Endoscopic suturing and knot tying: Theory into practice

Objective To advance modern surgical techniques of endoscopic knot tying, e ncompassing a new appreciation of knot-tying theory and the application of second-generation, purpose-designed instruments. Summary Background Data During open surgery, surgeons automatically create the surgical half-hitch by using either instrument or hand/finger knot-tyin g methods (figure 4). Each of these methods, which are mirror images of eac h other, forms the same result, the half-hitch. Two opposing half-hitches a re needed to form a square knot. There are many ways for new-generation ins truments to create a secure square knot during endoscopic surgery. An overv iew of the current endoscopic knot-tying methods is presented. Methods The author presents a theoretical analysis of square knot-tying tec hniques as applied during instrument and hand/finger movements. The applica tion of a mirror-image concept was considered in the analysis of these two contrasting methods. Results There are 12 ways to create a square knot, some of which have previ ously not been described or needed in open surgery. Some of these methods h ave particular application in endoscopic surgery. Conclusions A new understanding of knot-tying theory has been developed, wi th innovative methods being defined for tissue approximation during endosco pic surgery. These ergonomic, efficient, and contrasting methods of knot ty ing are described using second-generation endoscopic instruments. The new t echniques have direct and broad application in many fields of minimally inv asive surgery.