Laparoscopic suturing during liver surgery

Suturing is one of the most complex gestures in laparoscopic surgery; this difficulty is caused by the bi-dimensional vision, the reduced tactile sensitivity and the trocar fulcrum that limits instruments movement  and may create contrasting movements between them.

For these reasons, the success of laparoscopic suturing is dependent on a key concept of laparoscopic surgery, the triangulation of instruments.

The right and left hand of the surgeon should be positioned on either sides of the camera, ideally forming a 90° angle with the camera, in order to avoid the knitting-needle effect of the surgical instruments.

Intra-abdominal triangulation prevents the surgical instruments from aligning themselves parallel to each other, which would make suturing extremely difficult.

The trocars should be inserted perpendicular to the abdominal wall, in order to obtain a fulcrum that allows a greater freedom of movement within the abdomen, especially in obese patients with an extremely thick abdominal wall.

Approaching laparoscopic liver surgery, it is important to have good laparoscopic stitching and suturing skills, as sutures may be necessary to stop bleeding or bile leakage.

An additional difficulty in hepatic surgery suturing is that the suturing plane could  be tangential; this makes it difficult to have a good stitch grip or to tighten the knot properly. In such cases, clips can be used to lock the suture thread or to tighten the knot.

For a continuous suture the use of self-locking suture threads is of considerable help; as they do not need to be tied or maintained under tension they allow a quick suture, leaving both hands of the surgeon free for the suturing.

In the event of  bleeding  is important keep calm and localise precisely the bleeding point; the suture must be as precise as possible, without involving other structures that are to be preserved.

Are therefore important measures to reduce bleeding and continue  the dissection, before starting a liver resection is importante prepare a tourniquet aroud the hepato-duodenal ligament in order to  achive inflow occlusion (pringle manouver) in case of bleeding from a vascular pedicle

In the case of bleeding from a venous branch it is important to keep the central venous pressure low, this can also be achieved by increasing the reverse Trendelenburg position; furthermore the pneumoperitoneum can be increased up to 15 mmHg; this allows to limit blood loss and  continue with the dissection until achieving bleeding control.