Intracorporeal Knot Research Articles

What is the cost associated with the implementation of the FLS program into a general surgery residency?

The implementation cost of the Fundamentals of Laparoscopic Surgery (FLS) program is unknown. The objective of this study was to evaluate the cost associated with the implementation of the FLS program into the skills curriculum of a busy general surgery residency. All general surgery residents (n = 15) followed a proficiency-based laparoscopic skills curriculum based on the FLS program. They watched the FLS CD-ROM and trained to proficiency on the five FLS tasks (peg transfer, pattern cut, ligating loop, and extracorporeal and intracorporeal knot tying). Training occurred in weekly 1-h supervised sessions. The cost associated with the implementation of the FLS program was assessed based on supplies, equipment, and personnel involvement. To decrease cost, task 3 (ligating loop) was modified to allow multiple uses of each endoloop, and sutures and Penrose drains were reused for task 4 (extracorporeal) and task 5 (intracorporeal). Resident skills lab attendance averaged 51% (range = 16-84%) and totaled 211 h. Fifty-three percent (8/15) of residents achieved proficiency in at least three of the tasks (peg transfer, pattern cut, and ligating loop) after a total of 577 repetitions during the study period. The overall cost associated with the FLS program was $13,091 (personnel cost, $3,338; equipment cost, $8,567; and supplies cost $1,186). The modification of task 3 (each endoloop was used an average of 8.8 times) and the reuse of sutures and Penrose drains saved $3,446. This is the first study to describe the cost associated with the implementation of the FLS program in a surgical residency. It demonstrates cost savings by the modification of task 3 (to allow for multiple uses of each endoloop) and tasks 4 and 5 (reuse of suture and Penrose drains) without compromising task quality. This information may be useful to programs implementing FLS into their curricula.

FLS Skill Retention (Learning) in First Year Surgery Residents

Fundamentals of Laparoscopic Surgery (FLS) certification is reliable and valid; the American Board of Surgery requires FLS certification. Dynamics of skill retention after FLS training effect training schedules for residents. We hypothesized that the initial elevation of performance levels after FLS training would deteriorate predictably with time. FLS performance data on 16 new surgical residents (R01s) was examined retrospectively. These R01s trained at 16 weekly sessions. Training included 4 FLS tasks, VR simulator tasks, and open surgical skills. FLS skills were practiced weekly with feedback but no instruction. Performance was tested PRE, POST, and DELAY. Outcome metrics were task completion times (TCTs). POST TCTs were below PRE TCTs in all R01s for all FLS tasks (P < 0.05). No difference was seen between the DELAY TCT and POST TCT for peg transfer (P = 0.726) and pattern cut (P = 0.114). The DELAY TCTs were longer than POST TCTs for extra- and intra corporeal knot-tying (P < 0.0001 and P = 0.029). Relative retention was 103% for peg transfer, 85% for pattern cut, 47% for extracorporeal knot tying, and 59% for intracorporeal knot tying. However, many individual's displayed DELAY TCT equal to or lower than POST TCT implying full retention. This study extends the data on FLS skill retention to an actual "production" training curriculum. This FLS training provided effective learning in R01s. Although performance levels fell across these tasks on average and for the majority of individual R01s, significant skill retention remained at 7-8 months. Early training will enable R01s to maintain or elevate skill levels with additional training sessions.

Hand-assisted laparoscopic surgery is associated with enhanced depth perception in novices

