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It is ironic that while in open-surgery, suturing has been considered a basic skill, in the early days of laparoscopy, suturing was used only by the advanced laparoscopic surgeon. It was thought that basic procedures could be managed by clips and pre tied loops. Nothing could be further from the truth. The predominant change in this attitude was the difficulty in mastering endoscopic suturing making it time consuming, frustrating, and even hazardous in the wrong hands. Indeed this is but a misapprehension stemming from the reluctance of established surgeons to retrain due to the inevitable hassle or the time required to develop proficiency in endoscopic suturing . The necessity of the book stems from the fact that the laparoscopic world has undergone a dramatic change, where it is well recognized that knotting and suturing is an essential laparoscopic skill. Besides, with the right training even the laparoscopy-naïve surgeon can master this . Gynecologists have been at the forefront of therapeutic laparoscopy with Kurt Semm having paved the way for therapeutic laparoscopic procedures with the first appendectomy using the endoloop . Unfortunately, Semm passed away in the beginning of the century, and the world of laparoscopy and gynecology lost a master innovator, great thinker and surgeon. Fortunately, as long as gynecologists like Nutan Jain churn out these teaching books, the field will not want for good teachers.
The title of the book ‘State of the Art Atlas and Textbook of Laparoscopic Suturing in Gynecology’ does not do full justice to what is a comprehensive teaching book for laparoscopic gynecologists and surgeons alike. The book starts with the basics of set up of an endoscopic suite and the basic training on pelvic trainers and ends by teaching extremely complex techniques of robotic, microsurgical and even Laparoscopic Endoscopic Single Site Surgery (LESS) suturing without triangulation. Newer suture materials like the barbed suture are touched upon and the usage is shown in the DVD. These sutures have made a difference as, in minimally invasive surgeries, the ability to quickly and properly tie surgical knots presents a new challenge. In cases in which knot tying is difficult, the use of knotless barbed suture can securely re-approximate tissues with less time, cost and aggravation .
In between, the numerous chapters’ authors read like a who’s who of gynecologists and surgeons in India and across the globe. In the guise of teaching us laparoscopic suturing, this book also details techniques of various procedures from appendectomy and ovarian cystectomy to the more complex myomectomy and hysterectomy. Interesting is what is described as the Jain technique of bagging the specimen and removal through a posterior colpotomy with external morcellation. While this is a common enough seen technique for specimen removal, its precise description is likely to bring relief to the peripheral and rural surgeons who may not be able to afford expensive Endo bags and Morcellators.
There is also ample and detailed discussion of the techniques of dealing with pelvic floor descent and incontinence, afflictions that plague more and more middle-aged women these days. Techniques with and without a mesh are well described. The authors also recommend fixation in all TLHs to prevent vault prolapse later.
Meticulous attention to functional anatomy is detailed in the video on rectosigmoidectomy in endometriosis with instructions to preserve the nerves of sexual and bladder bowel function, yet eradicating all the endometriotic lesions. This is considered essential even in malignancy these days so should be imperative in benign disease. Radical surgery for endometriosis can induce urinary dysfunction in up to a sixth of operated patients, and the surgeon’s knowledge of the anatomy of these nerves is the main factor for preserving postoperative urinary function .
The book lists all the possible complications of each procedure and the ways to tackle them as well. Detailed accounts are given of managing ureteric, bladder injuries and enterotomies. While some pictures in the book may be difficult to follow, the accompanying DVD-ROM more than makes up for this with some clear videos on the various techniques.
Finally, if all this surgical exercise tires you out, we are given the option of sitting and operating with the ‘chair laparoscopy’ to cut down on surgeon fatigue.
I highly recommend this book for the trainee and the accomplished, gynecologists and surgeons alike.
did his training from KEMH and advanced Laparoscopic Surgery training from France under pioneering Laparoscopic Surgeon Prof Jacques Perissat. One of the first to start advanced Laparoscopic surgery in Mumbai, he is credited with doing the first single-port procedure in the world using an access device in 2007. He has authored many articles and text book chapters and has been invited as faculty to talk about and demonstrate Single port surgery all over the world. He is a sectional editor for JMAS and has reviewed for many journals including the BJS. He is currently Director of GI Surgery and Minimal Access Surgery at Global Hospitals, Mumbai. He practices advanced Laparoscopic surgery and is credited with having done Mumbai's first Total Laparoscopic Whipple's Pancreaticoduodenectomy.
No conflict of interest.
Dr. Prashanth Rao is Chairman, Department of GI Surgery and MAS.