3. Horizontal mattress stitch (horizontal U-suture)
Fix the needle with the needle holder. Grab the opposite wound edge with the surgical forceps, and sew into the skin 1 cm far from the incision line. If the needle is hard to sting through, try to push from wrist. Catch the top of the needle with the needle holder and pull the thread through until there is only 2-3 cm is left outside the wound. Open the incision the view the wound base, and sew it too. Catch the top of the needle and pull it out from the wound. Take care of the needlepoint and the cutting edge. Grab the needle with hand and position it correctly again into the needle-holder. Grab the closer wound edge with the forceps and sew out from the incision in at least 1 cm distance from the wound edge. The next step is the so called backhand positioning of the needle. Grab the closer wound edge with the forceps and start sewing 1 cm sidelong to the previous, and 1 cm far from the wound edge. Catch the top of the needle and pull it out, then fix it again backhand into the needle holder. Grab with the forceps the opposite wound edge, and sew out from the wound at least 1 cm far from the wound edge. The 4 stitches should form a tetragon. Get the needle out of the holder, and put the forceps on the table. Grab the longer end of the thread with the left hand (on which the needle is).Go around the needle holder with the thread catch the shorter end of the thread with the needle holder end finish the first instrumental knot. Position the knot on one side of the incision; take care not to place it in the middle because it inhibits the wound healing. Hold the two ends of the threads together and cut them together. Make further 3 or 4 knots. The advantage of the instrumental knot, that there are just a few threads is waste if you leave only 2-3 cm out of the wound at the beginning. Do the same process on the following suture. The stitches should be 1 cm far from each other.
Removing the suture: Hold the knot or one end of the thread with the forceps, and cut the thread just above the skin.
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6. Practice
Practicing of basic sutures on porcine tissue (running stitches)
1. Simple running suture (with needle-thread combination)
We create a 5-6 cm long incision on the liver skin-specimen. We put the needle into the needle-holder. We grab the opposite side of the incision with a surgical forceps, and start sewing 1 cm far from the wound edge and without interruption finish the suture on the closer wound edge, exactly 1 cm far from the edge. Make an instrumental knot. Cut the shorter end of the thread with 1 cm waste. Continue sewing with the longer end where the needle is in a way, that all the stitches should be 1 cm far from each other. By the last stitch, do not pull the thread totally through, leave short loop, and tight the not with this double end. Make further instrumental knots. Hold the three ends together, and cut them 1 cm above the skin.
Removing the suture: Hold the knot or one end of the thread with the forceps, and cut the thread just above the skin, and pull the whole thread out.
2. Intracutaneous running suture
Create a 5-6 cm long incision, and fix the needle into the needle holder. Start sewing form outside the incision and get into the wound angle. Keep forwarding in the dermis layer. Get out from the incision by sewing the last stitch out from the wound angle. We make a knot to the thread itself, on both ends. We did correctly if the skin is bulk a bit, because the incision gets tensile free, and the scar will be very thin.
Removing the suture: Raise the end of the thread or the not, and cut the thread over the skin, under the knot, and pull the thread out from the other end.
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9. Practice
Basics of the laparoscopic surgery: demonstration of laparoscopic surgical tools, training of eye-hand coordination
1.Veress needle is a double shaft needle with a spring-loaded obturator. It is designed for „blind” insertion with minimal risk of injury to underlying organs. The outer shaft has a sharp beveled needle end, whereas the inner blunt-tipped obturator protrudes beyond the sharp tip of the outer needle in the resting state. As the needle enters the peritoneal cavity, the loss in tissue resistance allows the spring mechanism to extrude the obturator back to its original position to prevent injury. Both reusable and disposable needles are available.
2.Small incision 1 cm long is made intra/subumbilically. The Veress needle is checked for proper function before use. With lifting the lower anterior abdominal wall by the left hand, introduce the Veress needle. The surgeon will be able to feel the needle piercing through the fascia and the peritoneum separately. The position of the needle is checked with a syringe containing saline: 1. aspiration should yield no bowel contents, bile, blood, or gas, 2. injection of 5-10 ml of saline should meet no resistance, and 3. repeat aspiration should not withdraw the injected saline because this would have dispersed in the peritoneal cavity. The needle is then connected to an insufflator and carbon dioxide is instilled at a pressure of 10 mmHg and with a rate of near to 1 liter/min. After adequate insufflation (tympanic resonance), the Veress needle is removed and the pneumoperitoneum is ready for operation.
3.Trocar ports are then used to insert first, the video-endoscope and then, the operating instruments into the peritoneal cavity. A variety of reusable and disposable trocar ports are available in sizes ranging from 5-mm to 25-mm. The commonly used sizes are: 5-, 10-, and 12-mm. They have two main parts: inner spit and outer cannula (port). First, a 5-mm disposable trocar port is presented. It has a safety shield mechanism that reduces injury to organs during insertion: it has a built-in safety shield that retracts to expose the sharp tip during insertion, and spring back on entry into the peritoneal cavity. After insertion of trocar ports the inner part (i.e. trocar or spit) is removed while, the outer part (i.e.port) stays inside the abdominal cavity. Trocar ports have a valve which allows introduction and withdrawal of instruments with minimal air leak.
