place suture3. Place suture.

4. Throw 4‐6 square knots (opposite direction).• Vicryl 4 throws• PDS 6 throws

5. Cut suture, remove needle under direct visualization.

Replicate an instrument tie.

Intracorporeal Knot Tying

1. Select appropriate trocar size for needle delivery

2. Cut suture in advance (6-8 inches)

3. Place suture (use locking needle driver)TIP: Leave free end (tail) short

Tips:

4. Throw 4-6 square knots (opposite direction)

5. Cut suture and remove needle under direct visualization

TIP: Pull ends so the free end stays short

TIP: Keep heel of needle in-line with needle grasper

( )

Important TipsInterrupted Suture

Figure of Eight SutureTake 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

If you can do an instrument tie, you can do intracorporeal knot tying.

Conclusion

Laparoscopic suturing and intracorporeal knot tying is a skill that anyone can learn

and master in the dry lab setting.

Questions?

Continuous Running Suture

18

Alternative Suture and Alternative Suture and Technologies used in Technologies used in Gynecologic LaparoscopyGynecologic Laparoscopy

11

y g p pyy g p py

Karen C. Wang, MDKaren C. Wang, MDAssociate Director MIGS, Fellowship DirectorAssociate Director MIGS, Fellowship DirectorBrigham and Women’s HospitalBrigham and Women’s HospitalInstructor, Harvard Medical SchoolInstructor, Harvard Medical SchoolAAGL November 6, 2012AAGL November 6, 2012

DisclosuresDisclosures

22

I have no financial relationships to I have no financial relationships to disclose.disclose.

ObjectivesObjectives

Introduce alternative suture material and Introduce alternative suture material and devices utilized in gynecologic devices utilized in gynecologic laparoscopic surgerylaparoscopic surgery

33

Demonstrate utility of these alternatives Demonstrate utility of these alternatives to facilitate laparoscopic suturingto facilitate laparoscopic suturing

Laparoscopic suturingLaparoscopic suturing

Technically challengingTechnically challenging

Diminished tactile feedbackDiminished tactile feedback

44

Diminished tactile feedbackDiminished tactile feedback

Lack of depth perceptionLack of depth perception

Tremor amplificationTremor amplification

Limited instrument mobilityLimited instrument mobility

44

Solution?Solution?

55

Barbed sutureBarbed suture

Automated suturing devicesAutomated suturing devices

55

Barbed SutureBarbed Suture

QuillQuillTMTM

FDA approved 2004 FDA approved 2004

Initially used by PlasticsInitially used by Plastics

66

y yy y

V LocV LocTMTM

FDA approved 2009FDA approved 2009

Greenberg et al. 2008 JMIG

19

QuillQuillTMTM

AngiotechAngiotech

BidirectionalBidirectional

Helical patternHelical pattern

77

Anchors every 1mmAnchors every 1mm

V LocV LocTM TM 90 and 18090 and 180

CovidienCovidien

Unidirectional barbed sutureUnidirectional barbed suture

20 barbs/cm20 barbs/cm

88

Spiral configuration of barbsSpiral configuration of barbs

V LocV LocTMTM 9090 Similar to MonocrylSimilar to Monocryl

V LocV LocTMTM 90 and 18090 and 180

99

V LocV LocTMTM 180180 Similar to PDS, MaxonSimilar to PDS, Maxon

Suture lengths: 6, 9, 12, and 18 inchesSuture lengths: 6, 9, 12, and 18 inches Suture size: 3Suture size: 3--0, 20, 2--00

Advantages of Barbed SutureAdvantages of Barbed Suture

No knot tying requiredNo knot tying required

Equally distributed tension throughout Equally distributed tension throughout suturesuture

1010

suturesuture

Enables continuous suturing without Enables continuous suturing without backslidingbacksliding

Provides hemostatic closure of Provides hemostatic closure of myometrium during myomectomymyometrium during myomectomy

Barbed suture associated with Barbed suture associated with significantly shorter suturing times for significantly shorter suturing times for laparoscopic myomectomy compared to laparoscopic myomectomy compared to

Advantages of Barbed SutureAdvantages of Barbed Suture

1111

traditional sutures. traditional sutures.

