Endoscopic hand suturing

All procedure was conducted using a multi-bending scope with two working channels (GIF-2TQ260M; Olympus Co. Ltd., Tokyo, Japan). A transparent straight hood (D-201-13, 404; Olympus) was attached to a tip of the endoscope. The suturing procedure described below was conducted by one endoscopist and one assistant who had had clinical experience in EHS.

In five cases, we performed EHS with a continuous suturing method in the same manner as previously introduced¹³. As the first step of EHS, a 3–0 V-loc 180™ absorbable barbed suture (VLOCL0604; Covidien, Mansfield, Massachusetts, USA), which had short barbs to prevent the suture from sliding backward after the tissues being tightened, was delivered through the virtual anus by using the prototype of the flexible needle holder (Olympus) by grasping the thread close to the tail of the needle. The suture thread was once released and the body of the needle was grasped. Then, the needle was passed through the full layer on the proximal part of the anastomosis, followed by passing through the layer on the distal side (Fig. 1c, d). We circumferentially sutured the layers between the anastomosis at intervals of a little less than 1 cm. The remaining portion of the thread was cut with the dedicated scissors forceps (Olympus) and transanally retrieved by grasping the thread part (Fig. 2a).

Schemas of endoscopic hand suturing for rectal anastomosis. (a) The continuous suturing with a barbed suture. The anastomosis was sutured circumferentially. (b) The nodule-suturing method. (c) In the nodule suturing, the slipknot is created outside the tract after retrieving the needle. The knot is delivered to the lumen by using the tip of the endoscope with the notched hood (red direction) while the thread remains tensioned by the assistant (green direction).

In other five cases, we performed EHS with a nodule suturing method with extra corporeal ligation. In these cases, the transparent hood attached to the tip of the endoscope had been notched (about 3 mm) at 3 and 9 o’ clock in advance (Fig. 1e). The suture thread used was a 3–0 absorbable monofilament suture (Biosyn™; Covidien Japan). The needle was delivered and passed through both sides of anastomosis in the same way as continuous suturing cases. Subsequently, the needle was completely retrieved outside. The endoscopist tied the thread with slipknot and hooked each side of the thread to corresponding notches at 3 and 9 o’clock in the hood. Then, while the assistant was pulling the thread, the endoscopist delivered the knot using the endoscope itself as a knot pusher to the anastomotic site (Fig. 1f). We carried this procedure four times per stitch and cut the remaining thread with scissors forceps. Finally, the needle was retrieved by pulling the thread. The intervals of stitches were set at approximately 1 cm (Fig. 2b, c).