Techniques in Coloproctology | 2019
Utilisation of a modified Roeder’s knot in the era of minimal invasive surgery
Abstract
The era of minimally invasive colorectal surgery has spurred the development of novel vessel-sealing and suture devices. This is in part due to the increased technical demand of performing minimally invasive surgery. Novel technology benefits the surgeon and at times reduces operating time, but does increase the cost of the operation. We describe the application of the extracorporeal Roeder knot in advanced laparoscopic and transanal procedures, which is a highly cost effective tool to add to the minimally invasive colorectal surgeon’s armamentarium. The original Roeder’s knot was first described by Hans Albert Röder in 1931 [1], and it has a 1:3:1 formula—i.e. one half hitch, three winds, and one locking hitch. Its use in laparoscopic surgery was pioneered by Semm in 1981 when the knot was tied extracorporeally to ligate a vessel before transecting it [2]. This has also allowed approximation of tissue laparoscopically, used in earlier procedures such as laparoscopic tubal ligation or laparoscopic appendicectomy [2, 3]. Modifications to the original Roeder’s knot have been described due to the tendency of the original knot to slide back. These include the Melzer–Buess modification that is now commonly used in the proprietary Endoloop Ligature (Ethicon, Summerville, NJ, USA) [4] and the Sharpmodified Roeder’s knot that was originally recommended for laparoscopic colposuspension [5]. In our colorectal unit we perform a modification of the classic Roeder’s knot and utilise this in laparoscopic colorectal resection to provide a more secure ligation around a skeletonised vascular pedicle vessel of a thick mesentery. We find that especially in patients with inflammatory bowel disease, the thick mesentery makes ligation with a vessel-sealing device less secure. We also use this same modified Roeder’s knot for the closure of mucosal defects after transanal endoscopic microsurgery (TEMS).