1111

Alessandri et al. 2010 JMIGEinarsson et al. 2011. JMIG

VV--LocLocTM TM vsvs continuous continuous suture in lsc myomectomysuture in lsc myomectomy

N = 19N = 19

Solitary intramural fibroids 3Solitary intramural fibroids 3--5 cm5 cm

12121212Angioli et al. 2012. IJGO

VV--loc 90loc 90 ConventionalConventional PPEBLEBL 113.7 113.7 ++ 74.1 ml74.1 ml 168.6 168.6 ++ 75.1 ml75.1 ml 0.00760.0076

Operative time Operative time (total)(total)

51 51 ++ 18.1 min18.1 min 58 58 ++ 17.8 min17.8 min 0.06160.0616

Suturing timeSuturing time 9.9 9.9 ++ 4.3 min4.3 min 15.8 15.8 ++ 4.7 min4.7 min 0.00040.0004

20

Advantages of Barbed SutureAdvantages of Barbed Suture Does barbed suture reduce the risk of Does barbed suture reduce the risk of

vaginal cuff dehiscence?vaginal cuff dehiscence? Retrospective study N = 387, Jan 2007Retrospective study N = 387, Jan 2007-- Jan 2010Jan 2010

149 Barbed suture vs. 229 with Vicryl or Endostitch149 Barbed suture vs. 229 with Vicryl or Endostitch

Mean time dehiscence 45 daysMean time dehiscence 45 days

1313

Two layer closure 0Two layer closure 0--PDO Quill 14 x 14 cmPDO Quill 14 x 14 cm

No. DehiscenceNo. Dehiscence Length of followLength of follow--up (days)up (days)

Quill (149)Quill (149) 00 9696

Vicryl or Endostitch or Vicryl or Endostitch or Monofilament sutureMonofilament suture

10 (4.2%)10 (4.2%) 281281

Siedoff et al. 2011. JMIG

Downside of Barbed SutureDownside of Barbed Suture

Does barbed suture increase the risk of Does barbed suture increase the risk of adhesion formation?adhesion formation? Unidirectional barbed sutureUnidirectional barbed suture 13 canine enterotomy model13 canine enterotomy model

N i ifi t diff i dh i t 21N i ifi t diff i dh i t 21

1414

No significant difference in adhesion scores at 21 No significant difference in adhesion scores at 21 days days Miller et al. 2012 J Invest SurgMiller et al. 2012 J Invest Surg

Bidirectional barbed sutureBidirectional barbed suture 23 non23 non--pregnant ewespregnant ewes Necropsy at 3 monthsNecropsy at 3 months 12 horns (52.2%) with barbed suture12 horns (52.2%) with barbed suture--adhesionsadhesions 10 horns (43.5%) with Vicryl closure10 horns (43.5%) with Vicryl closure--adhesionsadhesions

Einarsson et al. 2011 JMIGEinarsson et al. 2011 JMIG1414


“His” pareunia“His” pareunia Limited dataLimited data

117 TLH, 82 completed questionnaires117 TLH, 82 completed questionnaires

1515

p qp q

5 reported persistent dyspareunia (6.8%) at 5 reported persistent dyspareunia (6.8%) at

6 months post6 months post--opop

6 reported “his”pareunia (8.2%)6 reported “his”pareunia (8.2%)

1515

Einarsson et al. 2010 JSLS


Case report Case report

Bowel obstruction after TLHBowel obstruction after TLH

00--PDO 14 x 14 cm Quill with Lapra Ty PDO 14 x 14 cm Quill with Lapra Ty

1616

Presented POD #30Presented POD #30

On laparoscopyOn laparoscopy--tail of left end of barbed suture tail of left end of barbed suture (4cm) found as cause of point of volvulus(4cm) found as cause of point of volvulus

1616Donnellan et al. 2011, JMIG

QuillQuillTMTM Suturing Video: Suturing Video: Myomectomy ClosureMyomectomy Closure

17171717

VV--LocLocTMTM Suturing Video: Suturing Video: Vaginal Cuff ClosureVaginal Cuff Closure

18181818

21

Automated Suture DevicesAutomated Suture Devices

RD 180RD 180TMTM and TKand TK®®

LSI SolutionsLSI Solutions

Single useSingle use

First used for heart valve surgeryFirst used for heart valve surgery

1919

First used for heart valve surgeryFirst used for heart valve surgery

Vaginal cuff closureVaginal cuff closure

EndostitchEndostitchTMTM

CovidienCovidien

Single useSingle use

Vaginal cuff closureVaginal cuff closure

RD 180RD 180TMTM and TKand TK®®

“Running Device”“Running Device” 5 or 10 mm5 or 10 mm

2020

“Titanium Knot”“Titanium Knot” Trims sutureTrims suture

Secures sutureSecures suture

Permanent clipsPermanent clips

RD 180RD 180TMTM and TKand TK® ® VideoVideo

2121


10 mm10 mm

Shuttle needleShuttle needle

Option articulating tipOption articulating tip

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Option articulating tipOption articulating tip

Intracorporeal knot tying 18 cmIntracorporeal knot tying 18 cm

Extracorporeal knot tying 120 cmExtracorporeal knot tying 120 cm


Comparative study of pyeloplasties and Comparative study of pyeloplasties and bladder neck suspensionbladder neck suspension Automated intracorporeal suturing versus Automated intracorporeal suturing versus

ti l t iti l t i

2323

conventional suturingconventional suturing

2323

EndostitchEndostitch ConventionalConventional PP

Stitch placementStitch placement 43 43 ++ 27 sec27 sec 151 151 ++ 24 sec24 sec <0.0001<0.0001

