THE KNOT BEFORE LOOP TECHNIQUE FOR THE ENDOSCOPIC LIGATION AND SUTURE-INSTRUMENT SET - KNOT FORMATION AND APPLICATION

Background: In minimally invasive surgery intracorporal knot-tying is complicated by a limited field of vision and depth perception. Methods : The ''knot before loop'' technique aims to reduce intraabdominal mov ements in number and space needed. A grasping instrument 3 mm in diame ter guides a slipfit hollow knot pusher with a notch to hold the threa d, when extracorporally forming the knot on the instrument tip and an axial slot. The loop is finished under endoscopic vision, yet a second loop is created along the thread. The knot is tightened and secured b y closing the second loop without troublesome instrument change. Resul ts: The strength of the knot was tested and the feasibility of the ins trument set was proven in pigs and 25 cholecystectomies and hernia rep airs in humans. Conclusions: Endoscopic application of a secured slip knot is simplified by the ''knot before loop'' technique. The independ ent formation of the knot by the assisting personnel allows quick appl ication, equivalent to the use of clips and staples. The benefit in co st saving is high.