The visual information obtained in hand-assisted laparoscopic surgery (HALS) and total laparoscopy is based on two-dimensional depth cues. This study was designed to test the hypothesis that intracorporeal hand improves depth perception in HALS. Ten subjects were divided into two groups using HALS or total laparoscopy. The first task was passing a 10-cm thread through four small metallic loops five times; the second was tying 30 square three-throw intracorporeal laparoscopic knots. End points were (1) number of past pointing as an index of movement accuracy and reflection of depth perception, (2) execution time, and (3) knot quality score. The HALS group was significantly faster than total laparoscopy with a median (interquartile range (IQR)) of 117 s (75.5) vs. 179 s (235.5; P = 0.001) for the thread passing task and 97 s (43.3) vs. 130 s (68.3; P < 0.0005) for knot tying. The number of past-pointing events was significantly lower with HALS compared with total laparoscopy with a median (IQR) of 12 (8) vs. 23 (24; P = 0.001) for the thread passing task and 7 (5) vs. 13 (10; P < 0.0005) for knot tying. There was a significant main effect of whether the targeted object was in contact with the other instrument in knot tying task when past-pointing occurred (P = 0.031). No difference in a knot quality score was found between the HALS and total laparoscopy. The accuracy of instrument movement was significantly better in the HALS group compared with total laparoscopy. The study confirmed the hypothesis that intracorporeal hand improves depth perception in HALS. Also, the touch of the assisting instrument with the target object enhances spatial orientation in the laparoscopic operative field. However, further study is needed to test the hypothesis in experts.

V764 ROBOTIC UPPER POLE PARTIAL NEPHRECTOMY WITH ENBLOC ADRENALECTOMY

You have accessJournal of UrologyOncology (TCC & Adrenal) & Teaching Techniques1 Apr 2010V764 ROBOTIC UPPER POLE PARTIAL NEPHRECTOMY WITH ENBLOC ADRENALECTOMY Georges-Pascal Haber, Riccardo Autorino, Michael A. White, Rakesh Khanna, Sylvain Forest, Robert J. Stein, and Jihad H. Koauk Georges-Pascal HaberGeorges-Pascal Haber More articles by this author , Riccardo AutorinoRiccardo Autorino More articles by this author , Michael A. WhiteMichael A. White More articles by this author , Rakesh KhannaRakesh Khanna More articles by this author , Sylvain ForestSylvain Forest More articles by this author , Robert J. SteinRobert J. Stein More articles by this author , and Jihad H. KoaukJihad H. Koauk More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1358AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic partial nephrectomy (RPN) is emerging as a viable treatment option for renal tumors amenable to nephron-sparing surgery. At our institution we have cautiously expanded the indications of RPN to more challenging cases. Herein we present a case of robotic partial nephrectomy with en bloc adrenalectomy for an upper pole right renal mass and concomitant suspicious adrenal mass. METHODS The patient was a 54 years old lady with no previous urological disease who had been incidentally diagnosed with an upper pole renal mass. CT scan showed a 4.9-cm round solid cystic mass in the upper pole of the right kidney and a concomitant 1.6-cm round mass involving the right adrenal gland. A robotic transperitoneal partial nephrectomy with enbloc adrenalectomy was planned. RESULTS The ureter id identified and lifted from the psoas muscle while keeping the gonadal vein attached to the vena cava medially. With the ureter lifted off the psoas muscle, dissection proceeded cephalad towards the hilum. Renal vein and artery were isolated and both prepared for bulldog clamping. The adrenal was dissected from the vena cava and its medial and superior attachments freed with robotic hook. Adrenal vein and arteries were controlled with Weck clips and divided. Superior dissection was completed. The upper pole of the kidney was then mobilized and deffated while preserving peritumoral fat. Under intraoperative ultrasound guidance, the renal mass was identified and the margins scored. After clamping renal artery and vein with bulldogs, the tumor was excised using cold scissors and collecting system opened securing negative margins. The base of the excision and the collecting system were sutured with 2-0 Vicryl in a running fashion. To minimize ischemia time, weck clips replaced intracorporeal knotting. Hilum was early unclamped and additional parenchymal sutures placed over a Surgicel bolster with kidney perfused. Hemostatis was found to be excellent and Tisseel was spread over the excision bed. Operative time was 2.5 hrs, Warm ischemia time 22 min and blood loss 100 mL. At the end of the procedure, a right side pneumothorax was diagnosed and successfully managed with a chest tube. Hospital stay was 4 days. Pathological report revealed a clear cell, pT1b, grade 2, renal cell carcinoma with negative surgical margin. The adrenal mass was a nodular cortical hyperplasia. CONCLUSIONS In cases of upper pole renal tumor with concomitant ipsilateral adrenal disease, RPN with en bloc adrenalectomy is feasible and can be efficaciously performed while adhering to surgical oncological principles Cleveland, OH© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e299 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Georges-Pascal Haber More articles by this author Riccardo Autorino More articles by this author Michael A. White More articles by this author Rakesh Khanna More articles by this author Sylvain Forest More articles by this author Robert J. Stein More articles by this author Jihad H. Koauk More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Comparison of Holding Strength of Suture Anchors on Human Renal Capsule

