Tissue approximation is the fundamental and essential pre-requisite of all surgeries. Tissue approximation permits reconstruction of viscera, prevents leakage of body fluids. Exclusive reliance on mechanical devices for tissue approximation restricts the surgeon to the devices’ limitations. The principles, approach, and techniques of efficient precision laparoscopic suturing and knotting techniques are described that, when mastered, result in obtaining high-quality repairs in conjunction with an improvement in the surgeon’s overall laparoscopic surgical skills.

There are many ways of laparoscopic tissue approximation but most commonly used one are:

• Laparoscopic extracorporeal and intracorporeal knots.
• Surgical glues which act as a tissue adhesive.
• Laparoscopic clips
• Laparoscopic staplers
• Laser welding.

Extracorporeal (Tied outside the body and then slipped inside using a push rod)

– Roeder’s knot
– Meltzer’s knot
– Tayside knot.

Intracorporeal (tied with the help of needle holder within the body cavity)

– Square knot
– Surgeons knot
– Tumble square knot
– Dundee jamming knot
– Aberdeen termination

Laparoscopic clips :

Titanium clip is most widely used tissue approximation technique used by general laparoscopic surgeon. Correct size of clip for the structure and double clip should be applied over important structures . Fatty pedicles should not be clipped. Cross clipping should be avoided.

Laparoscopic Staplers:

Different tissues have different properties. Different staplers, staples and cartridges are available to adapt to the type of surgical procedure to be performed. Depending on the form of the stapler, they can be linear, curved or circular, either disposable or reusable. The staples are also made of different materials, such as titanium, which causes less immune reaction, stainless steel, or synthetic absorbable materials. Cartridges are classified by colour according to the staple characteristics.

Each stapler model has specific characteristics to adapt to specific situations:

– Non-cutting linear staplers
– Cutting linear
– Cutting curved
– Circular stapler

Each type of stapler has its own set of cartridges, where the height of the staple varies. The most important factor in staples is the height of the closed staple, because it must be able to contain the relevant tissue when closed. Each height adapts to the different tissues, such as the mesentery, which requires smaller staples, and vessels or gastrointestinal tissues, which require larger staples. The colour assigned to each staple size may vary depending on the commercial brand.

Laser Tissue Welding :

It is the first combination (laser and biologic) surgical device intended to join and seal tissues accurately and instantly. The treatment process uses thermal energy created when a laser excites photosensitive dye molecules, to coagulate the protein albumin which transforms from a liquid to a solid instantly. Laser tissue welding creates a non-compressive, non-ablative sealing of tissues with microscopic thermal damage.