Ann Thorac Surg 2009;88:1989-1992. doi:10.1016/j.athoracsur.2009.06.029
© 2009 The Society of Thoracic Surgeons
New Technology
A Novel Ligation Technique Facilitating Minithoracotomy
Wei Bo, MD, PhDa,*,
Jiang Fusheng, MDa,
Wang Tianyou, MDb
a Division of General Thoracic Surgery, Beijing Shijitan Hospital, Beijing, People's Republic of China
b Oncology Department of Capital Medical University, Beijing, People's Republic of China
Accepted for publication June 9, 2009.
* Address correspondence to Dr Wei, Division of General Thoracic Surgery, Beijing Shijitan Hospital, Haidian Yangfangdian, Beijing, 100038, People's Republic of China (Email: greatweibo{at}yahoo.com.cn).
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Abstract
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Purpose: We describe a simple knot tying technique that facilitates minithoracotomy, can be rapidly executed, and is easy to learn.
Description: The technique is described in detail as a stepwise approach with photographs.
Evaluation: A total of 117 consecutive patients underwent elective minithoracotomy in which this novel deep ligation technique was used during the past 16 months. Those patients included 54 with anatomic lung resection, 29 with esophagectomy, and 34 with other operations. Knot security has been adequate with this knot, as evidenced by its clinical performance and our experiences to date.
Conclusions: This novel knot-tying method promotes the expeditious formation of secure square knots in deep-seated operating fields through a small incision. It provides an improved visualization, gentle manipulation of tissue, and precise placement of sutures within a confined space. The surgeon who has learned this new tissue approximation skill will return suturing and knot tying to the forefront of minimally invasive surgery in a cost-effective and efficient way.
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Introduction
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In minithoracotomy operations that are undertaken through small incisions and deep-seated operating fields, the suture ligation procedure is still a technical challenge for surgeons to perform. Ligation methods currently used in minimal access operations mainly include endostapling devices, vascular clips, and some standard instrumental knots. The use of mechanical staplers and vascular clips could add to the cost of the operation and present potential malfunction risks from dislodgement, user errors, mechanical failures, and application difficulties [1, 2]. There have been concerns with the security of instrumental knots, especially for vital structures such as the lung hilum. Those disadvantages led us to develop a simple, secure, and cost-effective ligation technique that facilitates minithoracotomy.
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Technology
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This technique requires the use of a common right-angled forceps to throw the knots. The main steps include transferring extracorporeal left-hand created knots to the intracorporeal tissue site with instrument-pushing techniques and tightening in a novel way.
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Technique
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The sutures are placed through the tissues in the conventional fashion. The two opposite ends of the suture line are held extracorporeally with the left hand and clamp, respectively, and the one-hand tie technique is performed to create the first half-hitch in a similar way to an open procedure (Figs 1A and B). The tip of the right-angled dissector then slowly pushes the suture knot along a suture strand advanced toward the tissue site, while the left fifth finger is used to gently hold the end of the suture, thus preventing the suture from slipping out of the jaws of the instrument (Fig 1C). This movement can be facilitated by slightly opening the jaws of the dissector that assists in slipping the loop proximally onto the tissue site. It is easy for the operator to stabilize the knot's position by using the clamp at this moment.
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Fig 1. Deep manual ligation procedure is shown. (A, B) The half-hitch is created extracorporeally using hand-tie methods, (C) then, it is slid down along the forceps groove. (D) The jaws of the right-angled forceps are closed at the intracorporeal tissue site to hold the suture clamping; and the usual push–pull maneuvers are done with the left index finger simultaneously to tighten the knot (arrows). (E) Subsequently, another opposing half-hitch is made and is tied in the same way to form a standard square knot. Additional knots opposite to the second throw can be performed as needed. (C, D) Please note the left-hand maneuver when the knot sliding down and tightened.
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The suture is then grasped with the tip of the forceps, and the loop is tightened by pulling the left index finger and pushing the instrument simultaneously in opposite directions to create equal tension on the knot (Fig 1D). A firm, tight knot is thus formed.
Additional knots can be placed that are mirror images of each other for a series of throws (Fig 1E). The surgeon and the assistants are able to see the whole tying process and can ensure the correct position of the knots at all times in a deep and narrow thoracic surgical field. This makes the surgeon comfortable in deep knot tying, while the reliability of the knots is well visualized during the tying procedure.
Other than knot tying, the right-angle forceps can also be applied to tissue, separating, grasping, or manipulating as a common surgical instrument during the minithoracotomy operation. No special knot pushers are required.
To describe this technique clearly, we illustrate two other typical types of similar skills: one using a modified right-angle forceps, and in a different way, the other needs a special knot pusher (Fig 2). With those two kinds of skills, however, the surgeon must grasp both suture strands tightly with his or her left hand to keep enough strength at all times. This makes the process unstable, clumsy, and even possibly weakens the knot tension.