The use of surgical clips as suture anchors has made laparoscopic partial nephrectomy (LPN) technically simpler by eliminating the need for intracorporeal knot tying. However, the holding strength of these clips has not been analyzed in the human kidney. Therefore, the safety of utilizing suture anchors is unknown as the potential for clip slippage or renal capsular tears during LPN could result in postoperative complications including hemorrhage and urinoma formation. With the above in mind, we sought to compare the ability of Lapra-Ty clips and Hem-o-lok clips to function as suture anchors on human renal capsule. Fresh human cadaveric kidneys with intact renal capsules were obtained. A Lapra-Ty clip (Ethicon, Cincinnati, OH) or a Hem-o-lok clip (Weck, Raleigh, NC) was secured to a no. 1 Vicryl suture (Ethicon) with and without a knot, as is typically utilized during the performance of LPN. The suture was then placed through the renal capsule and parenchyma and attached to an Imada Mechanical Force Tester (Imada, Northbrook, IL). The amount of force required both to violate the renal capsule and to dislodge the clip was recorded separately. Six Lapra-Ty clips and six Hem-o-lok clips were tested. The mean force in newtons required to violate the renal capsule for the Lapra-Ty group was 7.33 N and for the Hem-o-lok group was 22.08 N (p < 0.001). The mean force required to dislodge the clip from the suture for the Lapra-Ty group was 9.0 N and for the Hem-o-lok group was 3.4 N (p < 0.001). When two Hem-o-lok clips were placed on the suture in series, the mean force required to dislodge the clips was 10.6 N. When compared with Lapra-Ty clips, using two Hem-o-lok clips may provide a more secure and cost-effective method to anchor sutures on human renal capsule when performing LPN.

A simple technique for knot tying in single incision laparoscopic surgery (SILS)

A simple technique for knot tying in single incision laparoscopic surgery (SILS)

The Minailo knot: a time-saving and cost-saving technique.

Endoscopic knot tying during minimally invasive surgery can be complicated, time consuming, and associated with a protracted learning curve. The Minailo knot seems to be a reasonable option because the technique does not require any specialized instrumentation or skill to perform. In particular, vaginal closure is obtained with the placement of a single intra-corporeal knot. Our initial and successful experience with this knot-tying technique during robotic hysterectomy for treatment of gynecologic disease suggests that the method is safe and feasible.

Extracorporeal “Giant” Locking Sliding Knot in Pediatric and Neonatal Minimally Invasive Surgery: Indications, Techniques, and Outcomes

A prospective study to assess the clinical application of extracorporeal "Giant" locking sliding knot (GLSK) in pediatric and neonatal minimally invasive surgery (MIS). A total of 152 MIS, of various complexities were performed over a 14-month period with more than 1100 GLSKs used in 126 procedures. There were no major complications or deaths in this cohort. Unraveling of the GLSK was observed in three instances (0.3%) secondary to excessive manipulation. Only a copolymer of glycolic acid/trimethylene carbonate material (Maxon suture; Covidien, Norwalk, CT) and polyproplene (Prolene suture; Ethicon, Sommerville, NJ) can be used for the GLSK technique due to their very smooth surface. Extracorporeal GLSKs can replace intracorporeal knots because they are safe, faster to tie, and reduce the surgeon's fatigue during complex MIS.

