Laparoscopic Suturing and Intracorporeal Knot-Tying for Gynaecologists: A Technique Guide Built Around the SUTT Standard

Why Is Laparoscopic Suturing Harder Than Open Suturing?

Laparoscopic suturing is the placement of stitches and the tying of knots inside a body cavity, using long instruments passed through fixed ports under two-dimensional video vision. Three constraints make it a distinct skill rather than a variation on open suturing: the port acts as a fulcrum, so the instrument tip moves opposite to the hand; the monitor removes stereoscopic depth, so depth must be inferred from shadow, contact and parallax; and the rigid shaft removes the wrist, so the needle follows its curve only if the whole instrument rotates about its own axis.

Ergonomics decides how much of that difficulty the surgeon has to fight. The monitor should sit in line with the target at or slightly below eye level, so that the eye–hand–target axis is straight. The two working ports should let the instruments meet the suture line at roughly sixty to ninety degrees, with the needle holder able to address the tissue perpendicular to the intended stitch; a needle holder entering parallel to the suture line forces the needle to be driven sideways. Table height should keep the elbows near ninety degrees and the shoulders down, because a surgeon suturing with raised elbows fatigues quickly and loses fine rotation.

Instrument position matters more than instrument choice: jaw design is a preference, but the jaw must hold the needle at a fixed angle through a full rotation. The assisting grasper in the non-dominant hand does half of the work in every stage below, and a surgeon who treats it as passive will re-grasp the needle repeatedly.

How Do You Load and Position the Needle?

Needle loading is the act of seating the needle in the needle holder's jaw at a defined angle and a defined point along its curve, so that a single rotation of the instrument drives it through the tissue. The standard load for a perpendicular stitch is at ninety degrees to the shaft, grasped roughly two-thirds of the way from the tip towards the swage; grasping nearer the tip weakens control, grasping at the swage bends the needle. For an oblique stitch line the load is opened deliberately to a wider angle, which is why structured suturing courses teach the perpendicular and the open-angle load as separate techniques.

The assisting grasper presents the needle rather than watching it. Holding the suture one to two centimetres from the swage lets the surgeon rotate the needle into the ideal orientation before the needle holder closes on it, and a needle that has landed at the wrong angle is corrected by touching its tip lightly against a fixed surface so that it swings into the perpendicular — a self-righting manoeuvre that saves several re-grasps. Loading is done away from the target, in clear view, never blind behind tissue.

Driving the needle is a rotation, not a push. The tip enters perpendicular to the surface, the wrist supinates so the needle travels along its own arc, and the tip is re-grasped on exit before the suture is drawn through, again following the curve. Pulling through at an angle to the arc enlarges the track and tears friable tissue. For an intracorporeal knot the pull stops with a tail of about two to three centimetres left on the far side of the stitch.

How Do You Tie an Intracorporeal Square Knot Step by Step?

An intracorporeal square knot is a series of flat throws formed inside the cavity by wrapping the long limb of the suture around the assisting grasper, grasping the short tail through the wrap, and pulling the two limbs apart in the plane of the tissue. The first throw is usually doubled — a surgeon's throw — so that it holds tension while the reversed second throw is formed; a third throw locks the knot. The sequence below describes the common C-loop method.

The needle is parked safely throughout, away from tissue. Every pull is made with the hands moving apart horizontally, parallel to the tissue surface, never upwards; the moment one limb is lifted the throw rises off the tissue and becomes an air knot.

1. Draw the suture through until a tail of two to three centimetres remains on the far side of the stitch; keep the tail in view.
2. Holding the long limb a few centimetres from the exit point, lay the suture on the tissue as a C-shaped loop that bows towards the tail.
3. Place the tip of the assisting grasper inside the C and rotate the needle holder around it to wrap the long limb twice around the grasper's jaws.
4. Open the grasper, grasp the short tail, and draw the hands apart in the plane of the tissue so the doubled first throw lies flat and square.
5. Lay the long limb as a mirror-image C on the opposite side, wrap once around the grasper in the opposite direction, grasp the tail and pull in the direction opposite to the first throw.
6. Check that the second throw sits squarely on the first; if it has slid into a granny throw, repeat it rather than tightening it.
7. Add a third, single throw in the original direction to lock the knot, again pulled flat and parallel to the tissue.
8. Cut both limbs to a short, consistent length and confirm the knot is seated on the tissue.

