RU2827880C1 - Method for training laparoscopic intracorporeal sutures - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: invention can be used for simulation training of laparoscopic intracorporeal sutures. Training is performed with the help of box simulators for practicing laparoscopic skills of open and closed types. Training consists in sequential performance of the following actions by trainees, consisting of 4 parts: laparoscopic manipulations with thread and needle (LMN); formation of an interrupted intracorporeal suture with a surgical knot (ISK); formation of a continuous intracorporeal suture (CICS) with an Aberdeen knot (IAK); formation of an interrupted intracorporeal suture with a slip knot (ISK).

EFFECT: method increases the effectiveness of training laparoscopic intracorporeal sutures, provides the necessary visual and tactile control during suturing, which prevents the occurrence of errors during training, facilitates and speeds up training in simulation conditions, enables to standardize the training process due to the sequence of actions for mastering the suturing technique.

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Description

The invention relates to the field of medicine, namely to surgery, and can be used for simulation training of laparoscopic intracorporeal sutures.

An important component of the competence of doctors of surgical specialties is the ability to perform surgical interventions [1]. Modern surgical technologies allow many interventions to be performed endoscopically. One of the options is laparoscopic interventions (LI), when the surgeon performs an operation on the abdominal organs using special instruments inserted into the abdominal cavity through 1-2 cm incisions and special instruments - trocars, which serve as a place for the introduction and removal of instruments during the operation (ports). This allows the operation to be performed with minimal trauma for the patient and reduces the rehabilitation period for patients.

One of the most important skills for performing LV is the surgeon's ability to perform an intracorporeal suture (ICS). Proficiency in the ICS technique determines the spectrum of LV for the surgeon and safety for the patient. ICS is a method of restoring tissue integrity or stopping bleeding using special instruments and suture material, when after suturing the tissue, a knot is formed in the cavity. Using endosurgical instruments in the abdominal cavity, tissue is suturing with a needle and thread and the suture is fixed with knots. The completed knot consists of several consecutive half-knots. Like all surgical sutures, ICS must meet three basic requirements: match the edges of the sutured tissue, firmly fix them, without damaging them with excessive compression of the thread [2].

There are many types of laparoscopic surgical knots [2]. A distinction is made between interrupted (knotted) and continuous surgical sutures, with different knots [2, 3].

The implementation of IKS consists of the following stages:

1. delivery of suture material - thread with a needle - to the suture site;

2. taking the needle and placing it in the needle holder;

3. stitching the required area of fabric with a needle;

4. formation of a node.

The most commonly used method in laparoscopic surgery is the standard intracoproral surgical knot at the end of an interrupted or continuous suture [3]. Less commonly used are the sliding knot (SK) after an interrupted suture and the Aberdinius knot after a continuous suture [4].

A surgical suture begins with grasping the needle with a needle holder, placing the needle in the position necessary for suturing the tissue, and suturing the tissue itself. As with any suture, minimal tissue trauma is important when suturing with a needle. Safe laparoscopic needle manipulations (SLNM) are especially difficult because they are complicated by limited instrument movement through the instrument insertion port, decreased tactile control due to the length of the instruments, difficulty in visually monitoring the operation of the instruments, and assessing the position of the needle through a flat-screen monitor (FSM). The ability to perform SLNM involves the following actions:

1. grasping the needle with the instrument from different positions, when the needle lies on the surface of the fabric and when it is held in space by the thread by the instrument;

2. determine the optimal direction of stitching the needle through the existing port, with minimal trauma to the tissue;

3. position the needle in any desired position in the needle holder (NH) to stitch the fabric in the selected direction;

4. the ability to rotate the needle in the ID in the required directions, along each of the three axes in space;

5. stitching the fabric with a needle in selected directions that allow this to be done with minimal trauma to the fabric.

The intracorporeal surgical knot (ICSK) after a continuous suture is performed by forming loops on the thread fragment formed by the last loose stitch of the suture; this stitch has the shape of an arc consisting of two sections of the thread: the one closest to the suture and the one closest to the end of the thread with the needle. Thus, the formed loops are tightened at once on two sections of the thread, shifted relative to each other [3]. This reduces the strength and reliability of the knot. An alternative to the ICSK after a continuous suture is the intracorporeal Aberdeen knot (IAK) [2], which is free of these disadvantages [4].

The most common mistakes when performing the IAU are loosening the first half-knot when tightening the second loop. This happens when, when forming the second loop, the first half-knot is touched by the tool and displaced.

Among the various types of knots used to complete the ICS, the sliding knot (SK) occupies an important place [2]: it has advantages in cases of resistance, rigidity and tension of the tissues being sutured, and limited space for safe manipulations with laparoscopic instruments. The intracorporeal SK (ISK), unlike the extracorporeal one, is formed entirely inside the cavity, for example, the abdominal cavity. The ISK has a number of advantages over the extracorporeal SK (Raeder's knot), since it traumatizes the tissue to a lesser extent (one of the main requirements for surgical sutures), does not require an additional instrument (pusher) and reduces the consumption of suture material. The ISK is considered more difficult to perform; its execution is an advanced skill of a surgeon performing endoscopic interventions. First, an intracorporeal sliding half-knot (ISK) is formed, which is then tightened and displaced along the passive end of the thread (PET) in the direction of the edges of the tissue being sutured, and then they are aligned. ISU 2-4 is completed with additional fixing half-knots.

The strength of the SPU is achieved by its shape and tightening to the required degree to create such a friction force inside the SPU that it can only be moved along the PCN under the action of the surgeon's instrument - this ensures reliable retention of the edges of the sutured tissue.

Thus, when performing ISU, the surgeon must control: 1) its strength when tightening the ISU and 2) the degree of matching of the edges of the tissue without excessive compression. In practice, it is very difficult to control these two processes simultaneously, which is the main cause of errors when performing ISU.

There are several reasons that influence premature tightening of the ISPU:

1. formation of a “twisted” knot, in which increased friction of the knot with the PCN is created;

2. insufficient visual and tactile control over the state of the ISPU.

The knot strength and friction force in the knot are affected by such a property of the thread as friction ability. Premature tightening of the ISPU more often occurs with a thread that has properties of increased friction, such as, for example, the braided complex thread Vyclril. Therefore, the surgeon must take into account the properties of the thread when tightening the ISPU.