Single-knot running suture anastomosis (one-knot pyeloplasty) for laparoscopic dismembered pyeloplasty: training model on a porcine bladder and clinical results

The one-knot running ureteropelvic anastomosis is a modification of the single-knot running suture that was previously described for urethrovesical anastomosis. In this study, we present a novel porcine model for laparoscopic pyeloplasty training and report the results obtained in patients who underwent one-knot pyeloplasty. A porcine bladder was used for the ureteropelvic junction simulation in this training model. The laparoscopic one-knot pyeloplasty technique was attempted by five laparoscopic surgeons using this model, and the technique was then incorporated into clinical practice. The data of all patients who underwent this procedure between January 2006 and February 2008 were evaluated. The one-knot pyeloplasty technique was easily applied in a short time by laparoscopic surgeons in a novel porcine pyeloplasty model. The participants successfully performed a watertight anastomosis in the porcine bladder model, completing the task in <30 min by the fifth attempt. The time required to succeed before and after training decreased by 20.8% (P = 0.01). In the clinical portion, 40 laparoscopic pyeloplasty procedures were performed with this technique, and the mean time to complete the anastomosis was 27.1 min (range: 12-41). This time was concordant with the final anastomosis time performed in the pelvitrainer. The one-knot pyeloplasty is feasible and reproducible, and it overcomes the obstacles caused by multiple intracorporeal knots when performing laparoscopic pyeloplasty. Furthermore, the porcine bladder model that we introduce herein is a readily available and simple model to refine suturing techniques for pyeloplasty.

Laparoscopic Suturing – Tips and Tricks

Study Objective: Laparoscopic suturing is an important skill for the minimally invasive surgeon. In this video, basic suturing techniques as well as several tips and tricks are shown in a case based fashion. The techniques shown are: intracorporeal knot tying and ovarian suspension during laparoscopic cerclage placement, three vaginal cuff closure methods using bidirectional barbed sutures or the Ti-knot device, extracorporeal knot tying, cinch knot and rectosigmoid suspension during laparoscopic apical suspension cases, suturing techniques for laparoscopic myomectomy closure and utero-ovarian suspension for added exposure during surgery for advanced endometriosis.

Laparoscopic ureterolysis and dissection of the paravesical space for deeply scarred adnexal masses

Laparoscopic ureterolysis is a delicate procedure that requires advanced laparoscopic skills. We are reporting two cases of laparoscopic hysterectomy and salpingo-oophorectomy with severe adhesions to the pelvic sidewall that required ureterolysis and describing a modified technique suitable for the laparoscopic performance of this procedure. In more than 15 years of doing laparoscopic ureterolysis to deal with various gynecological cases, we have never had a ureteral injury related to the ureterolysis procedure. There have been uterine artery lacerations, usually when trying to apply clips for uterine artery ligation in which case the artery can be compressed with a clamp until it is reclipped, bipolar-cauterized or suture-ligated using intracorporeal knot tying. However, we did not have a single patient that required open surgery because of these lacerations. Because of the advantage of magnified viewing and laparoscopic dissection techniques which control small vessel bleeding, the laparoscopic route for ureterolysis is far easier to use than its open counterpart once it is learned. Laparoscopy, in addition, offers the added advantages of shorter hospital stay, reduced patient pain, reduced transfusion requirements and far better cosmetic results.

Feedback in laparoscopic skills acquisition: an observational study during a basic skills training course

This study aimed to obtain insight in the effect of expert feedback during a basic laparoscopic skills training course for residents. A questionnaire was held among participants regarding provided feedback and the self-perceived laparoscopic skills improvement. The participants (n = 24) who completed the questionnaire were in their first to fifth postgraduate year. Most feedback was directed at intracorporeal knot tying (47% reported extensive feedback), while camera navigation and body positioning received the least feedback (40% and 43%, respectively, responded to have received no feedback at all). After the course, the self-perceived competence in intracorporeal knot tying and cutting had improved significantly, while camera navigation, body positioning, pointing, and grasping tasks did not improve. In conclusion, most benefit from expert feedback can be obtained at the start of the learning curve. Therefore, the basic laparoscopic skills course should be attended early in residency. Additionally, it is crucial that training objectives are clear prior to a course for both the expert and the trainee, in order to focus the feedback on all training objectives.

