Application of an Extracorporeal-Assisted Intracorporeal Sliding Knot-Tying Technique in Minimally Invasive Surgery in Children

Abstract

Background:

A retrospective study was carried out to determine the feasibility and safety of an extracorporeal-assisted intracorporeal sliding knot-tying technique in minimally invasive surgery in children.

Materials and Methods:

From June 2009 to December 2017, a total of 333 cases of pediatric minimally invasive surgery were performed using the extracorporeal-assisted intracorporeal sliding knot-tying technique. Polyester, polyglactin, and polydioxanone sutures were used for suturing and knotting. The average time used for knotting was recorded during the surgery. The patients were followed up for unraveled knots and recurrence of the diseases.

Results:

All 333 surgical procedures were performed successfully, including 152 cases of thoracoscopic diaphragmatic hernia repair, 151 cases of thoracoscopic diaphragmatic plication, 7 cases of thoracoscopic esophageal anastomosis, and 23 cases of laparoscopic esophageal hiatal hernia fundoplication. No serious complications or mortalities were observed. Twelve-month to 9-year follow-up showed that all pediatric patients recovered well and no recurrence or unraveled knots were found.

Conclusions:

This new knot-tying technique is safe and feasible for various minimally invasive endoscopic surgeries, especially for suturing tissues under tension, such as thoracoscopic diaphragmatic hernia repair, laparoscopic esophageal hiatal hernia repair, and fundoplication. All types of sutures can be used for this knot-tying technique. It is easy to learn and can be quickly mastered by doctors with endoscopic surgery experience.

Introduction

Minimally invasive, safe, and fast surgery techniques are continuously being developed. With the improvements of minimally invasive surgical techniques such as thoracoscopic and laparoscopic surgeries, the types of diseases that can be treated with endoscopic surgery have increased rapidly.^1,2 However, as the complexity of the surgery increases, there is a higher demand for delicate surgical procedures. Intracorporeal knot tying has always been a difficult procedure in thoracoscopic or laparoscopic surgery, especially in minimally invasive surgery in children,^3,4 because of the restrictions of thoracic or abdominal cavity in pediatric patients and limited movement of surgical instruments.

Many surgeons have explored various endoscopic knotting techniques.^3–9 There are mainly two types of knotting techniques: extracorporeal knotting and intracorporeal knotting.

Extracorporeal knotting mostly uses knot-pusher, which pushes the loop formed outside the body cavity into the thoracic or abdominal cavity for tightening. Intracorporeal knotting is mainly accomplished using surgical instruments such as grasping forceps, needle holders, and some special right-angle grasping forceps.⁷ Intracorporeal knotting techniques, such as square knot and surgeon's knot, can be operated smoothly under an endoscope in tissues without tension.³ However, suturing tissues with tension requires some special knotting techniques, such as giant knot^7,10 and field knot. Giant knot is a type of sliding knot that requires special sutures with smooth surface like Maxon™ (Covidien, Norwalk, CT) or Prolene^® (Ethicon, Somerville, NJ). Field knot is complex and needs longer time to operate, and thus it is not easy to master without long time practice.^3,11

The endoscopic knot-tying technique used in this study is a type of extracorporeal-assisted intracorporeal knot-tying technique that we developed during our clinical practice. It has been successfully applied in many thoracoscopic and laparoscopic procedures in our department.

Materials and Methods

From June 2009 to December 2017, 333 cases of thoracoscopic/laparoscopic surgery were performed using extracorporeal-assisted intracorporeal sliding knot-tying technique. The mean age of the patients was 1.7 years (2 days–9 years). These patients were diagnosed with diaphragmatic hernia, diaphragmatic eventration, esophageal stenosis, and esophageal hiatal hernia. They received thoracoscopic diaphragmatic hernia repair, thoracoscopic diaphragmatic plication, thoracoscopic esophageal end-to-end anastomosis, and laparoscopic esophageal hiatal hernia fundoplication. All the surgeries were performed by Dr. Qi Zeng using the extracorporeal-assisted intracorporeal sliding knot-tying technique. This study was approved by the Ethics Committee of Beijing Children's Hospital of Capital Medical University.

The extracorporeal-assisted intracorporeal sliding knottying procedure was as follows (See Supplementary Video S1): (1)

The suture needle was made into a sled-like shape (Fig. 1). Under thoracoscopic monitoring, the needle was punctured into the thoracic cavity from the outside of the thoracic wall, and the end of the suture remained outside the thoracic cavity.