Errors in the implementation of the ISU are considered to be failure to comply with the requirements for the ISU (see the requirements for the IKS above) in the following cases:

- there is no adequate comparison of the edges of the fabrics being sewn. This may occur as a result of:

a) premature and excessive tightening of the ISPU, which leads to premature fixation of the ISPU on the PCN due to the creation of high friction between the ISPU and the PCN. This does not allow the surgeon to move the ISPU in the direction of the tissue to approximate and match its edges without applying significant force. The use of significant force reduces the control of the surgeon's hands and means a high risk of tissue damage. In such cases, it is necessary to remove the applied knot and repeat the tissue suturing, which increases the risk of tissue damage, leads to a loss of time during the operation, creates a stressful situation and increases the risk of medical errors.

b) weakness of the ISPU and insufficient fixation by subsequent half-knots. In this case, the knot does not perform its function, which leads to life-threatening complications of the operation.

- tissue damage when the edges of the sutured tissue are brought together and matched. This is possible as a result of:

a) insufficient tightening of the ISPU (weak knot), which leads to the lack of fixation of the ISPU on the PCN and insufficient matching of the tissue edges. When attempting to simultaneously tighten the ISPU and match the tissue edges, excessive sliding of the ISPU along the PCN and excessive compression of the tissue by the thread occurs. This occurs because both adequate tightening of the ISPU and matching of the tissue edges require increased attention and control of movements from the surgeon. Since simultaneous control of these actions is difficult and often insufficient, this leads to errors in the execution of the ISPU with subsequent complications or an increase in the duration of the operation and an increase in the stress level of the surgeon;

b) excessive force displacement of the ISPU along the PCN under pressure or pulling of the tool when attempting to move the ISPU that was prematurely fixed from its place.

Importance and features of the SO for all stages of the IKS

IKS is a complex voluntary motor act. Mastering the IKS technique requires special teaching methods, in accordance with the general principles of conscious practice EricssonK.A. [6]:

- regular multiple repetitions of the necessary movements;

- segmentation, dividing a complex skill into separate components and concentrating efforts on practicing them;

- constant feedback, evaluation and adjustment of performance;

- increasing level of difficulty of movements.

A recognized and increasingly used approach to teaching practical technical skills is the so-called “Ilemoua(Peyton) 4-step approach” [7].

- demonstration,

- division into elements,

- awareness,

- execution.

To develop the ability to perform ICS, it is advisable to use training in simulation conditions - the so-called simulation training (ST), with subsequent transfer of the skill to the real practice of operations on patients [8, 9].

SO means that the development of the ability to perform IKS is carried out without the participation of real patients, but with the use of special simulation equipment that replaces patients - these can be dummies, mannequins, simulators of varying levels of complexity, including computer technologies, as well as biomodels. This is safe for patients - it eliminates the risk of causing them harm, and is effective, since it allows trainees to repeatedly practice actions to achieve the required level of skill. Currently, SO is an integral part of training programs for mastering IKS [8, 9].

The ultimate goal of the ICS is to develop in doctors (hereinafter referred to as students) the ability to perform ICS in surgical practice on patients, while minimizing the risk of errors on the part of the doctor.

Taking into account the requirements for IKS, an important task is to train surgeons in the necessary control over the safety of tissue suturing, the degree of tightness of stitches and knots, taking into account the properties of the thread, with subsequent control over the safe alignment of the sewn edges of the tissue, taking into account their properties.

However, the goals of the SS are not always achieved: the level of skill achieved by different participants in the training program may differ; in real practice, the physician is exposed to various stress factors that complicate and often prevent the application of skills achieved during the SS. For example, the proportion of physicians who used the ICS after the SS in real practice ranges from 44% [10] to 72.2% [11].

It was not possible to find any publications on the results of using the ISU after training.

Description of existing methods of CO of various stages of IKS

SO LMI allows to master this skill faster and without harm to patients. At the same time, training requires special exercises to practice this responsible and complex part of IKS.

As in other cases of mastering laparoscopic knots, the SO IAU promotes safe and accelerated development of this skill.

In accordance with the above requirements for the ability to perform LMI, the tasks of the LMI SO are:

1. practicing techniques for grasping the ID needle from different positions before stitching;

2. development of the ability to rotate the needle in the ID without dropping it, along various axes of space - longitudinal, transverse and vertical, if we consider them relative to the ID;

3. development of the ability to determine the optimal direction of suturing for curved wound trajectories, taking into account the limitations of movement of the I., with minimal trauma to the tissue;

4. development of the ability to position the needle in the branches of the ID in any position necessary for stitching in the chosen direction;

5. development of the ability to stitch fabric with a needle in selected directions with minimal trauma.

Methods of SO LMI

1. Publications (books, journal articles)

The publications found on the IKS technique demonstrate illustrations showing manipulations with the needle. They describe such techniques for correcting the position of the needle in the ID as rotation along the transverse axis by grasping the thread [12, 13, 14], by the end of the needle [14]. Stitching of the tissue in the ID position parallel to the wound is demonstrated, where the position of the needle is most facilitated. In one case, a task is described that requires stitching in different directions [15].

No publications were found that recommended rotating the needle in ID along each of the three axes; no needle positioning techniques were shown for stitching the fabric in different directions. No description of the sequence of actions for mastering the LMI technique was found.

2. Demonstration of LMI video recordings (Internet resources) Video materials with demonstrations found in Internet resources

Various types of IKS provide a visual representation of the LMI, which can be used for training purposes [24-35]. They demonstrate movements such as grasping the needle when the needle lies on a plane and when it is held in space by the thread.

It also demonstrates the rotation of the needle by the instrument in the ID branches along the transverse axis with only one grip - holding the needle by the thread.

Rotation along the longitudinal axis (in the frontal plane) is demonstrated to intercept the needle in a small amplitude in the range of 20-30 degrees.

The following elements necessary for LMI training are not shown in the sources found, or their combination is not presented:

exercises for correcting the needle in the ID branches by rotating along the vertical axis;

safe correction of the final position of the needle in the ID for stitching the fabric at specified points and in different directions;

passing the needle through the tissue in a direction that matches the curvature of the needle; failure to do so will in reality result in additional tissue trauma.

Thus, LMI training requires a method that allows developing the necessary skills to perform LMI.

Methods of SO IAU

1. Publications devoted to the technique of forming the IAU.

The publication we found devoted to the technique of forming the IAU contains illustrations showing the stages of its formation [45]. The sequence of actions is shown, but their descriptions and comments by the author are missing. The illustrations show that when forming the second loop, the tool pulls the section of the thread responsible for preserving the first half-knot, which can lead to the weakening of the latter. There are no comments warning of this technical error.

It was not possible to find any publications of training programs describing the methods and techniques of teaching IAU.

2. Demonstration of video recordings of the IAU (Internet resources)

Video materials found in Internet resources demonstrating the process of forming the IAU provide a visual representation of the technique of forming the IAU, which can be used for the purposes of teaching the technique of the knot [42, 43, 44]. However, these materials do not contain comments, recommendations for correct execution and error prevention.

