Laparoscopic suturing is the final stage in endoscopic surgery training. It needs good dexterity and hand / eyes co-ordination. Though not needed in every day laparoscopic practice, it is still a very important skill which should be learnt by all surgeons involved in operative laparoscopy especially for the treatment of deep pelvic endometriosis. Beside the obvious need during laparoscopic myomectomy it is also needed to repair intentional and non-intentional bladder wounds and accidental small or large bowel lacerations.
Suturing with both intra and extracorporeal knotting could be used for different purposes. Extracorporeal suturing is considered to be more suitable for tight tissue approximation while intracorporeal suturing is suitable for tissue approximation without tension. I see that differently as tight approximation and very strong intracorporeal knots could be thrown if the technique is applied correctly.
All types and sizes of needles could be used for intracorporeal suturing as for open surgery. Straight needles are easy to use especially on the bowel, bladder and fallopian tubes but are not suitable for ligating pedicles. Furthermore to facilitate easy intracorporeal knot formation the suture should be 8-10 cm long whereas 70 cm length is necessary for extracorporeal suturing.
The following points should be observed to facilitate intracorporeal suturing
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The needle holder should be parallel to the long axis of the defect to be sutured. This could be facilitated by inserting the lateral operative trocars only after proper assessment of the area and planning the direction of the incision to be sutured. For vertical uterine incisions needle holders should be introduced through high trocars lateral to the umbilicus. On the other hand transverse uterine incisions are best dealt with by needle holders introduced through low trocars in the right and left iliac fossae. In both cases this technique would help in keeping the needle holders parallel to the long axis of the incision. Alternatively it might be easier to align the incision along the long axis of the lateral trocar instead but not the suprapubic one.
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The needle should be held at right angle to the long axis of the needle holder.
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The needle should be inserted at right angle into the cut edge of the incision and advanced across to the other side by moving the hand in pronation.
Ideally 2 needle holders should be used, one on each side, to allow both right and left hand suturing and facilitates knots formation.
Occasionally all these efforts might not help with easy suturing and the target organ should be moved to bring it into more favourable position to the needle and needle holders. Moving the uterus in different directions with a Zumi manipulator is a good example to give. It is occasionally important to free the uterus of all adhesions to allow its free mobility upwards and sideways in cases expected to need laparoscopic suturing. | 
