Clarke instruments and methods for Operative Laparoscopy-Techniques

Since 1970 the suture needle forceps has been improved. Originally it was marketed as a forceps on an extendible jaw of which was a needle with a groove at the distal end. Later, a needle with eye at the distal end was fixed to an extendible jaw. Today, on one of the double acting jaws, there is a detachable needle with an eye at its distal end. Various types of needles and suture are changeable on the instrument.

Simple suture ligation. The suture needle forceps is introduced intracorporeally through a 5 mm trocar. With the new instrument the procedure is as described in 1972:"Through one trocar sheath the tissue forceps are inserted and the tissue to be suture-ligated, for example the tube on that side, is held. Through the other trocar the laparoscopic needle threaded with suture is introduced ....The needle is flexed and the tissue is pierced bringing suture through the tissue. The tissue forceps disengage suture from the needle, which is then withdrawn from the tissue......Next the suture is carried around the transfixed tissue to the clamp of the laparoscopic needle forceps which is closed and withdrawn through the trocar carrying suture with it"(Clarke H.C. Laparoscopy - New Instruments for Suturing and Ligation. Fertil Steril 23:274, 1972). The Clarke ligator completes ligation. Simple suture ligation takes less than three minutes.

In the following procedures, The suture can be drawn through the eye of the needle to permit a second suturing without withdrawing extracorporeally for re-threading of the needle.

The "sentinel stitch" of Reich. For suturing in areas where space is restricted, needles are available which extend from the open jaw of the suturing needle forceps in a clockwise or anti-clockwise direction. Rotation of the shaft facilitates penetration of the tissue by the curved needle. Reich, in his laparoscopic hysterectomy inserts a curved needle on top of the unroofed ureter and applies a "short rotary movement" which "brings the needle around the uterine vessel pedicle"(Hulha JF, Reich H. Textbook of Laparoscopy. 2^nd ed. Philadelphia: W.B. Saunders, 1994). Sutures are tied extracorporeally using a Clarke knot pusher. A single suture placed in this manner on each side serves as a 'sentinel stitch', identifying and watching over the ureter for the rest of the case."

Suturing and ligating are basic surgical techniques. By mastering these techniques early, the laparoscopist is better prepared for surgery and for treating complications, when they arise, thus avoiding laparotomy.

The ability to suture and tie has been an important requirement of a surgeon. An important principle in suturing in the abdomen is that the surgeon should be in control of the needle at all times. In laparotomy, the needle holder can hold a needle securely during suturing. In laparoscopy it has been difficult to reproduce this great grasping force. The needle tends to angulate and rotate in the laparoscopic needle holder. In the abdomen the needle requires positioning in the needle holder with the aid of another instrument before suturing. Re-positioning of the needle in the holder or pulling of the needle by the attached suture, is necessary for its retrieval. In these maneuvers, there is the risk of misplacement of needles and visceral injury. For closure of an incision, such as that of myomectomy, the fixed right angle needle holder requires to be positioned with its shank parallel to the line of incision in order to give an angle of incidence at right angle to the incision.

The needle of the Clarke suture needle forceps is controlled by the surgeon at all times. There is no erratic angulation or rotation of the needle. There is no dangling, free needle in the abdominal cavity. The angle of incidence of the needle is adjustable by opening and closing of the jaws of the forceps. This is not possible with the usual fixed right angled needle holder. With the suture needle forceps, only the distal end of the needle traverses the tissue to complete suturing. Both the needle and the suture are changeable to suit the particular procedure. Re-threading and re-applying the suturing needle forceps during surgery, permits more elaborate procedures than those which have been described here.

Suture having been applied to tissue in the abdomen, both ends are brought out through a trocar sheath. A tie of both ends is made extracorporeally. The proximal ends of suture are held between thumb and index finger of one hand and the ligator in the other. The groove of the ligator engages either strand of suture proximal to the tie, and slides the tie through the trocar sheath directly to tissue to be ligated. No pulling and minimal pushing force is required until the tie is applied. The ligature is now tightened by applying force distally with the ligator while pulling proximally on the ends of suture held extracorporeally.

Separation of the proximal strands of suture, such as over the index finger of the holding hand, provides better sensitivity of suture take up and tightening of the ligature.

While sliding the tie, pulling on suture proximally is not indicated, and should be avoided. This tightens the tie and increases resistance to the slide. It also causes tissue pull.

A continuous sliding action of the ligator, applying minimal force, is most effective. "Juggling" and "Twirling" is to be avoided. Juggling is a series of short jabs, while twirling is rotation of the ligator on the long axis, as it is inserted through the trocar sheath. This results in loss of the tie, or bunching of suture with failure of the tie to progress.