Methods of SO ISU

Description of methods for training in performing laparoscopic ISU in simulation conditions:

1. Publications (books, journal articles)

The publications found on the implementation and training of IKS, and ISU in particular, demonstrate illustrations showing various forms of the knot. They lack comments and descriptions of the sequence of actions for mastering the ISU technique, there are no descriptions of the methods of their formation and prevention of the above-mentioned errors in execution, 12, 16, 17,18, 19, 20, 21].

It was not possible to find any publications of training programs describing the methods and techniques for teaching ISU

2. Demonstration of video recordings of the ISU (Internet resources) Video materials with demonstrations found in Internet resources

The process of forming the ISU in various ways provides a visual representation of the technique of forming the ISU, which can be used for the purposes of teaching the ISU[37-41].

However, although the available video materials demonstrate successful completion of the ISU, many of them contain techniques that can potentially lead to errors in the execution of the ISU. Formation of a twisted ISU, lowering the ISU onto the tissue by pulling the active end of the thread in the direction of the tissue, can lead to premature tightening of the ISU, preventing the edges of the wound from being aligned [36]. Or it is the simultaneous tightening of a weakened ISU and alignment of the edges of the tissue [39, 40], leading to weakening of control over the safety of the sutured tissues and damage to the latter [37, 38, 39].

These videos do not contain a description of the sequence of actions for mastering the ISU technique and comments that prevent mistakes when performing ISU.

The described demonstrations of the execution of the ISU do not indicate the necessary visual and tactile control over the degree of tightening of the ISU.

Thus, it was not possible to find a training program for the IKS that would pay attention to the development of techniques at all stages of the IKS formation, using different types of nodes. In addition, there is a lack of uniform technique and standardization of the IKS training process [22].

To eliminate the above-mentioned shortcomings and more fully comply with the requirements for training the IKS, a method of simulation training of the IKS (hereinafter referred to as the Method) is proposed.

The purpose of the Method is to increase the efficiency of the IKS by consistently performing actions aimed at training doctors in needle manipulation, forming intracorporeal surgical, Aberdeen and sliding knots, and standardizing the IKS training process.

Description of the Method:

The invention relates to the field of medicine, namely, to surgery, and can be applied to the laparoscopic endoscopic surgery. The method is performed using endosurgical instruments: two laparoscopic needle holders or one needle holder and one dissector, box simulators for practicing laparoscopic skills (laparoscopic simulators) of open and closed types, simulators for practicing surgical sutures, suture material (needle with thread), a camera and technical means for video recording and demonstration.

Necessary equipment:

1. endosurgical instruments used to perform laparoscopic and other endosurgical interventions: endosurgical needle holder (ENH) - for work with the dominant hand (DH), endosurgical dissector (ED) - for work with the non-dominant hand (HP), endosurgical scissors;

2. box simulators for practicing laparoscopic skills of open (TOT) and closed (CCT) types:

a. TOT allows manipulation of endo-instruments under the control of stereo vision;

b. TZT provides an image of intracorporeal manipulations on a flat screen video monitor (VSM); the resolution of the video camera and VSM is Full HD

3. simulators for practicing surgical sutures with imitation of a "wound" (hereinafter referred to as TS) on a horizontal plane; used in TOT, TZT and outside them, in open space (OS). TS contains elements for suturing, located circularly, around the circumference;

4. suture material:

a. threads on an atraumatic needle of various sizes: braided with a thickness from 1 to 3/0, absorbable (hereinafter thread No. 1) and non-absorbable (thread No. 2);

b. atraumatic needle: 31 mm in size, 1/2 g in circumference, with a 4-6 cm piece of thread. The atraumatic needle has a sharp end and an end with an attached thread - the "eye" of the needle; the point of capture of the needle by the needle holder for installation in the working position (point A) - at a distance of one third of the length of the needle from the "eye";

5. video recording equipment;

6. equipment for demonstrating video recordings.

The method of teaching laparoscopic IBS consists of students sequentially performing the following actions, consisting of 4 parts:

1.1 laparoscopic manipulations with thread and needle (LMI);

1.2 formation of a nodal (intermittent) intracorporeal suture with a surgical knot (ISU);

1.3 formation of a continuous intracorporeal suture (CISS) with an Aberdinius knot (AUK);

1.4 formation of a nodal (intermittent) intracorporeal suture with a sliding knot (ISK).

Part 1. Laparoscopic manipulations with thread and needle (LMI)

1.1 complete task 1.1: watch an educational video film demonstrating the implementation of the LMI and the teacher’s comments;

1.2 complete task 1.2: watch the teacher demonstrate the performance of LMI - techniques for taking and positioning the needle on the TZT.

The purpose of tasks 1.1-1.2 is to form a visual picture of the technique for performing LMI in students.

1.3 complete task 1.3: watch the teacher’s demonstration of techniques for grasping and operating an endoscopic dissector (ED) in the non-dominant hand (HP) in open space (OS) (outside the TOT and TZT);

1.4 perform task 1.4: grasping and working with the dissector (ED) in the non-dominant hand (HP) in the OP, paying attention to grasping the handle, turning the rack on and off, opening and closing the jaws, rotating the jaws using the ED “lamb” (the “lamb” is an element of the ED for rotating the jaws).

Repeat the manipulations 10 to 20 times.

Notes:

1) the number of repetitions of manipulations varies and depends on the success of mastering the manipulation by the listeners;

2) here and in the future, take breaks of 5-7 minutes every 15-20 minutes of work

When completing task 1.4 it is important:

1) firmly grasp the ED handles with the HP brush;

2) the index finger is placed on the ED “lamb” for correct control of the rotation of the ED branches;

3) the degree of compression of the ring handles should not block the rotation of the branches;

4) the working surfaces of the branches should be located in a horizontal plane for better control over the accuracy of grasping objects or tissues.

The goal of task 1.4 is to practice capturing and operating ED in HP.

1.5 complete task 1.5: watch the teacher’s demonstration of gripping and working with a needle holder (NH) in the DR in the OP;

1.6 perform task 1.6: capture and work of the ID in the DR in the OP: capture the handle, turn on and off the rack, open and close the branches. Repeat the manipulations 10 to 20 times.

When completing task 1.6 it is important:

1) tight grip of the handle with fingers;

2) the index finger is placed on the handle at the beginning of the tool shaft to direct the movements of the ID.

The goal of task 1.6 is to practice the capture and operation of the ID in the DR.

