X Marks the Knot: Simplified Laparoscopic Intra-Corporeal Knot Tying

Abstract

Video Objective The objectives of this video are to present a novel technique for simplified laparoscopic intra-corporeal knot tying and to demonstrate the importance of laparoscopic simulation in learning new techniques. Setting Traditional intra-corporeal knot tying can be difficult, depending on the angle of the suture, port placement, or other technical difficulty. Many surgeons have turned to alternatives to circumvent this procedure, including the use of barbed suture, knotless suture re-load devices, Lapra-ty's, and extra-corporeal knot tying. However, this remains an important skill to for the gynecologic surgeon. This video presents a step-by-step technique of a novel intra-corporeal knot tying method. The setting includes both a simulation trainer for laparoscopy and a live surgery. The patient in the surgery is a 48-year-old female with abnormal uterine bleeding undergoing total laparoscopic hysterectomy; we use our laparoscopic knot to reinforce the vaginal cuff closure. Interventions The simplified extra-corporeal knot starts with placement of an interrupted suture. The primary surgeon crosses the suture to create an X, which is stabilized by the assistant surgeon. The primary surgeon passes the tail of the suture through the loop created by the X twice to create a surgeon's knot. The ends are then pulled downward to create a flat knot. This process is repeated. In order to create square knots, the tail should be passed in front of or behind the loop with each alternating throw. Conclusion The simplified intra-corporal knot is a useful resource for surgeons who experience difficulty with traditional laparoscopic knot tying. The maneuvers are intuitive and are similar to open two-handed knot tying. There is a learning curve associated with this procedure, and it is important to practice in a simulated setting. We hope this video will provide an alternative method for surgeons planning to tie intra-corporeal knots.