The lost tie may be located by engaging a proximal strand of suture extracorporeally with the ligator and following it into the trocar sheath until resistance of the tie is met. The tie is slid down to continue ligation.

Where the tie cannot be located, or there is failure to progress due to bunching, the bunch of suture is pushed out of the trocar sheath into the abdominal cavity. The ligator is applied to either strand of suture proximal to the bunched suture. Unraveling of suture occurs as sliding is continued. The use of forceps to aid in unraveling of bunched suture is seldom necessary.

"Trocar hang-up" occurs when the trocar impedes the slide of the tie. This results when the diameter of the trocar is not adequate for the thickness of the suture being applied. With the usual surgical sutures this occurs rarely even with the more complicated valvular types of trocar. Trapless short trocars (R. Wolfe, Rosemont, IL; Apple Medical, Bolton, MA) and other simple trocars are often more effective.

Various types of ties, such as the square knot or surgeon's knot, utilizing various types of suture, can be applied by the ligator. Double or triple throw ties, and multiple ties, are simple to apply. Besides strength and absorbability, consideration is given to suture resistance, memory and visibility. A useful length is 75 cm.

So far it has not been possible to replace the simple ligator because the basic principles for tying that it involves is uniquely suited for operative laparoscopy. Several attempts have been made for various reasons to improve or modify it.

The Clarke ligator with angled tip has been marketed by Marlow Surgical Technologies. "Weston narrowed the groove so as to facilitate tying of the clinch and Roeder knots. Encasing the Weston modification of the Clarke ligator in a tube resulted in the Roeder loop knot pusher of Semm. The advantage of this over the forked knot pusher proposed by Weston is that the Semm knot pusher could be marketed as a unit disposable after each knot" (Clarke HC. A New Clinch Knot. Letter to the Editor. Obstet Gynecol; 78: 156, 1991).

-A single strand tie which tends to back slide. What slides down tends to slide back up.

-Marketed as an instrument disposable after each tie. It is more expensive than loop ligation with the ligator.

-May be applied for loop ligation where there is limited tension on the tie.

While this clinch knot is simpler than the Roeder knot and more secure, it may lock while sliding and require removal.

This was first described by Clarke in 1972 (Clarke H.C. Laparoscopy - New Instruments for Suturing and Ligation. Fertil Steril 23:274, 1972).

Pomeroy procedure: a, fallopian tube is grasped through loose suture tie held by ligator; b, loop of tube is drawn through tie; c, ligator drives tie down to ligate tube; and d, suture is cut and excision of tube is indicated.

With electrocauterization of the fallopian tubes there appeared several women with premature menopause and heavy irregular menstruation who after multiple dilatation and curettage procedures required hysterectomy. The effect on the ovaries was obvious. With loop ligation and excision a specimen was available to confirm the procedure and the destruction of the adnexa was contained.

-Forces of maximum stress on suture, for tightening of the tie, are directed out of the operative field when risk of suture slippage or rupture is greatest.

Poor countries have avoided this new surgery or offer it only to the wealthy. This has been because of the introduction of expensive and often unnecessary methods aimed at a good profit return. Lasers, disposable clip applicators and pre-tied loop ligatures, which exact a fee for each tie, while useful in some procedures, displaced simple suturing and tying methods. The latter, with electrocautery, performed the same procedures at a significantly lower cost. This increased the cost of surgery eroded the benefits of lower morbidity and shorter hospital stay. Thus, expensive and exotic methods resulted in operative laparoscopy being less acceptable by poor countries where these benefits were most needed.

Following the original concept of Clarke, all of the procedures suitable for surgery by laparoscopy in the third world can be accomplished by suturing and tying. The instruments required are of much lower cost than that of other technology. These consist of a ligator, a suture needle forceps, a tissue forceps and scissors which are re-usable. In 1972 Clarke proposed the use of electrocautery to supplement suturing and tying (Clarke, H.C., Laparoscopy: New Instruments for Suturing and Ligation: Fertil Steril 23; 274, 1972).

In the third world laparoscopic surgery is still called LASER surgery. This resulted from the aggressive marketing of powerful surgical instrument corporations. This expensive technology was unnecessary in the third world. The result has been a glamour surgery for the wealthy class. The Clarke concept of operative laparoscopy was a surgery with less cost, shorter hospital stay and more rapid recovery for direct benefit of poor patients.

In the third world there is apprehension by patients when metal clips have been left in the abdomen. Survival after hematomas, draining bile ducts after cholecystectomy, inadvertent cutting of ureters in hysterectomy, reported with clip-guns, can be significantly lower in poorly equipped hospitals. Some of these complications can be avoided or treated during laparoscopy by a surgeon experienced in suturing and tying techniques.