1.7 perform task 1.7: on the TZT, grasp the thread with the ED branches in HP. The thread is placed on the THS in the direction: for right-handers - from 10 to 16 o'clock on the dial, for left-handers - from 8 to 14 o'clock on the dial. Repeat the manipulations 50 to 100 times.

When completing task 1.7 it is important:

1) use the holes for inserting instruments (ports) of the TZT so that the instruments are positioned at an angle of 90 degrees to each other;

2) When grasping, the thread should be positioned across the branches and at a distance of 2-5 mm from the tips of the branches.

The goal of task 1.7 is to practice the control of the ED, the accuracy of grasping the thread with the end of the ED branches, activating the work of the HP, and improving the function of visual-spatial orientation through the PEV.

1.8 perform task 1.8: on the TZT, sorting the thread with two instruments - ED in HP and ID in DR - from left to right and from right to left. Repeat the manipulations 50 to 100 times.

When completing task 1.8 it is important:

1) when grasping, the thread should be positioned across the ID and ED branches, at a distance of 2-5 mm from the tips of the branches;

2) when sorting, hold the thread “in the air”.

The goal of task 1.8 is to practice handling tools, improve coordinated work with two hands, and improve tactile control when grasping a thread.

1.9 Perform task 1.9: Grasp the needle with a piece of thread lying on the horizontal plane on the TZT. Before grasping the needle, press on the middle of the needle with the upper branch of the ID so that the needle turns 90 degrees into the frontal plane; then grasp the needle with the branches of the ID. Repeat the manipulations 15 to 30 times.

When performing task 1.9, it is important: to grasp the needle no earlier than turning the needle into the frontal plane;

The purpose of task 1.9 is to practice grasping a needle in the ID lying on a horizontal plane, improve tactile control when grasping a needle, and improve the function of visual-spatial orientation through the PEV.

1.10 perform task 1.10: on the TZT, grasp and turn over the ID needle with a piece of thread lying on the horizontal plane. The needle is turned 180 degrees in the frontal plane by pressing the upper branch of the ID, grasped, turned 180 degrees by rotating the ID and lowered onto the horizontal plane. Repeat the manipulations from task 1.10 10 to 20 times.

When completing task 1.10 it is important:

1) maintain the rotation of the needle in the frontal plane;

2) when lowering the needle onto the plane, avoid piercing the needle into the tissue of the THSh;

3) if necessary, rotate the needle in a horizontal plane, holding it by the end of the thread;

4) 20-minute breaks every 1.5 hours of work

The goal of task 1.10 is to practice grasping a needle lying on a plane in any position, and to improve the function of visual-spatial orientation through the visual-spatial orientation system.

1.11 perform task 1.11: on TOT, grasp the needle by the thread and intercept the ID. The needle with a piece of thread lying on a horizontal plane, with the sharp end on the left, is grasped by the thread 2-3 cm from the "eye" of the needle and held above the surface of the THS; then grasp the ED needle close to the sharp end, turn the ED so that the end of the needle is directed upwards; then turn the needle by the thread along the vertical axis "away from you" with the needle holder, and grasp the needle ID at point A. Repeat the manipulations 10 to 20 times.

When completing task 1.11 it is important:

1) control the grip of the needle using the lower branch of the ED,

2) hold and intercept the needle in the branches without dropping the needle. The purpose of task 1.11 is to practice handling the instruments,

grasping the needle held in free space by the thread; visual and tactile control of the position of the needle in the instrument.

1.12 perform task 1.12: on the TZT perform manipulations from task 1.11. Repeat manipulations 10 to 20 times.

When completing task 1.12 it is important:

3) control the capture of the needle using the lower branch of the ED,

4) hold and intercept the needle in the branches without dropping the needle. The purpose of task 1.12 is to practice handling the instruments,

grasping the needle held in free space by the thread; visual and tactile control of the position of the needle in the instrument, improving the function of visual-spatial orientation through the PEV.

1.13 Perform task 1.13: Rotate the needle in the frontal plane clockwise by 360 degrees on the TOT. Grasp the needle ID with a piece of thread at point A (starting position); the end of the needle is directed to the left; intercept the ED in the middle of the needle, rotate the ED with the needle clockwise by 180 degrees; intercept the needle ID near the point of needle capture ED, rotate the ID with the needle another 180 degrees clockwise with the needle. Complete the movement by installing the needle in the ID in the starting position. Repeat the manipulations 10 to 20 times.

1.14 perform task 1.14: perform the manipulations from task 1.13, rotating the needle “counterclockwise”. Repeat the manipulations 10 to 20 times.

When completing tasks 1.13 and 1.14 it is important:

1) control the needle grip points;

2) to grasp the needle, rotate (pronate) each hand with the instrument by 180 degrees;

3) the instruments must not overlap;

4) breaks in work lasting 5-7 minutes every 15-20 minutes.

The purpose of tasks 1.13 and 1.14 is to practice rotating the needle along the longitudinal axis, grasping the needle with instruments in various positions, and visual and tactile control of the position of the needle in the instruments.

1.15 perform task 1.15: on the TZT repeat the manipulations from Task 1.13 10 to 20 times.

1.16 perform task 1.16: on the TZT repeat the manipulations from Task 1.14 from 10 to 20 times

The purpose of tasks 1.15-1.16 is to practice gripping and rotating the needle with instruments, visual and tactile control of the position of the needle in the instrument, and improving the function of visual-spatial orientation through a flat monitor screen.

1.17 perform task 1.17: on the TOT, rotate the needle in the branches of the ID along the axis transverse to the ID, grasping the end of the needle.

The needle with a piece of thread I. is grasped by the middle so that the needle is located in the frontal plane across the branches of the ID; grasping the ED by the sharp end, the needle is rotated along the transverse axis by 10-15 degrees in both directions, gradually increasing the amplitude of rotation to 45 degrees. The manipulations are repeated 20 to 40 times.

Then do the same, grasping the needle at point A. - repeat 20 to 40 times.

When completing task 1.17 it is important:

1) control the grip of the needle by the ID branches so that rotation of the needle is possible without it falling;

2) control the direction of rotation of the needle, minimize deviation from the transverse axis.

1.18 perform task 1.18: on TOT repeat the manipulations from task 1.17, grabbing the thread 2-3 cm from the “eye” of the needle, 20 to 40 times.

The purpose of tasks 1.17 and 1.18 is to practice rotating the needle along the transverse axis by grasping the end of the needle and the thread, and visual and tactile control of the position of the needle in the instrument.

1.19 perform task 1.19: on the TZT repeat the manipulations from task 1.17. Repeat the manipulations from task 1.17 from 20 to 40 times.

1.20 perform task 1.20: on the TZT repeat the manipulations from task 1.18. Repeat the manipulations from task 1.18 on the TZT from 20 to 40 times.