Comparison of Text versus Video for Teaching Laparoscopic Knot Tying in the Novice Surgeon: A Randomized, Controlled Trial

Background Video seems advantageous over traditional text as an educational tool in conceptually-based procedures such as laparoscopy. However, this has never been tested directly. Objective The purpose of this study was to compare the use of text versus video as an educational tool for laparoscopic training, through a randomized controlled trial. Study Design Prospective, randomized, controlled clinical trial (Canadian Task Force classification I). Methods Eighty (n = 80) medical students, who had no experience with tying a laparoscopic intracorporeal knot, were randomly taught to do so by either reading a text with accompanying pictures (n = 40) or watching a short video with audio of comparable content (n = 40). The participants were allowed to review the material for as long as they needed to achieve understanding of the procedure. They were then asked to tie a laparoscopic square knot in a box trainer, with a limit time of 15 minutes. Time to review the educational material(s), time to tie the knot(s), numbers of attempts at the task (n), and numbers of those who expressed understanding of the task (n) were recorded. Results The number of participants who were able to complete the knot (n = 14 text v. n = 18 video, p = 0.49) and the average time needed for completion (479 s text v.494 s video, p = 0.38) were not statistically different in the two groups. However, time to review the material (407 s text v. 258 s video, p < 0.001), number of attempts at the task (15 text v. 5 video had n>2 attempts, p = 0.01), and number of those who expressed understanding when they could not complete the task (35% text v. 59% video, p = 0.047) were statistically different. Conclusions This is the first randomized trial evaluating video alone as an educational tool in laparoscopic training. It demonstrates that video is superior to text in achieving superior conceptual understanding, without improving operative times. Understanding through video instruction cannot make up for a lack of technical ability in novice surgeons.

Axial-spin Technique of Endoscopic Intracorporeal Knot Tying: Comparison With the Conventional Technique and Objective Assessment of Knot Security, Learning Curves, and Performance Efficiency Across Training Levels

A major limitation of conventional laparoscopic surgery is the placement of an intracorporeal (IC) knot, which requires a significant amount of training and practice. An easier technique of IC knot tying using 90-degree grasper is compared with the conventional technique (CLT). The new axial-spin technique (AST) uses the spin of the instrument shaft to tie IC knots. Fourteen participants stratified into 3 training levels were instructed to tie 50 reef IC knots using each technique on trainers in 3 sessions. The final 5 knots tied using each technique were deemed to be representative of maximal performance efficiency (PE) and randomly subject to tensile strength measurements using a tensiometer at 50 mm/s distraction. Mean knot execution time (mKET) measured in seconds (s), normalized KE time (nET=group mean/mKET), knot holding capacity, relative knot security (RKS), and PE (PE=RKS/nET) of the knots tied were computed and analyzed using paired t and analysis of variance. Variables included knot-tying session, technique and the training level. On completion of the study, junior residents (JR) averaged 51.72 seconds more, senior residents (SR) averaged 26.22 seconds more and attendings (ATT) averaged 19.17 seconds less to tie using CLT compared with the AST (F=40.52, P=0.0001). Across all levels, the CLT technique was taking 83.26 seconds on average to execute an IC knot compared with 59.08 seconds with AST method (t=2.784, P=0.015). Learning curves revealed that JR significantly improved mean KE times with the AST technique (first session vs. final session: 473.8 s vs. 55.9 s) compared with CLT (672.5 s vs. 107.6 s) across the sessions as compared with those in advanced levels of training. The RKS of knots executed by AST was significantly stronger (AST: 13.1 vs. 5.44 N, t=4.9, P=0.0001). The PE of knots executed using the CLT increased geometrically across training levels (JR: 1.35% SR: 5.58% ATT: 11.22%) whereas those of AST showed a linear trend (17.09%; 17.11%, and 13.95%). The AST follows a linear pattern of learning across training levels compared with the steep exponential learning of the CLT. Inexperienced JRs were surprisingly 1.5 times more efficient with AST and 8 times less efficient with CLT compared with ATT using the CLT to execute the same knot. The AST is significantly easier to learn for JRs and could serve as a platform before acquiring more advanced knot-tying skills. Overall, with the AST, execution times are significantly shorter whereas the RKS and PE are significantly higher. JRs achieve a level of proficiency comparable with the senior level residents and ATT after participating in a reasonable training session consisting of at least 25 knots.

