Laparoscopic Suturing Module
To Suturing Prep
The overall educational goal of the Suturing Module is to develop or enhance skills in laparoscopic suturing.
OBJECTIVES
By the end of the Laparoscopic Suturing Module, the resident will be able to:

  1. Describe different port configurations for laparoscopic suturing
  2. Describe and demonstrate various ways of introducing needles and sutures into the abdomen to close the vaginal cuff during TLH, myometrial defect during laparoscopic myomectomy or cystotomy repair.
  3. Improve suturing techniques such as picking up needle, preparing to throw a stitch (2 ways), throwing stitches forehand and backhand, tying knots (intra- and exra-corporeal) 
  4. Review the different suturing device options (dolphin nose needle drivers, self righting needle drivers, suturing devices [endostitch], LapraTy) as well as the different types of suture (barbed, delayed absorbable) and surgeon ergonomics (suprapubic port vs. ipsilateral vs contralateral suturing). 
  5. Discuss clinical scenarios and appropriate suturing options for each scenario including: vaginal cuff closure, myometrial defect closure, and bladder repair.
STATION 1. Needle Management and Running Suturing
Tasks
  1. Pass a curved needle into the peritoneal cavity through a 5mm incision.
  2. Pass a  6 inch long "V-Loc" barbed suture into the peritoneal cavity, throw first stitch and thenanchor by passing the needle through the loop
  3. Close the simulated defect using a "baseball stitch" 
  4. Compare port set-ups: Laparoscope between the accessory ports (ipsilateral-contralateral) vs both accessory ports on one side (ipsilateral-ipsilateral)
Clinical Vignette 1
 A 45 yo P 2002 with AUB-L and chronic pelvic pain presents to discuss route of hysterectomy. A total laparoscopic hysterectomy (TLH) and bilateral salpingectomy  is agreed upon so that the upper abdomen can be evaluated. The patient is very concerned with minimizing size and number of abdominal incisions. A three, "5-mm" port configuration is discussed with the patient including: one in the umbilicus, along with one each in the RLQ and LLQ below the “bikini line.” Specimen removal is planned per vagina.
  1. What are your options for cuff closure?
  2. What sutures can be used and what is the absorption rate of each suture?
  3. How can barbed suture on a curved needle be introduced and cuff closed without making any additional or larger incisions?
  4. How can you support the vaginal cuff using suturing techniques?
STATION 2. Needle Drivers & Extracorporeal and Intracorporeal Knot Tying
Tasks
  1. Work with a standard vs self-righting needle driver
  2. Throw a figure-of-8 stitch and tie extra-corporeally with closed knot-manipulator
  3. Intracorporeal knot tying
Clinical Vignette 2.
 A 60 yo P 5005 with a BMI of 45 and multiple comorbidities including diabetes, hypertension and asthma has presumed Grade 1 FIGO Stage 1 endometrial adenocarcinoma. She undergoes a da Vinci assisted Total Laparoscopic Hysterectomy and Grade 1, Stage 1 endometrial adenocarcinoma is confirmed. On postoperative day 1, the patient presents to the emergency department with the sudden onset of pain and “something coming out of (her) vagina” after straining during a bowel movement.

  1. What is your differential diagnosis and what do you do?
  2. What risk factors does this patient have for vaginal cuff dehiscence?
  3. What can you do preoperatively and intraoperatively to help reduce the risk vaginal cuff dehiscence?
  4. How do you manage this vaginal cuff dehiscence?
  5. What are your options for cuff closure?
STATION 3. Needle Drivers & Extracorporeal and Intracorporeal Knot Tying
Tasks
  1. Cuff closure with "Stratafix"
  2. Figure of 8 stitch and tie with extracorporeal technique
  3. Intracorporeal knot formation
Clinical Vignette 3.
  A 30 yo P 0000 with AUB-Lsm and infertility with a single 7cm Type 2-5 leiomyoma presents for a laparoscopic myomectomy.  
  1. What are the advantages and disadvantages of making the myometrial incision vertically vs. horizontally?
  2. What port configuration can you use to suture the myometrial defect?
  3. What type of suture can be used?
  4. What are your thoughts on hemostatic agent use during this case?

STATION 4. Cystotomy
Tasks
  1. Repair injury to dome of bladder
  2. Throw a series of continuous stitches and use "Lapara-Ty" clips at one or both ends
CLINICAL VIGNETTE 4
 A 50 yo P 4004 with a history of cesarean delivery section x 4 is undergoing a TLH for AUB-A refractory to medical management. While dissecting the bladder, Anesthesia alerts you that there is air in the Foley bag.
  1. What is your diagnosis?
  2. How do you confirm a bladder cystotomy?
  3. How do you locate a cystotomy?
  4. How would you repair a 4cm defect in the dome of the bladder? Please include port configuration and suture type as well as how you will tie your knots.  
  5. How would you repair a 3cm defect in the trigone?
  6. What are your post operative considerations and instructions for the patient?
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