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Fig 2. Diagram displays the three kinds of ligation methods when the knot is being tightened. Different from the others, in the A type approach, forceps clamping (solid arrow) allows one suture strand to be relaxed (dashed arrow). (A) Wei Bo-type, (B) Sakihara-type, and (C) Naruke-type.
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Clinical Experience
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Ethical approval for clinical application of this technique was obtained from the Ethics Committee of Beijing Shijitan Hospital. An informed consent form from all patients was signed individually before operation.
During the past 16 months, 117 consecutive patients underwent elective minithoracotomy in which this novel deep ligation technique was used (Fig 3). They included 54 with anatomic lung resection, 29 with esophagectomy, and 34 who underwent other procedures. For the suture material selection, we primarily use silk sutures in the ligation procedure due to the increased friction and pliability. All of the procedures have been accomplished thus far without any major difficulty or complication encountered. This skill helps us to obviate the technical difficulty of frequent intrathoracic manual ligation maneuvers through very limited access, for example, the work incision rather than trocars during video-assisted thoracoscopy operations, therefore it has been routine used at our center.
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Comment
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Knot tying is an essential surgical technique to achieve adequate tissue approximation, reliable vascular ligation, and to improve the final surgical outcome. It is of paramount importance that each knot placed be tied with precision and security. In addition, knot tying should not be difficult to master, time consuming, or bulky, and knot displacement must be avoided.
In minithoracotomy operations, there are specific situations that require secure knot tying, such as pulmonary vessels closure. Well-secured knots are critical for success in such cases. However, they are not easy to obtain because of the limited access and the depth of the surgical site.
As early as 1935, Sakihara [3] had primarily devised a deep vascular ligation apparatus for small thoracotomy in animals such as dogs and rabbits. The apparatus was later introduced into clinical practice and regarded as a "knot pusher." With assistance of the device, surgeons can use an extracorporeal hand-tie method to make knots, with subsequent transfer to the intracorporeal tissue site using instrument-pushing techniques. This instrument provides the surgeon with a robot-like extension of his or her hand, thereby enhancing suture control. This was an aim of concern to surgeons working in limited spaces and remote areas; a situation that makes knot tying more complex, such as in arthroscopy [4], gastrointestinal endoscopy [5], and thoracic operations [6]. This technique thereby facilitates the tying of a wider range of other intracorporeal knots at the tissue site [7].
Naruke [8] later adopted modified right-angled forceps as a knot pusher for intracorporeal knot tying during minithoracotomy. Those kinds of ligation skills, however, require that continuous pressure be applied on both suture strands throughout the entire procedure. This would possibly degrade the expeditious formation of secure knots in the tissue site or would loosen the first throw while tightening the second half-stitch, resulting in a sliding knot.
We believe there are basic technical principles to achieve a secure square knot and have developed an easy modification of the common instrument tie so that a secure, reproducible square knot can be created and premature locking or inadequate knot security is avoided. The knot security has been evidenced by its clinical performance in our experiences to date.
The more complex a skill is, the more time and patience is required to master the technique. In this respect, our technique combines the sophistication of intracorporeal knot tying with the ease and simplicity of extracorporeal knotting. Extracorporeal knotting, like in open operations, is rapid and easier to perform. Meanwhile, the right-angled forceps is also a very useful surgical instrument applied to the minithoracotomy operation. This makes the novel suture ligation technique efficient and convenient.
Some authors regard the type of suture material used as an important contributor to knot security [9]. The main characteristics of suture material that affect knot security are memory and coefficient of friction: more friction results in a more secure knot [10]. The configuration of the square knot relies on sequential throws that deform the suture material [11]. Sutures with a high coefficient of friction, generally multifilament sutures, are easy to handle and manipulate for tying knots [12]. Therefore, we mostly prefer silk sutures during minithoracotomy because of the increased friction and pliability. We believe silk sutures may be most appropriate for the deep ligature knot. But less frequently, we also used braided absorbable Vicryl suture (Ethicon, Somerville, NJ) in minithoracotomy without a major problem so far, and often the first throw is a surgeon's knot, followed by three single-hitches to prevent knot slippage.
In the current era of cost-containment, thoracic surgeons must control costs and reduce rates of morbidity and mortality while maintaining quality of care for patients. Performing minimal access operations in a cost-effective way is an inevitable trend for the development of surgery in the future.
In conclusion, this technique has advantages in difficult situations where it is easier, faster, and more secure. Its clinical performance renders it a potential knot tying technique for routine use during minithoracotomy.
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Disclosures and Freedom of Investigation
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No financial support was received for this study. The authors had full control of the study design, methods used, outcome measurements, analysis of data, and production of the written report.
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Acknowledgments
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We wish to thank Huang Jing for her excellent photographing assistance.
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Footnotes
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Disclaimer The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.
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References
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Abstract
Introduction