The purpose of tasks 1.19 and 1.20 is to practice rotating the needle in the branches of the ID along the transverse axis by grasping the end of the needle and the thread, visual and tactile control of the position of the needle in the instrument, and improving the function of visual-spatial orientation through the PEV.

1.21 perform task 1.21: on the TOT, rotate the needle in the ID branches along the vertical axis by grasping the end of the needle

The needle with a piece of ID thread is grasped by the middle so that the needle is located in the frontal plane across the ID branches; grasping the ED by the sharp end, the needle is rotated along the vertical axis by 10-15 degrees in each direction, gradually increasing the amplitude of rotation to 45 degrees in each direction. The manipulations are repeated 20 to 40 times.

Then do the same, grasping the needle at point A. - repeat 20 to 40 times.

When completing Task 1.21 it is important:

1) control the grip of the needle by the ID branches so that rotation of the needle is possible without the needle falling;

2) control the direction of rotation of the needle, minimize deviation from the vertical axis.

1.22 perform task 1.22: on the TOT, rotate the needle in the ID branches along the axis along the vertical axis by grasping the thread. Repeat the manipulations from task 1.21, grasping the thread 2-3 cm from the "eye" of the needle from 20 to 40 times.

The purpose of tasks 1.21 and 1.22 is to practice rotating the needle in the ID branches along the vertical axis by grasping the end of the needle and the thread, and visual and tactile control of the position of the needle in the instrument.

1.23 perform task 1.23: on the TZT repeat the manipulations from task 1.21 20 to 40 times.

1.24 perform task 1.24: on the TZT repeat the manipulations from task 1.22, from 20 to 40 times.

The purpose of tasks 1.23-1.24 is to practice rotating the needle along the transverse axis by grasping the end of the needle and the thread, visual and tactile control of the position of the needle in the instrument, and improving the function of visual-spatial orientation through the visual-spatial orientation system.

1.25 perform task 1.25: on the TOT stitching the fabric of the THSh elements by rotating the needle "clockwise" of the fabric of the THSh elements: for right-handers - in the "12-3 o'clock" sector, for left-handers - in the "9-12 o'clock" sector. Repeat the manipulations 20 to 40 times.

When completing task 1.25 it is important:

1) before each stitching of the fabric, adjust the position of the needle along the transverse and vertical axes, achieving a stitching line as close as possible to perpendicular to the “wound” line;

2) correct the needle in the ID immediately before inserting the needle to more accurately determine the direction of needle correction;

3) remove the needle from the tissue along the radius of the needle circumference, avoiding additional tissue trauma;

1.26 perform task 1.26: on the TOT stitching the fabric of the THSh elements by rotating the needle “counterclockwise”: for right-handers - in the “12-3 o’clock” sector, for left-handers - in the “3-6 o’clock” sector. Repeat the manipulations 20 to 40 times.

The purpose of tasks 1.25-1.26 is to improve instrument control, determine the optimal position of the needle for stitching, and stitch the tissue with minimal tissue trauma.

1.27 perform task 1.27: on the TZT perform manipulations from task 1.25 from 20 to 40 times.

1.28 perform task 1.28: on the TZT perform manipulations from task 1.26 from 20 to 40 times.

The purpose of tasks 1.27 and 1.28 is to improve the control of tools, determine the optimal position of the needle for stitching,

stitching of tissue with minimal tissue trauma, improvement of visual-spatial orientation function through PEV.

Part 2. Formation of a nodal (intermittent) intracorporeal suture with a surgical knot

2.1 complete task 2.1: watch a video film with the IKS with the IHU and the teacher’s comments;

2.2 carry out task 2.2: watch the teacher’s demonstration of the implementation of the IKS with the IHUna TZT.

The purpose of tasks 2.1-2.2 is to form a visual picture of the technique for performing IKS with IHU.

2.3 perform task 2.3: on TOT stitch the fabric with a needle and thread No. 1 (20-40 cm), straighten the thread. Repeat the manipulations 10 to 20 times.

When completing task 2.3 it is important:

1) before stitching, adjust the position of the needle in the ID for minimally traumatic stitching (as in tasks 1.25-1.28);

2) when pulling the thread with the tool in HP, the ID is used as a lever support to control the direction of pulling the thread from the fabric;

3) if the thread is twisted, straighten it along its entire length, including the needle.

The objective of task 2.3 is to improve instrument control, tissue stitching and thread pulling with minimal tissue trauma.

2.4 perform task 2.4: on TOT, form a "horseshoe" from the long end of the thread (DKN) to prepare the thread for forming loops. Repeat the manipulations 10 to 20 times.

When completing task 2.4 it is important:

1) capture of the thread by the branches of the ED in HP at 10-12 cm from the point of exit from the tissue 2) the captured section of the thread should be located across the longitudinal axis of the branches and at a distance of 2-5 mm from the tips of the branches of the ED (as in task 1.7)

3) bring the captured section of thread to the place where the fabric is being stitched with HP in order to position the thread in the shape of a horizontal “horseshoe” with the convexity towards the DR.

The purpose of task 2.4 is to practice manipulations to prepare the thread for forming loops.

2.5 perform task 2.5 on TOT formation of a triple loop from the DKN, wrapping the thread around the ID by rotating the instruments in the direction "clockwise" relative to the ID. Repeat the manipulations 20 to 30 times.

When completing task 2.5 it is important:

1) ensure that the section of the thread closest to the capture point is parallel to the longitudinal axis of the ID;

2) for this, the ends of the instruments are at a distance of 5-10 mm from each other;

3) HP has priority when rotating tools;

4) the instruments are positioned perpendicular to each other.

2.6 perform task 2.6: on TOT form a triple loop from the DKN, wrapping the thread around the ID by rotating the instruments in the direction "counterclockwise" in relation to the ID. Repeat the manipulations 20 to 30 times.

When completing task 2.6, it is important to - see task 2.5.

The purpose of tasks 2.5-2.6 is to improve instrument control and practice the technique of forming multiple multidirectional loops for IHU.

2.7 perform task 2.7: perform manipulations from tasks 2.5-2.6 on the TZT. Repeat the manipulations 20 to 40 times.

The purpose of task 2.7 is to improve the management of tools, to practice the formation of multiple

multidirectional loops for the IHU, the function of visual-spatial orientation through a flat screen monitor (PEV).

2.8 perform task 2.8: on the TZT form a double loop in the direction "counterclockwise" or "clockwise", grab the short end of the thread (SET) and pull it through the double loop. Repeat the manipulations 10 to 20 times.