4.A reusable 5- mm trocar port without safety shield is presented.
5.An 11-mm trocar port with a safety shield is presented. Correct holding of the trocar port during insertion.
6.A 10-mm trocar port without safety shield is presented. The spit is not sharp, it is coneshaped.
7.A reusable 12-mm trocar port with safety shield is presented.
8.“5-11-mm trocar ports”: means that instruments with 5-11 mm in diameter are inserted without a need for reducers. In case of other trocar ports, when using 5-mm instruments through their larger-sized ports, reducers are required to prevent air leak.
9.A 15-mm trocar port without safety shield is presented.
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10.A 10-mm in diameter trocar without safety shield is presented. After insertion of the trocar port the outer cannula (port) is screwed into the abdominal wall the same as a corkscrew.
11.First trocar port is inserted blindly. This is a 10-mm trocar port with safety shield. It is checked for proper function before use. After insertion of the trocar port the inner part is removed and, while the outer part remains inside the abdominal cavity. The port is then connected to an insufflator to supply the missing gas. Camera and light (fiber-optic) cable are connected to the optic (e.g. lens system). Then, the optic is inserted through the port into the abdominal cavity for inspection. The insertion of the subsequent trocar ports must be done under direct endoscopic vision.
12.Laparoscopic instruments are precisely ended long surgical tools with insulated or noninsulated handle. In most cases, these handles are ring-ended to guarantee a good grip. Close to our index finger a rotatable part is located for turning round the precise end. Some instruments have ratchet handle. First, a dissector is presented with a pistol handle.
13.Laparoscopic scissors with insulated handle. Above the handle there is a metal part, which is connectable to the electrocautery device. In this way, it will have both cutting and coagulating functions.
14.Curved dissectors are useful for preparation and gripping of fine tissues.
15.During laparoscopic operations two needle holders are necessary. One of this is shorter and thicker, namely “parrot”. The another one is longer and thinner, namely “flamingo”. Needle holders have linear (coaxial) handle.
16.Laparoscopic scissors.
17.Blunt-ended gripping instrument.
18.A crooked-ended instrument (Hook) is presented. Above the handle there is a metal part, which is connectable to the electrocautery device.
19.Dissecting forcepses (or dissectors) are useful for preparation and coagulation.
20.Laparoscopic irrigation/suction device. If its key is in the middle position the tool is closed. If we put it in forward position the fluid (saline solution) will irrigate the region (irrigating function), while setting it in a backward position leads to aspiration of fluids (i.e. blood, bile, etc.) (aspirating function).
21.Fan-retractor is useful to retract the liver during operation.
22.Dissector is demonstrated.
23-24. A disposable 10-mm in diameter 0° optic is presented. That one which has a bigger diameter and a white end is the ocular.Light cable is connected to the sideward metal part. The other end is the objective, which is going into the abdominal cavity. This rigid tool utilises the Hopkins rod-lens system to obtain clarity. End-viewing or 0° lens is adequate for most laparoscopic works.
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25.A reusable 10-mm in diameter 30° optic is demonstrated. This side-viewing optic allows better visualisation of awkward corners.
26.Camera. The first generation endoscopic cameras are the one-chip cameras, whereas the new generations are the three-chip cameras. These latter ones produce images of a higher quality and a better colour.
27.Light cable. A halogen cold-light source provides illumination via a fibreoptic cable, and a videoscope (camera) transfers the eyepiece image to a high resolution video monitor.
28.In the videooptic system the the light cable and the camera join to the optic.
29.Endoloops are useful to ligate tissues during operations (Endoloop©, Roeder-loop©). During laparoscopic suturing the atraumatic ski-shaped needle is used.
30.Monitor.
31.The insufflator tube is joined to the Veress needle.
32.Insufflator set. A filter is between the tube and the insufflator device, which is supporting the sterile CO2 gas flowing into the patient’s body cavity. With this device we can also monitor the most important parameters, such as intraabdominal pressure (here, 6 mmHg), the rate of gas flow (here, 5 liter/min) and the volume of the gas in the peritoneal cavity (here, 00.0 liter). Among these parameters, we can change the values of intraabdominal pressure and the flow rate.
33.The upper device is the camera set. The lower one is the light source with the light cable. The camera set is also joined to the monitor.
34.Here are the optic with the camera and the light cable, and they are joined to the camera set and the light source.
35.Electrocautery set.
36.Hook is attached to the electrocautery set.
37.Working of the electrocautery set by pedal. Cutting function is fulfilled by pressing the yellow pedal, while the coagulating function is excuted by the blue one.
38.To work with the monopolar electrocautery system the negatíve electrode should touch the patient’s dry skin.
39.The irrigator is jouined to the device with plastic tubes.
40.Pelvitrainer or trainer box. This is a laterally opened box. On the top of the box there are some holes to lead the laparoscopic instruments and the optic. It is a necessary thing in training the laparoscopic technique.
41.We cover the top of the pelvitrainer with a paper (or cloth) sheet. The instruments are inserted through the ports and we can follow our activity only on the monitor.
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