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Intracorporeal (IC) knot tying is a valuable and versatile skill for the laparoscopic surgeon. There are several techniques of laparoscopic IC knot tying with and without mechanical assist devices. The Rosser needle-post technique is depicted in this series. The moves are broken down into a series of discrete steps, leading to the smooth execution shown in this video. This skill should be practiced under supervision in the lab using a dry trainer before it is attempted in the operating room. The mastery of this technique also helps perfect the other aspects of laparoscopic manipulation.
Working ports should ideally form an angle between 45 and 60 degrees (instrument convergence angle) relative to the target site. The camera port should be outside this angle to avoid interference. The angled scope tip compensates for the offset camera position. The surgeon’s forearms should be aligned with the shafts of the instruments for efficiency and comfort, and this is determined by the instrument entry angle (a function of port placement). The optimal suture length for a single stitch is 10cm. A curved needle is optimal for atraumatic tissue penetration and adequacy of depth, and must be introduced through a 10 mm or larger port. Silk suture has the best “hand” for IC suturing, and should be stretched and wet to remove the “memory” of packaging kinks. The suture is grasped with the assist device in the surgeon’s non-dominant hand. The suture is grasped 2-3 cm proximal to the needle (grasping point) and the needle is oriented in the direction the point will be passed (position of function). The needle driver in the surgeon’s dominant hand is placed on the target to assist the surgeon’s stereotactic “feel” for the direction of introduction of the needle-suture complex.
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