Tubal interruption by electrocauterization has resulted in premature menopause, dysfunctional uterine bleeding and hysterectomy in younger women. In the third world sterilization is usually a final procedure. The use of plastic clips for temporary sterilization requires a second operation which the patient often cannot afford. Suturing and tying for interruption of tubes is a localized procedure with less effect on the ovaries. The complications of wide electrical burn in the adnexa are catastrophic in women of the third world. Follow up care is often non-existent.

It was 2 am when Clarke, a volunteer surgeon on his first night at the Port-of-Spain General Hospital, Trinidad, was summoned to see a patient. Clarke, a general practitioner, with training limited to Gynecology, had been invited by the Minister of Health to volunteer . As he approached the ward, a room with some forty patients he heard the rosary being said by the nurse in charge "Holy Mary full of grace---", with the patient congregation answering. As Clarke pondered what action to take an orderly came and advised "Don't be to harsh with her. No doctor has been here for three days. Some are going to die tonight. This is the best that she can do." When the prayers ceased a horrible general moaning became audible. The nurse directed him to a young man in severe pain with an acute abdomen and possible ruptured gallbladder. Clarke ordered analgesics and antibiotics, thanked the nurse and left. The rosary continued. If this man had enough money he would have been treated earlier by a surgeon in a private hospital. Today, around the world, there are patients like these whom operative laparoscopy could help if it were kept cheap as it was meant to be.

In April 1972 Clarke and Prof. Piver at the Roswell Park Memorial Hospital in Buffalo NY performed a second look biopsy for ovarian cancer with suture closure of the peritoneum. In 1983 Semm published endoscopic appendectomy claiming to have done the first one in 1981. In 1991 (Am J Surg) Mouret claimed to have performed the first cholecystectomy in 1987 (personal communication). In 1989 Reich did the first total laparoscopic hysterectomy by suturing and tying (Reich H., De Caprio J., Mc Glynn F. Laparoscopic Hysterectomy. Journal of Gynecologic Surgery 5, 213-6, 1989).

In laparoscopy, suturing with the Clarke suture needle forceps is easier and safer to learn than suturing with the various needle holders. The needle of the Clarke suture needle forceps is controlled by the surgeon at all times. There is no erratic angulation or rotation of the needle. There is no dangling, free needle in the abdominal cavity. The angle of incidence of the needle is adjustable by opening and closing of the jaws of the forceps. This is not possible with the usual fixed right angled needle holder. With the suture needle forceps, only the distal end of the needle traverses the tissue to complete suturing. Both the needle and the suture are changeable to suit the particular procedure. Re-threading and re-applying the suturing needle forceps during surgery, permits more elaborate procedures than those which have been described here.

With the Clarke ligator different types of suture can be applied for various knots. Double or triple throw ties, and multiple ties to produce knots are simple to apply.

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. The double strand tie locks and holds. In laparoscopy, using various types of suture, these knots are easy to apply with the Clarke pusher-cutter (The ligator scissor forceps). 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 safely, 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 with 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 for the vaginal stump after hysterectomy with incorporation of the uterosacral ligaments.

With practice the surgeon can apply suturing and tying in laparoscopy to several laparotomy procedures and develop his own techniques. He is able to treat complications when they arise without laparotomy. Where the application of metal clips in tissue fails to stop bleeding the presence of metal in tissue can contraindicate the use of electrocautery. This is not the case where suture material has been applied. Also, suture ligation can control bleeding and avoid laparotomy. Unlike with the simple instruments for suturing and tying, the maintenance, repair and replacement of more expensive technology often require sending out of the country with unpredictable delays. Surgery stops when clips or loop-ligatures run out. With the Clarke instruments needles can be replaced or sharpened so that surgery continues.

The instruments required for suturing and tying in the abdomen in laparoscopy are the suture needle forceps, the ligator and the laparoscopic scissors. The suture needle forceps is simple, repairable locally, and can be manufactured in some third world countries. Needles are changeable when dull, and may be sharpened. Any suture suitable for the procedure can be utilized. There is no need for the more expensive non-reusable needles with fused on suture which laparoscopic needle holders require. The Clarke ligator, of proven value worldwide, is a simple rod with grooved distal end. Laparoscopic scissors have long been made in third world countries. These simple instruments and techniques are suitable for the poorly equipped, often isolated, hospitals of our third world.

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THE DOCUMENTED HISTORY OF MODERN LAPAROSCOPIC SURGERY Index
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Vertical figure-of-eight suturing. This is illustrated in: Figures A, B, C, D, E and F. ( Clarke HC, Reich H, Pollack S, Sekel L. Techniques Using the Clarke-Reich Suture Needle Forceps in Gynecological Laparoscopy. Gynaecological Endoscopy, 5, 69-73, 1996)