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      Analysis and Physics of Laparoscopic Intracorporeal Square-Knot Tying

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          Abstract

          Square knots are often used in open surgery to approximate tissue borders or tie off tubular structures like vessels or ducts. Three common methods are used for surgical square-knot tying: one-hand tying, two-hand tying, and the instrument-tying technique. Two types of suture placements are studied in both the open and laparoscopic surgical fields. The first called equal length has suture segment ends placed at equal distances from the tying site. The second called unequal length has one suture end further away from the tying site than the other. Laparoscopic intracorporeal square-knot tying maneuvers are analyzed herein. Mechanical analysis of square-knot tying movements reveals that regardless of location or method used in construction, all square knots consist of 2 half-knots. For study purposes, these sets of movements are identified in laparoscopy as maneuver A and maneuver B. Further breakout of these maneuvers reveals that they consist of 5 motions. This study reveals that 16 different ways exist to place a square knot by means of the laparoscopic intracorporeal technique. It is likely that difficulty mastering this essential skill is not just the result of poor instrumentation, improper port placement, or the limitations of a 2-dimensional video image. It may also be attributed to mixing up the different square-knot tying techniques during random practice exercises. This is possible if the surgeon is ignorant of the technical variations present in what most people consider a simple task.

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          Endoscopic suturing and knot tying: theory into practice.

          D. Murphy (2001)
          To advance modern surgical techniques of endoscopic knot tying, encompassing a new appreciation of knot-tying theory and the application of second-generation, purpose-designed instruments. During open surgery, surgeons automatically create the surgical half-hitch by using either instrument or hand/finger knot-tying methods (figure 4). Each of these methods, which are mirror images of each other, forms the same result, the half-hitch. Two opposing half-hitches are needed to form a square knot. There are many ways for new-generation instruments to create a secure square knot during endoscopic surgery. An overview of the current endoscopic knot-tying methods is presented. The author presents a theoretical analysis of square knot-tying techniques as applied during instrument and hand/finger movements. The application of a mirror-image concept was considered in the analysis of these two contrasting methods. There are 12 ways to create a square knot, some of which have previously not been described or needed in open surgery. Some of these methods have particular application in endoscopic surgery. A new understanding of knot-tying theory has been developed, with innovative methods being defined for tissue approximation during endoscopic surgery. These ergonomic, efficient, and contrasting methods of knot tying are described using second-generation endoscopic instruments. The new techniques have direct and broad application in many fields of minimally invasive surgery.
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            Image Rotation and Reversal - Major Obstacles In Learning Intracorporeal Suturing and Knot-Tying

            Background and Objectives: A major stumbling block to teaching and learning the finer skills of laparoscopy is related to the “optical illusions” the video camera plays on the surgeon's eyes. Until now, the belief was that lack of coordination was the result of depth perception deficiencies resulting from the two dimensional plane of the video monitor. In reality, this is a minor problem that is easily surmounted with practice. A closer analysis of how organ orientation at the operative site compares to the video camera's fields of focus reveals the real problem: the major optical difference between laparotomy and laparoscopy involves rotation of the images received by the brain. Conclusions: There are four major operating positions in laparoscopy: camera position, right camera position, left camera position and opposite camera position. The object in front of the camera has two components; the first, a reality image, which results from light reflected off the object as it exists in time and space. The second, a visual image, which represents the actual light entering our eyes. At right camera position the visual image is a 90 degree counterclockwise rotation of the reality image. At the left camera position the visual image is a 90 degree clockwise rotation of the reality image. At opposite camera position, a 180 degree rotation and complete reversal of the reality image occurs. It is only at camera position that the visual image is equal to the reality image, and we approach a scenario similar to that found in laparotomy. Every other position will be unlike what we were accustomed to in open surgery.
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              Formidable Challenges to Teaching Advanced Laparoscopic Skills

              Despite the acceptance of laparoscopy for performing routine operations, a need still exists for experienced surgeons and surgical residents to maintain and refine essential surgical skills. Unless used on a frequent basis, laparoscopic skills are not easily maintained. In addition, when new laparoscopic instruments are introduced, surgeons need a way to practice using them that does not involve immediate patient contact. Novice surgeons need the most training of all and ideally would be best served using a standardized teaching curriculum that would cover as many of the basic laparoscopic parameters as possible. This article discusses how best to set up a laparoscopic simulation training program that covers as much ground as necessary, while respecting the restraints of time limitations and monetary concerns
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                Author and article information

                Journal
                JSLS
                JSLS
                jsls
                jsls
                JSLS
                JSLS : Journal of the Society of Laparoendoscopic Surgeons
                Society of Laparoendoscopic Surgeons (Miami, FL )
                1086-8089
                1938-3797
                Jan-Mar 2005
                : 9
                : 1
                : 113-121
                Affiliations
                Rio Grande Regional Hospital, McAllen, Texas, USA.
                Author notes
                Address reprint requests to: Marelyn Medina, MD, The Family Urology Center, 412 E. Dove Ave, McAllen, TX 78504, USA. E-mail: mm@ 123456MedinaTrainer.com
                Article
                3015543
                15791984
                652ed31c-4ee3-4ffa-9d13-553eb92f22ce
                © 2005 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License ( http://creativecommons.org/licenses/by-nc-nd/3.0/), which permits for noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited and is not altered in any way.

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                Techniques

                Surgery
                pelvic trainer,laparoscopic trainer,laparoscopic square-knot tying,laparoscopic education,laparoscopic physics

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