Laparoscopic suturing and knot tying: the Indian rope trick

Laparoscopic suturing and knot tying require a lot of patience and practice and can be difficult, time consuming, and frustrating in spite of the advances made in the fields of instrumentation, optics, and imaging. The new technique described here is an effort to make the procedure simpler by providing extracorporeal control of one limb of the suture. It involves percutaneous placement of the needle end of the suture in the abdomen and its removal using a modified 10 cm long cloth-sewing needle. The part of the suture hanging from the abdominal wall helps in the formation and the tying of both the extracorporeal and the intracorporeal knots. The extracorporeal knot is just pulled in percutaneously to make it intracorporeal and can be tightened easily without a knot pusher. The loop for making the intracorporeal knot is formed in one of three ways, and the half hitch or the surgeon's knot can be tightened by pulling one end extracorporeally and the other intracorporeally. The technique has now been used for 36 laparoscopic procedures (8 transperitoneal and 28 retroperitoneal), including cholestectomy, varicocelectomy, ureterolithotomy, pyelolithotomy, pyeloplasty, and nephropexy. Compared with the conventional method of laparoscopic suturing and knot tying, it was found to be easier to learn.