Knot tyingKnot tying 74 74 ++ 50 sec50 sec 197 197 + + 70 sec70 sec <0.0001<0.0001

Adams et al. 1995. Urology

EndostitchEndostitchTM TM VideoVideo

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EndostitchEndostitchTMTM with Barbed with Barbed SutureSuture

2525

0, 20, 2--0, 30, 3--0 V0 V--LocLoc

10,15,20 cm lengths10,15,20 cm lengths

2525

Suture ComparisonSuture ComparisonSutureSuture Name, SizeName, Size TypeType Absorption RateAbsorption Rate Tensile Tensile

Strength Strength

QuillQuill PolydioxanonePolydioxanone MonofilamentMonofilament Complete by 180 daysComplete by 180 days 80% at 14 days80% at 14 days80% at 28 days80% at 28 days

V LocV Loc VV--LocLocTMTM 9090 MonofilamentMonofilament Complete 90Complete 90--110 days110 daysC l t b 180 dC l t b 180 d

75% at 14 days75% at 14 days

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VV--LocLocTMTM 180180 Complete by 180 daysComplete by 180 days 65% at 21 days65% at 21 days

RD 180RD 180 Strongsorb 2Strongsorb 2--00Monoglide 2Monoglide 2--00Monoglide 0Monoglide 0

MultifilamentMultifilamentMonofilament Monofilament MonofilamentMonofilament

Complete 60Complete 60--110 days110 daysComplete < 110 daysComplete < 110 daysComplete < 110 daysComplete < 110 days

49% at 21 days49% at 21 days77% at 21 days77% at 21 days77% at 21 days77% at 21 days

EndostitchEndostitch Polysorb3Polysorb3--00Polysorb 2Polysorb 2--00Poysorb 0Poysorb 0

MultifilamentMultifilament Complete 56Complete 56--70 days70 days 30% at 21 days30% at 21 days

Cost $$$Cost $$$

QuillQuill $20$20--60 60

VV--LocLoc VV--Loc 90 $20Loc 90 $20VV--Loc 180 $23Loc 180 $23

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VV Loc 180 $23Loc 180 $23

RD 180 + TKRD 180 + TK RD 180 $175 eachRD 180 $175 eachTK Device $150 eachTK Device $150 each53” suture $32 each53” suture $32 eachTi Knot clips $35 pack of 12Ti Knot clips $35 pack of 12

EndostitchEndostitch Device $140Device $140--150150Suture $20Suture $20--2828VV--Loc Suture $57Loc Suture $57

ReferencesReferences Adams JB, Shulam PG, Moore RG, Partin AW, and Kavoussi LR. New Laparoscopic Suturing Adams JB, Shulam PG, Moore RG, Partin AW, and Kavoussi LR. New Laparoscopic Suturing

Device: Initial Clinical Experience. Urology 1995;46(2):242Device: Initial Clinical Experience. Urology 1995;46(2):242--245.245.

Alessandri F, Remorgida V, Venturini PL, and Ferrero S. Unidirectional barbed suture versus Alessandri F, Remorgida V, Venturini PL, and Ferrero S. Unidirectional barbed suture versus continuous suture with intracorporeal knots in laparoscopic myomectomy: a randomized study. continuous suture with intracorporeal knots in laparoscopic myomectomy: a randomized study. JMIG 2010;17(6):725JMIG 2010;17(6):725--9. 9.

Angioli R, Plotti F, Montera R, Damiani P, Terranova C, Oronzi I, Luvero D, Scaletta G, Muzii 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. L, and Panici PB. A new type of absorable barbed suture for use in laparoscopic myomectomy. Int J Gynecol Obstet. 2012;117:220Int J Gynecol Obstet. 2012;117:220--223.223.

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Donnellan NM and Mansuria SM. Small bowel obstructing resulting from laparoscopic vaginal Donnellan NM and Mansuria SM. Small bowel obstructing resulting from laparoscopic vaginal cuff closure with a barbed suture. JMIG 2011;18(4):528cuff closure with a barbed suture. JMIG 2011;18(4):528--30.30.

Einarsson JI, Chavan NR, Suzuki Y. Use of bidirectional barbed suture in laparoscopic 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):92myomectomy: an evaluation of perioperative outcomes, safety, and efficacy. 2011;18(1):92--5.5.

Einarsson JI, GrazulEinarsson JI, Grazul--Bilska AT, and Vonnahme KA. Barbed vs standard suture:randomized Bilska AT, and Vonnahme KA. Barbed vs standard suture:randomized singlesingle--blinded comparison of adhesion formation and ease of use in an animal model. JMIG blinded comparison of adhesion formation and ease of use in an animal model. JMIG 2011;18(6):7162011;18(6):716--19.19.

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.

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).

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.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsianIndo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

24

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

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