Locking sliding knots in laboratory model of thoracoscopic repair of esophageal atresia

Aim The study aimed to assess feasibility and strength of locking sliding knots, in comparison to intracorporeal square knots, in a thoracoscopic model of esophageal atresia (EA). Methods A simple thoracoscopic model of EA was created, and inside this model, 26 sliding knots were used to suture a soft drain together. In all cases, ten 5-0 monofilament sutures were used for this “anastomosis.” The drain is then mounted on a motorized digital tensometer, and the knots with the best tension profile were retested 4 more times to obtain an average. The tensometer measured the knots' strength by producing a constant and increasing weight on the sutured EA model and continuous readings were taken by integrated computer software. The point, at which either the knot slipped, broke, or the drain disrupted, was taken as the maximum load tolerated by the sliding knots. Knot pushers were not required for any of these knots. Results Of the 26 sliding knots, only locking sliding knots tolerated reasonably high tensions. However, when comparing these knots to the standard square knot, only Giant and Field knots had similar tension readings. Field knot was found to be very complex and therefore impractical with 5-0 suture material, leaving Giant knot as the only knot with favorable results. Conclusions Locking sliding knots and particularly Giant knot could have an enormous impact in minimally invasive surgery of neonatal conditions and can potentially replace intracorporeal knots. Giant knot is faster to tie and thus could reduce surgeon's fatigue during complex procedures.

Robotic-assisted sacrocolpopexy: technique and learning curve

Laparoscopic sacrocolpopexy (LSCP) offers a minimally invasive approach for treating vaginal vault prolapse. The Da Vinci robotic surgical system may decrease the difficulty of the procedure. The objective of this study was to describe the surgical technique of robotic-assisted sacrocolpopexy (RASCP) and evaluate its feasibility, safety, learning curve, and perioperative complications. Eighty patients underwent RASCP between November 2004 and June 2007. Robotic dissection of the planes between the bladder and vagina anteriorly and between the vagina and rectum posteriorly was performed. A peritoneal incision was made to expose the sacral promontory and extended down to the vaginal apex. A Y-shaped mesh was sutured to the anterior and posterior surfaces of the vagina. The tail end of the mesh was sutured to the sacral promontory. Intracorporeal knot tying was used in all sutures. The peritoneal incision was closed to cover the mesh using a running suture. Mean operative time was 197.9 [standard deviation (SD) 66.8] min. After completion of the first ten cases, mean operative time decreased by 25.4% [64.3 min, 95% confidence interval (CI) 16.1-112.4 min, p < 0.01]. Two (2.5%) patients had injury to the bladder, one (1.2%) patient had a small bowel injury, and one (1.2%) patient had a ureteric injury. Postoperatively, five (6%) patients developed vaginal mesh erosion, one (1.2%) patient developed a pelvic abscess, and one (1.2%) patient had postoperative ileus. Four (5%) cases were converted to laparotomy. Mean follow-up period was 4.8 months (range 1-24 months). RASCP is a feasible procedure with acceptable complication rates and short learning curve.