When completing task 2.8 it is important:

1) control the position of HP and its active participation in manipulation;

2) when grasping the end of the thread, the ends of the instruments are located no further than 3 cm from each other, preventing tension on the thread;

3) when pulling the KKN through the double loop, do not allow the thread loops on the ID to tighten.

4) after performing the manipulation (pulling the KKN through the double loop), unravel the loops for repeated manipulations.

The purpose of task 2.8 is to practice the stage of forming the IHU, control of instrument movements in HP, and the function of visual-spatial orientation through a flat monitor screen.

2.9 perform task 2.9: on the TZT perform manipulations from tasks 2.3, 2.7, 2.8, followed by tightening the double loop and cutting off the long end of the thread with the needle (DKN), leaving the end of the thread 6-8 cm long. Repeat the manipulations 10 to 30 times.

When completing task 2.9 it is important:

1) when tightening the double loop, control the alignment and condition of the sewn edges of the fabric, preventing them from being damaged;

2) see also recommendations from task 2.8.

The purpose of task 2.9 is to practice the main stage of forming the IHU - forming and tightening a double loop, monitoring the condition of the sutured tissue, monitoring the movements of the instrument in HP, the function of visual-spatial orientation through the PEV, and manipulation of endo-scissors.

2.10 Perform task 2.10: on the TZT, form alternately single loops from different ends of the thread. Repeat the manipulations from 30 to 50 times.

When completing task 2.10 it is important:

1) loops are formed above the place where the fabric is stitched;

2) control the degree of tightening of the loops to prevent them from loosening.

The purpose of task 2.10 is to work out the final stage of forming the IHU, improve the control of tools, visual and tactile types of control of work with tools, and the function of visual-spatial orientation through a flat monitor screen.

2.11 perform task 2.11: on the TZT, sequentially perform manipulations from tasks 2.9-2.10 to form the IHU according to the formula 2+1+1, where a double and two single loops are made with thread No. 1. Repeat the manipulations 10 to 20 times.

When completing task 2.11 it is important:

1) minimize the amplitude of instrument movements,

2) control the degree of tightening of the loops,

3) control the condition of the fabric being stitched, avoiding damage to it.

The purpose of task 2.11 is to practice the formation of the IHU under visual control conditions through the PEV.

2.12 perform task 2.12: on the TZT perform manipulations from task 2.11 with thread No. 2. Repeat manipulations 10 to 20 times.

2.13 perform task 2.13: on the TZT, perform stitching with a needle and thread No. 1 and form the IHU; perform and watch the video recording of the performance.

The purpose of task 2.13 is the surgeon’s self-control when viewing a video recording of the execution of the ISU, identifying technical errors in the execution.

2.14 perform task 2.14: on the TZT, repeat the manipulations from task 2.13 with the correction of errors identified when viewing the video recording. Repeat 2-5 times.

The goal of task 2.14 is for the surgeon to self-correct errors in execution and practice the corrected set of movements.

2.15 complete task 2.15: on the TZT repeat task 2.13 (video recording and viewing it).

Part 3. Formation of a continuous intracorporeal suture (NICS) with an intracorporeal Aberdinius knot (IAK) Note! NICS with IAK consists of three stages:

1) initial - formation of the IHU, forming multidirectional loops from the DKN;

2) intermediate - formation of a seam from several stitches of thread;

3) final - formation of the IAU.

3.1. complete task 3.1: watch a video with NICS and IAU and teacher’s comments;

3.2. complete task 3.2: watch the teacher's demonstration of the implementation of the NICS

The purpose of tasks 3.1-3.2 is to form a visual picture of the technique of performing NIKSH and IAU

3.3. Perform task 3.3: on the TZT, form the IHU (double-single-single according to the formula 2+1+1), performing multidirectional loops from the DKN. Repeat the manipulations 10 to 20 times, using different sections on the THSh.

When completing task 3.3 it is important:

1) the first double loop is formed from the DKN (as in task 2.8.) above the place where the fabric is stitched; the KKN is pulled through it; subsequent loops are formed in different directions: sequentially “clockwise” and “counterclockwise”;

2) control the alignment and condition of the sewn edges of the fabric;

3) cut off the short end of the thread leaving 7-10 mm of thread. The purpose of task 3.3 is to practice the formation of the IHU with

multidirectional loops from DKN.

3.4. Perform task 3.4: on the TZT, using the blanks from task 3.3, form a continuous seam with 5-7 stitches; the seam line is located along the diagonal line parallel to the ID, in the direction from 10 o'clock to 5 o'clock on the dial. Repeat 5 to 10 times.

When completing task 3.4 it is important:

1) insert and remove the needle at a distance of 5-8 mm from the edges of the fabric being sewn;

2) the interval between stitches is 5-8 mm;

3) when pulling the thread, avoid traumatizing the tissue with the thread; use the ID as a support for the thread being pulled;

4) control the alignment and condition of the sewn edges of the fabric;

5) leave the last stitch of the thread loose, 2-3 cm high (blank for the Aberdeen knot (AU)).

The purpose of task 3.4 is to practice the formation of the initial and intermediate stages of the NICS, control over the state of the stitched tissue, and the function of visual-spatial orientation through the PEV.

3.5. Perform task 3.5: forming 4 loops for AU in OP, using the seam blanks from task 3.4. Repeat the manipulations 5 to 10 times.

When completing task 3.5 it is important:

1) form the first loop AU by wrapping the long end of the thread around the leg of the last loose stitch by grasping the thread in the branches ID;

2) control the tightness of the first loop of the AU and the condition of the sewn edges of the fabric;

3) when forming and tightening the second loop, avoid loosening the first loop;

4) tightly tighten each subsequent loop of the AU using the ID jaws;

5) when forming the 4th loop, remove the end of the thread from the loop completely.

The purpose of task 3.5 is to practice the technique of forming loops for AU in the OP, under the control of stereo vision.

3.6. Perform task 3.6: on TOT, repeat the manipulations from task 3.5. Repeat 10 to 15 times.

The objective of task 3.6 is to practice the technique of forming loops for the IAU, using the working position of the instruments on the TOT, under the control of stereo vision.

3.7. perform task 3.7: perform manipulations from task 3.6 on the TZT; repeat 10 to 15 times.

The purpose of task 3.7 is to practice the technique of forming the AU, with visual control through a flat monitor screen, with the most comfortable seam line.

3.8. perform task 3.8: perform manipulations from tasks 3.5 on the TZT when the seam line is located in the direction from 9 o’clock to 3 o’clock on the clock face; repeat 5 to 10 times.

When performing task 3.8, it is important to feed the thread into the ID using the ED through the loose stitch from left to right

3.9. Perform task 3.9: perform manipulations from task 3.8 on the TZT when the seam line is located in the direction from 3 o’clock to 9 o’clock on the clock face; repeat 5 to 10 times.

