THE DOCUMENTED HISTORY OF MODERN LAPAROSCOPIC SURGERY Index
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The Clarke Instruments for Suturing and Tying. SUTURING AND LIGATING - THE FIRST THIRTY YEARS The Scope Looks Back Henry Clarke © January 15, 2000

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THE CLARKE INSTRUMENTS

(A) The simple ligator or knot-pusher

A rod with a handle and grooved distal end for sliding a tie
 

The ligator is a rod with a grooved tip which is applied to suture proximal to a tie so as to slide the tie through a trocar sheath to tissue within the abdomen. It consists of a handle, a shank and an operating end. It is of stainless steel.

The handle which varies in size and shape is usually 5.5 cm long and slightly wider in diameter than the shank. It may be smooth, roughened, or flattened on one side. The smooth handle provides more tactile sensitivity but less control than the roughened handle. The flat sided handle provides the operator with knowledge of the direction and degree of rotation of the ligator on its longitudinal axis. In some ligators the flat side has been contoured to fit the grasping thumb.

The shank varies in length and diameter. The commonly used instrument has a smooth shank 24 cm long and 5.0 mm in diameter. Treatment of the shank with anti-glare finish prevents glare from reflection of light from the laparoscope or laser while maintaining smoothness of the shank. For delicate tying - as in tuboplasty - a shorter and thinner shank affords better control and tactile sensitivity. The shank may be tapered to provide a smaller diameter at the operating end.

The operating end is an open ended circular groove. The diameter is equal to that of the shank. The open ends are separated one to two millimeters in order to engage suture into the groove. The groove is contoured so as to facilitate sliding and to prevent bruising of suture.
 

MODIFICATIONS OF THE LIGATOR

The ligator, modified, with operating end flattened and angled 30 degrees with the shank, has been useful for applying ties in less accessible locations such as in the surgery of the common bile duct.

The ligator with closed ended circular groove has been discarded because of its limited usefulness. It is applied to one strand of suture, proximal to the tie, by bringing the strand through the closed circular groove. Following application of the tie in the abdomen the ligator has to be retrieved out of the abdomen along the strand of suture to be disengaged before it can be applied for a second tie. The open end permits disengagement at any point in the procedure and re-application intra-corporeally.

(B) The Scissor Forceps

A forceps with a scissor in the angle of the jaws for the intracorporeal holding of tissue and suture and for cutting of suture

This instrument was described by Clarke in patent in 1973. The scissors had blades which were straight or curved. The jaws of the forceps were tapered or rounded.
 

(C) The Ligator Scissor Forceps or "pusher-cutter"

A forceps with grooved distal ends for sliding a tie and a scissor in the angle of the jaws for cutting suture
 

This was similar to the scissor forceps, but when closed, there is an open-ended circular groove at the distal end of the jaws, in a plane at right angles to the line of separation of the jaws. This instrument combines the principles of the Clarke laparoscopic ligator or "knot pusher" with those of the Clarke laparoscopic scissor forceps or "graspercutter."

The ability to tie flat square knots has been accepted as an important and basic technique in all surgical procedures. Flat square knots and surgeon's knots are simple to apply with the Clarke ligator scissor forceps. This instrument was presented and demonstrated by Clarke at "Advanced Laparoscopic Surgery: The American Experience", the American Association of Gynecological Laparoscopists, (AAGL), Chicago, May 1989, and in "Simple Instruments for Suturing and Ligating", the 19th Annual Meeting, of the AAGL, Orlando, Florida, November 1990.
 

THE LIGATOR SCISSOR FORCEPS
 

Both ends of suture to be tied are introduced extracorporeally through a trocar sleeve. A single or double throw tie is made. Either strand is engaged by the groove at the closed end of the ligator forceps. The tie is slid through the trapless short trocar sleeve directly to the tissue to be ligated (Figure A). The jaws of the forceps are separated, pulling the suture laterally in both directions, thus laying a flat tie (Figure B). A second reversed tie is applied extracorporeally to complete a square knot (Figure C). The suture is cut by a cutter in the jaws of the forceps.
	The pusher-cutter with jaws closed can be applied as by the rod knot-pusher, or one strand of suture may be grasped by the pusher-cutter while traction is applied to another strand to tighten a tie. This instrument also facilitates loop ligation. With jaws opened it accurately locates the loop around tissue for ligation.
(Clarke, H.C., An Improved Ligator in Operative Laparoscopy: Obstet Gynecol, 83, 299-301 (1994).

Discussion

In laparotomy, laying down a flat tie to produce a square knot or a surgeon's knot has proven to be a reliable method of tying because the double strand locks and holds. In laparoscopy, these knots are easy to apply with the pusher-cutter. This instrument permits variation in the number of throws, the number of ties, and the type of knot. Laparoscopic square-knot tying intra-abdominally, using two forceps, has been described. Here the effective forces are directed peripherally, out of view of the scope, when the risk of slippage or suture breakage is greatest. Single-strand ties, such as the Roeder knot, tend to back-slide with tension. The more reliable clinch knot is complicated and may lock when sliding and require removal.

The ligator scissor forceps applies a square knot safety, because the forces of lateral traction are restricted to the distance between the jaws of the forceps. As with digital tying, the number of throws can be varied depending on the tension on the tie. The tie can be tightened by separating the jaws while holding the suture taut, by pulling on the suture while the jaws are held in the separated position, or by a combination of both methods. With practice, this method provides fine tactile sensitivity for tension on the tie. The pusher-cutter can tie as well on flat surfaces, such as the uterine wall for closure in myomectomy. It has been effective for closure under tension such as the vaginal stump after hysterectomy with incorporation of the uterosacral ligaments.
 

(D) The Suture Needle Forceps
 

A forceps with a detachable needle attached to an extendiblearm. There is an eye at the distal end of the needle.

The instrument can be applied intracorporeally through a 5mm trocar. Different types of needles utilizing various types of suture can be exchanged on the needle forceps. On extension of the jaw the needle selected can be curved on a plane parallel with the shaft of the forceps or at a right it. The Jaw is extendible to an angle of 120 degrees with the shank.

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