Endoluminal Suturing: Novel Instruments and A New Technique

Mohamed ezzeldeen Seleem, prof. Cairo university

Objective:

To provide a less costly technique for endoluminal suturing-in the esophagus, stomach, colon and rectum

 

Technology and methods

1) Design and Manufacturing of instruments (Patented)

A-The flexible needle holder (Figure 1)

It is of different shaft lengths (30 to 90 cm) according to the site used (colon & rectum or esophagus & stomach)

The shaft will range 2 to 5 mm in diameter according to the needed grasping force
The jaw can  make self alignment of the needle, so that a suture can be applied easily

The instrument may be fixed or rotating allowing a wider range of movement

B-Eyed needle holder (Figures 2 ,3) for taking interrupted sutures for small defects using extra corporeal knotting

C-The conduit (figure 4)

It is a flexible endoscope system (with no camera, only a working channel with 2 ends (proximal and distal) allowing the needle holder to pass in it   

2) How it works

A-taking sutures with the flexible needle holder

            – The gastroscope will be introduced to the stomach or colon and insufflations of air is done

            -An over-tube (50 cm-length and 19 mm external diameter) will be introduced

            -The needle holder is passed through the proximal opening of the conduit and advanced forward till the jaws come out at the distal end

A 3 – 5 cm length of the needle holder will protrude out of the distal end of the conduit allowing the jaws of the needle holder to grasp the needle with the self alignment mechanism
The conduit will pass through the Over tube beside the flexible gastroscope.(pediatric or adult ) (fig 5)
Sutures used need no intra luminal tying e g V-Loc TM from Covidien© or stratafix TM from Ethicon©
The needle and suture will be held by the needle holder and passed through the stomach/ colon then the scope will follow to work under vision
An instrument (grasper or spiral ) will pass through The working channel of the gastroscope holding tissue then the needle will be passed through the tissues to take sutures
 Endoscissor will be passed through the gastroscope to cut the sutures

B-taking sutures with the eyed needle

The fixed needle holder with the eyed  needle is loaded in a retrograde manner in the conduit (Fig:6)
The conduit is introduced in the over tube-the same way like the flexible needle holder- the needle will pass through the 2 edges of the stomach/colon defect  Fig( 7)
The suture will be cut by an endocissor
The conduit is removed
The knot will be pushed by using a flexible Knot pusher or a modified Nelaton catheter Fig (8) -(9)

Conclusions: Future Directions

Trials performed with the system in the animal lab shows the following:

More modifications are needed to allow precise direction of the needle holder

The need for modifying a type of suture to allow taking sutures through the eyed needle without extracorporeal suturing

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