When performing task 3.9, it is important to feed the thread into the ID using the ED through the loose stitch from right to left

The purpose of tasks 3.8 and 3.9 is to practice the technique of forming an IAU, with visual control through a flat screen, with a complicated seam line.

3.10. Perform task 3.10: on the TZT, repeat the manipulations from Task 3.7, perform and watch the video recording of the performance.

The purpose of task 3.10 is the surgeon’s self-control when viewing a video recording of the performance of NICS with IAU, and identifying technical errors in the performance.

3.11. Perform task 3.11: repeat the manipulations from task 3.7 sequentially with correction of errors identified while watching the video recording. Repeat 2-5 times.

The purpose of task 3.11 is self-correction by the surgeon of errors in the execution of the NICS with IAU, and practicing the corrected set of movements.

Part 4. Formation of a nodal (intermittent) intracorporeal suture with a sliding knot

Note! An original method of forming the ISU (OS ISU) is used, which consists of three stages:

1) the initial stage - stitching the fabric and forming two consecutive loops in different directions;

2) intermediate stage - tightening the loops, forming a sliding half-knot (ISPU) and testing the degree of its tightening on the PCN;

3) the final stage is matching the edges of the wound by lowering the ISPU onto the tissue being sutured and securing it with several loops.

4. 1 complete task 4.1: watch a video film with the implementation of the ISU OS and comments from the teacher.

4.2 complete task 4.2: watch the teacher’s demonstration of the implementation of the ISU OS in the EP conditions.

The purpose of tasks 4.1-4.2 is to form a visual picture of the technique for performing the ISU OS.

4. 3 perform task 4.3: stitch the fabric on the TOT with a needle and thread No. 1, leaving a “passive” (long with the needle) end of the thread (PET) 6-8 cm long; make two oppositely directed loops from the “active” end of the thread (AET); grab the PET and hold it in a vertical position; form the ISPU and hold the PET vertically so that the ISPU is at a distance of 2-4 cm from the sewn edges of the fabric (initial stage).

Repeat task 4.3 5 to 10 times.

The objective of task 4.3 is to practice the stage of forming the SPU shape with the smallest number of thread turns inside the SPU, according to the ISU OS

4. 4 perform task 4.4: perform manipulations from task 4.3 on the TOT; then hold the AKN and tighten the ISPU; while holding the instrument in the DR of the PCN, with the branches of the instrument in the HP, lower the ISPU along the PCN in the direction of the wound, not reaching the tissue by 1-2 cm and checking the degree of its tightening; then lower the ISPU onto the tissue until the edges of the wound are aligned as required. Repeat the task 5 to 10 times.

When completing task 4.4 it is important:

1) observe the direction of pulling the AKN at 9-11 o'clock on the dial and avoid uncontrolled sliding of the ISPU along the PKN down to the fabric,

2) pressing on the ISPU with the branches of the ID and lowering it down onto the tissue, focus attention on the tactile sensation of friction when the ISPU slides along the PCN. The degree of tightening of the ISPU is determined tactilely by the vibrations of the thread transmitted through the instrument to the surgeon's hand due to the friction of the ISPU when sliding down along the PCN.

The purpose of task 4.4 is to practice the stage of tightening the ISPU, tactile and visual control over the degree of its tightening and matching the edges of the fabric.

4.5 perform task 4.5: on the TOT form two to four loops on alternating ends of the thread, securing the ISPU; cut the threads, leaving ends of 6-8 mm (final stage).

4.6 perform task 4.6: on TOT repeat the sequential manipulations from Tasks 4.3-4.5 from 5 to 10 times with thread No. 1.

The purpose of task 4.6 is to practice the entire complex of movements for the formation of the ISU, combining visual and tactile control at each of the successive stages of the ISU execution.

4.7 perform task 4.7: on the TZT repeat the sequential manipulations from task 4.bot 5 to 10 times;

The purpose of task 4.7 is to practice the formation of the ISU under conditions of visual control through the PEV.

4.8 perform task 4.8: on the TZT, repeat the sequential manipulations from tasks 4.7 once; perform and watch the video recording of the performance.

The purpose of task 4.8 is the surgeon’s self-control when viewing a video recording of the execution of the ISU, identifying technical errors in the execution.

4.9 perform task 4.9: manipulations from task 4.8 sequentially with correction of errors identified while watching the video recording. Repeat 3-5 times.

The goal of task 4.9 is for the surgeon to self-correct errors in execution and practice the corrected set of movements.

4. 10 perform task 4.10: repeat the manipulations from task 4.9 with thread No. 2 5 to 10 times.

The purpose of task 4.10 is to practice tactile control over the formation of the ISU taking into account the changing properties of the thread.

Novelty of the Method

The novelty of the Method lies in the fact that:

1. an original method of forming the ISU was used;

2. For the first time, the procedure for the actions of the teacher and students to learn how to perform LMI, IAU, OS ISU has been described in detail;

3. Original training films with the implementation of the ISU OS, LMI, Aberdeen node (AU) were used.

4. the original THSh simulator was used;

5. For the first time, sequential training was applied in the OP, on the TOT and TZT for performing LMI, IHU, IAU, OS ISU;

6. For the first time, the method of watching auto-video recordings of the performance of LMI, IHU, AU, OS ISU by students during training was used.

Example of application of the Method

The method was applied in the Training and Accreditation Center - Medical Simulation Center of Botkin Hospital as part of the advanced training program for surgeons "Intracorporeal suture in laparoscopic practice. Basic course" in 2018-2020 [23]. A survey was conducted of program participants who had not previously received SO IKS and performed LV after training. Of the 24 surgeons, 9 (37.5%) did not use IKS before the start of the training. 8 (88.9%) of them began using IKS within the next 6 months. One doctor found no indications for it. None of the participants noted complications associated with IKS.

22 (91.7%) physicians did not use the ISU before the training. Of these, 17 (77.3%) began using the ISU in their surgical practice after the training. 3 physicians did not find indications for using the ISU (13.6% of those who did not use the ISU before the training); one (4.5%) experienced technical difficulties. One surgeon used an extracorporeal unit as an alternative to the ISU.

In addition to the introduction of ICS and ISU into practice, the majority of surgeons noted an expansion of the range of LV (70.8%), increased confidence during operations (91.7%), and a reduction in the duration of operations (58.3%). As can be seen from the presented data, the efficiency indicator of the applied method - the frequency of transfer into practice - is higher than that demonstrated in previous publications [10, 11].

