A decision on using stapling devices, electrosurgery -whether monopolar or bipolar-or suturing devices is dependent on the surgical situation and the surgeon's experience and skill. The goal should be a safe, efficient and relatively quick surgical procedure that benefits the patients and the surgeons alike.
Staplingdevices can provide an effective method for securing hemostasis. Single, inert, nonreactive titanium clips can be placed on a bleeding vessel with a reusable stainless steel laparoscopic applicator. These clip appliers can also be used in a disposable automatic system. The clips can be applied efficiently and quickly for individual bleeding sites where the application of any other form of energy sourcewould jeopardize adjacent structures.1,2
Hemostasis can also be obtained along an entire line of staples with the use of a stapling device which applies 4-6 layers of titanium staples and uses a self-contained knife blade to divide between the staple.3 Tissue thickness is estimated and a staple cartridge which occludes to 1.5 mm or one which compresses to 1 mm may be used. When using thestapling device care must be taken to ensure that the jaws of the stapler are beyond the cannula and completely free before opening the device. In addition, it is essential to ensure that when the tissue is compressed it does not bunch up, which may result in the tissue being inadequately stapled. The jaws are closed by depressing the handle. Check to ensure that no unintended structures are includedin the bite. The safety guard is then disengaged and the handles brought together to fire the staples. The dual staple lines must be carefully inspected to ensure that hemostasis is secured. Persistent bleeding may occur if the device is not correctly applied.4
During laparoscopic hysterectomy and oophorectomy, the linear stapling device can be effectively applied to the infundibulopelvicligaments and ovarian vessels. The staples are particularly advantageous and time saving for securing the round ligament, tube and uterovarian ligament. Staple application to the uterine artery must only be attempted after the ureter has been dissected free.5
Stapling techniques offer the advantages of speed in simultaneously securing hemostasis and division of tissue. They are, however, expensive.Endoscopic Suturing:
The use of sutures in laparoscopic surgery requires patience, persistence and practice. The development of advances in instrumentation have made suturing more accessible to surgeons whose are not comfortable with laparoscopic suturing. The aim of all laparoscopic suture techniques is to approximate tissue and ligate major blood vessels or tissue pedicles with the samedegree of security as during open surgery.
The endo-loop is the simplest of suturing devices. In this system a pretied Roeder loop applied to a plastic shaft is positioned around the tissue to be ligated.3 When correctly positioned the tissue or pedicle is pulled up through the loop, which is then tightened. The ligature is cut after the loop has been applied. This system has been used for organsas large as the uterus in the process of performing supracervical hysterectomies, for vessels as large as the uterine artery and for structures such as the infundibulopelvic ligament after it has been isolated. The use of the endo-loop system requires only that the surgeon develop a knuckle or a pedicle in order to apply the loop.6
If it is necessary to pass suture through tissue and then tyingit, the simplest method is an extracorporeal suture technique. Endosuture systems consist of a plastic shaft attached to a length of suture material and a straight or ski-shaped atraumatic needle. This system can be used to ligate vessels, reconstruct organs, approximate opposing tissue surfaces and suture anastomoses. The suture is grasped just below the swage point with a 3 mm needle holder...