Tying laparoscopic intracorporeal knots with one instrument: "Dowais tie"

In laparoscopic surgery, intracorporeal suturing is one of the most important and difficult techniques.Laparoscopic intracorporeal knot tying in minimally invasive surgery is an advanced skill. Mastering this skill is a difficult process with a long learning curve. Intracorporeal suturing is essential in advanced laparoscopy and is a rate-limiting step in many procedures. The technique we wish to describe makes the art of knot-tying simple and straightforward by the use of a single laparoscopic needle holder. This technique, which we called Dowais tie, is useful for totally trans-umbilical laparoscopic surgery. This simple and useful technique of intracorporeal knot tying is demonstrated in this report

Laparoscopic partial cystectomy for bladder endometriosis

Laparoscopic partial cystectomy performed for bladder endometriosis in selected patients requires advanced laparoscopic skills including pelvic dissection, suturing and intracorporeal knot tying. Cystoscopic skills to assess the extent of endometriosis involvement in the bladder and to place ureteral stents if endometriosis involves or is close to the trigone, ureters, or projected course of the intramural part of the ureter are also required. Previous authors have recommended the laparoscopic technique only with bladder endometriosis that is distant from the bladder neck, the ureteral orifices, and the trigone, to allow a resection margin of 1-2 cm. We find no reason to exclude patients with these involvements if the surgeon can safely do the resection and reconstruction. We report a 32-year-old patient referred by her urologist for the evaluation and treatment of biopsy-proven bladder endometriosis penetrating the bladder wall and mucosa above and to the right of the midline of the trigone approximately 1.5 in. in diameter with fibrotic scarring extending to the trigone and very close to the right ureteral orifice. The patient successfully underwent partial laparoscopic cystectomy as described in the body of the paper.

Suturing versus flowering technique of Bruhat after fimbrioplasty for endometriosis-related infertility

The objective of this study is to compare the effectiveness of two surgical techniques (suturing versus flowering of Bruhat) after fimbrioplasty for treatment of distal tubal pathology in infertile women with endometriosis. This is a historical cohort study with 12 months of follow-up comparing pregnancy rates achieved spontaneously or after controlled ovarian hyperstimulation (COS) with intrauterine insemination (IUI) in infertile women with endometriosis who underwent laparoscopic fimbrioplasty. A total of 154 patients with endometriosis-related infertility (pelvic inflammatory disease was excluded by absent history and negative Chlamydia trachomatis serology) had fimbrioplasty using salpingostomy procedure for treatment of distal tubal pathology. The edges of the fimbrial ostium were everted using either the flowering technique of Bruhat or 6-0 Vicryl sutures (intracorporeal knot) using microsurgical techniques. Forty-six patients had flowering (group 1) and 108 had suturing (group 2) technique, followed by timed intercourse and/or ovarian hyperstimulation with insemination (COS-IUI) with follow-up until pregnancy or at least 12 months. There was no significant difference in patients’ characteristics (age, infertility duration, and endometriosis stage) between the two groups. The pregnancy rate per cycle or per patient and cumulative pregnancy rates were not significantly different between the two groups. There appears to be no advantage of the suturing technique over flowering after salpingostomy for fimbrioplasty. The latter method is easier to learn and requires less operative time to perform.

A New Technique for Intracorporeal Knot Tying in Laparoscopic Surgery

Laparoscopic intracorporeal knot tying in minimally invasive surgery is an advanced skill. Mastering this skill is a difficult process with a long learning curve. Intracorporeal suturing is essential to advanced laparoscopy and is a rate-limiting step in many procedures. Many different instruments and methods have been described for laparoscopic suturing and knot tying. We have developed a new technique for laparoscopic knot tying. The long end of the suture is held with a left-hand instrument, and the instrument is rotated for 360 degrees in a clockwise direction to make a forward-direction loop. The end of the loop is grasped with the right-hand instrument, and the other end of the suture is grasped with the left-hand instrument. The suture end, held by the left hand, is pulled though the loop and tied, thus making a half-knot of a square knot. The second half-knot is made by using the right-hand instrument with the same technique. Laparoscopic suturing and knotting is difficult to perform, especially when the angle between the working instruments is narrow and working space is limited. In all these situations, knot tying using this technique makes knotting more simple and easy to perform, especially for those who have limited experience in intracorporeal suturing and knot tying. No special instrument is required to perform knot tying with this technique.