title: Retroperitoneoscopic and laparoscopic suturing: tips and strategies for improving efficiency.
abstract: BACKGROUND
  The difficulties of minimally invasive reconstructive surgery, laparoscopically or retroperitoneoscopically, are caused by spatial limitation and fixed trocar positions and, therefore, restricted movement and handling of the instruments. In addition to a standardization of the technique, continual training, and improved instrument technologies, optimization of the geometry of reconstructive surgery, such as angles and distances between the working ports or the camera and needle position, are imperative to providing an optimal clinical performance.
  
  
  METHODS
  After designing a standardized suturing technique and conducting an experimental analysis of the geometric factors important in reconstructive surgery, we transferred these results to our clinical setting. A series of 116 reconstructive laparoscopic and retroperitoneoscopic procedures (nephropexy, pyeloplasty, bladder neck suspension, and radical prostatectomy) were analyzed according to the technical realization and quality of reconstruction. Trocar and table positions were adjusted according to our preliminary results, as were the position of the instruments and camera.
  
  
  RESULTS
  The trocar and instrument positions are critical for the clinical outcome of reconstructive surgery. Continual training in a standardized suturing technique, together with the clinical application of the important geometric rules, can reduce surgery time by 50%. The time required for suturing single knots could be decreased even more: as much as 75%, thus ensuring efficient and safe reconstructive surgery.
  
  
  CONCLUSIONS
  Reconstructive procedures such as pyeloplasty or radical prostatectomy can be standardized and performed in an acceptable amount of time with adequate quality when adhering to a standardized technique and the important geometric rules. Improved performance in terms of time and quality will increase the acceptance of these procedures, which can help to solve the problem associated with a low total number of indications for laparoscopy and retroperitoneoscopy.
authors.affiliation: Department of Urology, Klinikum Heilbronn, Germany.
authors.forename: T
authors.initials: T
authors.lastname: Frede
authors.forename: C
authors.initials: C
authors.lastname: Stock
authors.forename: J J
authors.initials: JJ
authors.lastname: Rassweiler
authors.forename: P
authors.initials: P
authors.lastname: Alken
mesh_terms: D004867:Equipment Design; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D017410:Practice Guidelines as Topic; D019651:Plastic Surgery Procedures / Q000379:methods / Q000592:standards*; D012187:Retroperitoneal Space / Q000601:surgery*; D013536:Suture Techniques / Q000295:instrumentation / Q000592:standards; D014570:Urologic Diseases / Q000601:surgery; D020535:Video-Assisted Surgery