What Are the Common Faults, and How Are They Fixed?

A knot-tying fault is a repeatable error in one of the sub-skills above that shows up as a measurable defect in the finished stitch: extra time, a loose or displaced throw, or damage to the tissue around the track. Because the faults are repeatable they are diagnosable, and each has a specific correction.

The table groups the five faults most often seen on box trainers and in early operative suturing; what a candidate experiences as "the knot will not sit" is almost always one identifiable habit upstream of the moment the fault appears.

Where Do Gynaecological Cases Use These Knots?

The same needle mechanics and the same square knot serve almost every reconstructive step in laparoscopic gynaecology; what changes between cases is the depth of the bite, the tension the tissue tolerates and the order of the knots. The three examples below are surgical technique education for clinicians, not guidance for patients, and each stresses a different sub-skill.

The myomectomy bed is the test of depth and haemostasis. After enucleation the defect is closed in layers with full-thickness bites that eliminate dead space, often while the bed is bleeding, when secure throws matter most. Barbed suture has removed much of the knot-tying from running closures, but the start and finish of a layer and the deep interrupted stitches that anchor a large bed still depend on a reliable intracorporeal knot.

The vaginal cuff after total laparoscopic hysterectomy tests needle angle and knot security at the edge of the field: the cuff is addressed obliquely, the bites must include the full thickness of the vaginal wall, and the knots must lie flat. Ovarian cystectomy tests the opposite quality, gentleness: the ovarian cortex is reapproximated with one or two fine stitches under minimal tension, and tearing is the fault that matters most, because ovarian tissue does not forgive a needle that is pushed instead of rotated.

How Do You Progress to the SUTT Standard, and What Should You Do Next?

Progression is most usefully organised as a ladder of sub-skills rather than as repetition of the whole task. Basic coordination comes first: a randomised trial found that pre-training all three basic laparoscopic psychomotor skills — camera navigation, hand–eye coordination and bimanual coordination — shortened the subsequent learning curve for intracorporeal knot-tying, which is the experimental basis for practising LASTT-type camera and coordination exercises before suturing. Needle loading and stitch placement on a lined pad follow, untimed, until the needle sits at ninety degrees at the first attempt; the knot is then drilled in isolation until the three throws are consistently flat; only then are the two combined and timed, each run recorded against the surgeon's own previous times.

The SUTT station is a validated way to prove the result. Within GESEA Level 1 — alongside the TESTT theory examination and the LASTT and HYSTT stations — SUTT scores a defined suturing and knot-tying task against criterion-referenced benchmarks for accuracy and time, so a pass documents measured proficiency rather than an impression. The Basic Level task, as published for the Ankara programme, is five stitches on a central line followed by one intracorporeal knot, and a 2015 study of the European Academy SUTT programme reported that structured training on its suturing and knot-tying exercises significantly improved surgeons' performance. For orientation, the FLS programme of SAGES and the American College of Surgeons — accepted by ABOG as meeting its surgical-skills standard for obstetrics and gynaecology residents graduating from 2020 onward — assesses a general-surgery-derived skills set, whereas SUTT is the suturing station of GESEA, the European framework for gynaecological endoscopy.

For a gynaecologist or trainee who has worked through the technique in this article, the concrete next step is the officially approved GESEA Level 1 training and certification session held in Ankara on 20–22 November 2026: delivered in English for a cohort of up to twenty physicians, listed on the ESGE educational calendar, and pairing hands-on LASTT, SUTT and HYSTT training with an officially approved certification session, the certificate being issued by ESGE on successful assessment. The official ESGE Academy Level 1 e-learning is mandatory for every participant, including those on the training-only route, and is purchased separately from the ESGE Academy, so it should be started first. Applications are made on the programme page by 5 November 2026 and are reviewed academically before any payment is requested; fees are stated on the programme page.