(2)

The needle was held by the right-hand needle holder to suture the target tissue. After the tissue was closed, the suture was cut and the needle was removed from the thoracic cavity.

(3)

The left-hand grasping forceps lifted the inner end of the suture (white arrow). Using the suture (black arrow) as the axis, the inner end of the suture was looped clockwise around the suture once with the assistant of needle holder by right hand, and grasped by the left-hand forceps (white arrow) then (Fig. 2a). The suture was looped clockwise or counterclockwise around the needle holder by the right hand once (Fig. 2b).

(4)

After the tip of the needle holder passed through the loop formed between the suture and the tissue (Fig. 2c), the left-hand grasping forceps transferred the inner end of the suture (white arrow) to the right-hand needle holder (Fig. 2d), which held the end of the suture and pulled it toward the outside of the cavity. Thus, a sliding knot was formed (Fig. 2e).

(5)

The first knot was completed by pulling the end of the suture outside the cavity with the left hand, and at the same time, pulling the inner end of the suture to the opposite direction by right-hand needle holder (Fig. 2f).

(6)

The assistant surgeon helped to pull the end of the suture that was outside the thoracic cavity and maintained traction to prevent the first knot from unraveling because of high tissue tension. The surgeon made the second flat knot in the cavity using the grasping forceps and the needle holder for reinforcement (Figs. 2g–j).

(7)

The suture outside the thoracic cavity was cut by the assistant, and the surgeon continued to make two to three knots in the thoracic cavity using the conventional intracorporeal knot-tying technique to complete the whole knotting process.

FIG. 1.

The appearance of the sled-shape needle.

FIG. 2.

The procedure of suturing and knot tying during the surgery. (a) The inner end of the suture (white arrow) was looped clockwise around the suture (black arrow). (b) The suture was looped around the needle holder. (c) The needle holder passed through the loop formed between the suture and tissue. (d) The needle holder clamped the inner end of the suture. (e) A sliding knot was formed. (f) The first knot was completed. (g) Arranged a loop for another knot. (h) The needle holder clamped the inner end of the suture in the loop. (i) A second flat knot was formed. (j) The second knot was completed.

The following steps were used to evaluate the quality of the suture and whether there was unraveling: (1) stop the CO₂ injection into the thoracic cavity or abdominal cavity to relax the diaphragm and observe whether the diaphragm suture was loosened or not; (2) the stent tube was placed in the esophageal lumen to evaluate whether the esophageal lumen was unobstructed and whether the suture was unraveled.

In this study, 2-0 or 3-0 nonabsorbable polyester suture was used to suture the diaphragm, which was mainly for diaphragm hernia repair, diaphragm plication, and esophageal hiatus contraction. A 4-0 nonabsorbable polyester suture was used for fundoplication, 4-0 or 5-0 absorbable polydioxanone (PDS^®) or Vicryl^® (Ethicon) suture was used for end-to-end esophageal anastomosis.

The time needed for knotting during the surgery was also investigated. We recorded the time used for knotting in 20 cases of endoscopic surgery from October to December 2017. The knotting time was counted after the target tissue was sutured and the surgeon began to loop the suture to make the knot until knotting was completed. The knotting time was counted by a circulating nurse. The time unit was calculated in seconds.

After discharge, the patients were regularly examined by chest X-ray at 1, 3, and 6 months, 1 and 2 years to find out whether there was recurrence of the disease.

Results

In all the 333 cases, all surgical procedures were performed safely and smoothly. There were 310 cases of thoracoscopic surgery, including 152 cases of thoracoscopic diaphragmatic hernia surgery, 151 cases of diaphragmatic eventration surgery, and 7 cases of thoracoscopic esophageal anastomosis. The other 23 cases were laparoscopic esophageal hiatal hernia repair and fundoplication surgery. Overview of the surgeries is given in Table 1.

Table 1.

Overview of the Surgeries

Procedure	n	Knots used
Diaphragmatic hernia repair	152	3–5
Diaphragmatic plication	151	7–9
Esophageal anastomosis	7	10–14
Esophageal hiatal hernia fundoplication	23	6–8

The average knotting time was 36.1 seconds (range: 26–69 seconds). In comparison, the reported average knotting time of giant lock sliding knot and intracorporeal knotting is 45 seconds (range: 25–70 seconds) and 130 seconds (range: 80–220 seconds), respectively.⁴ The knotting technique used in this study is faster than the above two knotting techniques.

