A simple technique for knot tying in single incision laparoscopic surgery (SILS)

Minimal access surgery has been generally accepted as a method of operating through a very small incision or no incision at all. Today, all abdominal and thoracic surgeries can be performed with laparoscopy. Intracorporeal knot tying is an advanced skill that involves a difficult process with a long learning curve. In particular, when the angle between the working instruments is narrow and the working area is limited, ligation and suturing are substantially difficult to perform. A new concept known as single incision laparoscopic surgery (SILS) was recently introduced. With this technique, the approach to the abdominal cavity is made through a single incision. However, with this method, intracorporeal suturing is more difficult than it is with traditional laparoscopy. There are several reasons for the technical complexity of this surgical approach. The surgeon’s vision is restricted. It is difficult to handle the instruments. One lacks tactile perception, and there is a limited working area. Furthermore, the procedure necessitates excellent hand–eye coordination and manual dexterity. In routine practice involving laparoscopic equipment, port and optic entrances should be appropriately selected according to the type of the surgical procedure and feasible suturing. On the other hand, in SILS, such is not possible since the optic equipment and hand instruments are on the same plane. This configuration complicates the surgical procedure and frequently renders suturing impossible. Taking this fact into account, a technique called the ‘‘side winding’’ method was developed in an attempt to simplify the intracorporeal suturing procedure during SILS. By means of this safe, simple, and fast technique, intracorporeal suturing is performed remotely with a limited field of vision and it does not require a significant amount of experience.