[Laparoscopic knot tying]

Wound closure with sutures has been routinely used as a result of the technical and surgical development since the 20th Century. Knot tying in open surgery can be easily learned and performed; however, knot tying becomes challenging and frustrating when performed laparoscopically. Laparoscopic vessel ligation, suturing and performing anastomosis opened up a new horizon for laparoscopy. Laparoscopic knots can be performed extracorporally or intraabdominally. The most common intracorporal knots are the tumble square, Dundee, Aberdeen, midship and blood knots. Inherent disadvantages of intracorporal laparoscopic knot tying are decreased sensation of the tension applied to the tissues and the knot; and difficulty in knotting because of technical requirements and limited space. The most common extracorporal knots: Duncan, Roeder, modified 4-S Roeder, Tayside, Yanni and GEA knots. Extracorporally tied knots are obviously much easier to tie than intracorporal one;, but they can cause tissue trauma from pulling long lengths of suture through the needle tract, excessive tension on the tissue while pushing the knot into position, and loss of focus on the operative field during knotting. One kind of knot-pusher would not fit for all and we suggest to use different knot-pushers for different suture materials. In robotic assisted suturing the operative time decreased, the stability has increased and the skills can be developed in simulation labs.