No serious complications or mortalities were found in our study. Follow-up for 12 months to 9 years showed that no recurrence occurred in pediatric patients receiving diaphragmatic hernia, diaphragmatic eventration, and esophageal hiatal hernia surgeries. Small contained anastomotic leaks were found in 2 pediatric patients by postoperative esophagography. After conservative treatment for 2–3 weeks, both recovered and were discharged from hospital.

Discussion

With continuous advancement of thoracoscopic and laparoscopic minimally invasive surgery technology, the endoscopic technique used by pediatric surgeons has been greatly improved. The diseases that previously could only be treated by conventional surgery can be treated by minimally invasive endoscopic surgery, such as thoracoscopic esophageal stenosis surgery, thoracoscopic lobectomy, laparoscopic choledochal cystectomy, and laparoscopic surgery for Hirschsprung's disease.^1,2

Although minimally invasive surgery is widely used at present, knotting remains a difficult procedure. Reliable and fast knotting is a challenge for many surgeons, especially on tissues with tension. The extracorporeal-assisted intracorporeal knot-tying technique used in this study combines the advantages of extracorporeal knotting and intracorporeal knotting.

First, knotting is operated inside the cavity and only pulling suture needs to be performed outside the cavity. This knotting technique does not require knot pusher or special grasping forceps, and the grasping forceps and needle holder in the trocars do not need to be replaced, which shortens the knotting time.

Second, in the process of knotting, the surgeon pulls one end of the suture outside the cavity and the other end of the suture inside the cavity with endoscope forceps in the opposite direction so as to slide the knot to the target position of the tissue, and continues pulling to tighten the knot. The tightness of the knot can be felt by the hand that is pulling the suture outside the cavity. This is more direct than monitoring the tightness by surgical instruments during intracorporeal knotting.

Third, after the first knot is tied, the assistant surgeon maintains traction at the end of the suture that is outside the cavity to prevent unraveling of the knot. The surgeon operates the grasping forceps and needle holder in the cavity, and makes a single knot for reinforcement. At this point, the assistant surgeon can release the suture, and the knot will not unravel. It is especially suitable for suturing tissues with tension.

The knotting technique used in this study has a short learning curve and can be mastered skillfully by surgeons who are experienced in endoscopic surgery after operating several knots. For beginning surgeons with little experience of endoscopic surgery, it is recommended that they practice on a model or simulator for a period of time before actual operation. All types of sutures can be used in this knotting technique. The main advantage of this knotting technique is that it can be used to suture tissues with tension. Thus, it generally requires strong nonabsorbable sutures. We usually used 2-0, 3-0, or 4-0 braided polyester fiber suture for surgeries such as diaphragm plication and fundoplication. Prolene and PDS (Ethicon) sutures with smooth surface can also be used with this knotting technique. Even with braided suture, suturing and knotting are not affected by the braided surface that is not very smooth.

In our study, knotting was usually faster in the middle of the tissue that needs to be sutured, and it may be slowed down when suturing both sides of the tissue because of limited field of vision and the restriction of the operation space. The average knotting time required for our technique is 72.2% shorter than that of reported intracorporeal knotting.⁴ This knotting technique is especially suitable for suturing tissues with tension. Because of the extracorporeal assistance, the knot is not easy to unravel and thus suturing tissues with tension can be quickly completed.

Conclusions

Based on the clinical observation, the extracorporeal-assisted intracorporeal sliding knot-tying technique described in this study is safe and feasible. It is suitable for knotting in various minimally invasive endoscopic surgeries, especially for suturing tissues with tension, such as thoracoscopic diaphragmatic hernia repair, laparoscopic esophageal hiatal hernia repair, and fundoplication. All types of sutures can be used in this knotting technique. This knotting technique has a short learning curve and can be quickly mastered by surgeons who are experienced in endoscopic surgery.

Funding

This work was supported by the National Key Research and Development Program (grant no. 2016YFC1000805).

Footnotes

Disclosure Statement

No competing financial interests exist.

Supplementary Material

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Supplementary Material

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