Application of this Method:

1. reduces the risk of errors when performing IKS;

2. facilitates and accelerates the implementation of the ISU due to improved visual and tactile control over the degree of tightening of the ISU loops and safe comparison of the fabrics being sewn;

3. allows to standardize the process of the IKS SO and increase its efficiency;

4. increases the confidence and readiness of physicians to perform IBS in the operating room on real patients;

5. reduces the likelihood of stressful situations during surgery associated with errors in the performance of IBS, which will ultimately lead to a reduction in the overall number of errors during surgery.

The method can be recommended for widespread implementation in the practice of training surgical doctors.

Abbreviations used:

AKN - active end of thread

AU - Aberdinian knot

LEF - long end of thread;

DR - dominant hand;

IAU - intracorporeal aberdeen node

ID - endosurgical needle holder;

IKS - laparoscopic intracorporeal sutures;

ISPU - intracorporeal sliding half-knot

ISU - intracorporeal sliding knot;

ISU - intracorporeal surgical unit;

STE - short end of thread;

LV - laparoscopic interventions;

LMI - laparoscopic needle manipulation;

NICS - continuous intracorporeal suture

HP - non-dominant hand;

OP - open space;

OS ISU is an original method of performing an intracorporeal sliding knot;

PCN - passive end of thread;

PU - half knot; obtained by tightening a loop of thread;

FVS - flat screen video monitor;

SO - simulation training;

SU - sliding knot;

TZT - a box simulator for practicing closed-type laparoscopic skills;

TOT - a box simulator for practicing open-type laparoscopic skills;

THSh is a simulator for practicing surgical sutures with a simulated “wound”.

ED - endosurgical dissector;

Keywords:

laparoscopic suture, intracorporeal suture, laparoscopic surgical knot, intracorporeal sliding knot, needle positioning in laparoscopy, Aberdeen knot, simulation training in surgery.

laparoscopicsuture, laparoscopic needle handling, laparoscopicslipknot, laparoscopicknottying, intracorporealcinchknots; Aberdeen knot, simulative laparoscopic suturing training Bibliography

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Claims (68)

A method of teaching laparoscopic intracorporeal sutures, which includes, at the first stage, training in laparoscopic manipulations with a thread and needle (LMI), while: - watch an educational video demonstrating the implementation of the LMI; - on a box simulator for practicing closed-type laparoscopic skills (CTS), they watch a demonstration by a teacher of performing LMI; - watch the teacher demonstrate techniques for grasping and manipulating an endoscopic dissector (ED) in the non-dominant hand (HP); - perform grasping and manipulation of the endoscopic dissector (ED) in the non-dominant hand (HP); repeat the manipulations 10 to 20 times; - watch the teacher demonstrate the grip and manipulation of the needle holder (NH) in the dominant hand (DH); - perform the capture and operation of the ID in the DR: capture the handle, turn the rack on and off, open and close the branches; repeat the manipulations 10 to 20 times; - the thread is captured by the ED branches in HP on the TZT, where the thread is placed on the simulator for practicing surgical sutures with imitation of a wound (TSW) in the direction: for right-handers - from 10 to 16 o'clock on the dial, for left-handers - from 8 to 14 o'clock on the dial; the manipulations are repeated 50 to 100 times; - perform the thread sorting on the TZT with two instruments - ED in HP and ID in DR - from left to right and from right to left; repeat the manipulations 50 to 100 times; - a needle is grasped on the TZT with a piece of thread lying on a horizontal plane, where before grasping the needle, pressure is applied to the middle of the needle with the upper branch of the ID so that the needle turns 90 degrees into the frontal plane; then the needle is grasped with the branches of the ID; the manipulations are repeated 15 to 30 times; - perform a horizontal capture on the TZT and a 180 degree rotation of the ID needle with a piece of thread; repeat the manipulations 10 to 20 times; - perform on a box simulator for practicing open-type laparoscopic skills (OTL) the grasping of a needle by a thread and interception of the ID; repeat the manipulations 10 to 20 times; - on the TZT, the needle is grasped by the thread and the ID is intercepted; the manipulations are repeated 10 to 20 times; - perform a clockwise rotation of the needle along the longitudinal axis of the needle holder in the frontal plane by 360 degrees; repeat the manipulations 10 to 20 times; - perform a rotation of the needle on the TOT along the longitudinal axis of the needle holder in the frontal plane “counterclockwise” by 360 degrees; repeat the manipulations 10 to 20 times; - perform rotation of the needle on the TZT along the longitudinal axis of the needle holder in the frontal plane clockwise by 360 degrees; repeat the manipulations 10 to 20 times; - perform rotation of the needle on the TZT along the longitudinal axis of the needle holder in the frontal plane “counterclockwise” by 360 degrees; repeat the manipulations 10 to 20 times; - perform rotation of the needle on the TOT by grasping the end of the needle along the axis transverse to the longitudinal axis of the ID; repeat 20 to 40 times; - perform a rotation of the needle on the TOT along the axis transverse to the longitudinal axis of the ID, capturing the thread 2-3 cm from the “eye” of the needle, from 20 to 40 times; - perform rotation of the needle on the TZT by grasping the end of the needle along the axis transverse to the longitudinal axis of the ID; repeat 20 to 40 times; - on the TZT, the needle is rotated along the axis transverse to the longitudinal axis of the ID, grasping the thread 2-3 cm from the “eye” of the needle, from 20 to 40 times; - on the TOT, the needle is rotated along the vertical axis by grasping the end of the needle; repeated 20 to 40 times; - on TOT, the needle is rotated along the vertical axis, capturing the thread 2-3 cm from the “eye” of the needle from 20 to 40 times; - on the TZT, the needle is rotated along the vertical axis by grasping the end of the needle; repeated 20 to 40 times; - on the TZT, the needle is rotated along the vertical axis, grasping the thread 2-3 cm from the “eye” of the needle 20 to 40 times; - perform stitching on the TOT by rotating the needle “clockwise” through the fabric of the elements of the THS located on the horizontal plane; for right-handers - in the 12-3 o’clock sector on the dial, for left-handers - in the 9-12 o’clock sector on the dial; repeat the manipulations 20 to 40 times; - stitch the THSh fabric on the TOT by rotating the needle “counterclockwise”; for right-handed people - in the 12-3 o’clock sector on the dial, for left-handed people - in the 3-6 o’clock sector on the dial; repeat the manipulations 20 to 40 times; - perform stitching on the TZT by rotating the needle “clockwise” through the fabric of the elements of the THS located on the horizontal plane; for right-handers - in the 12-3 o’clock sector on the dial, for left-handers - in the 9-12 o’clock sector on the dial; repeat the manipulations 20 to 40 times; - stitching of the THSh fabric is performed on the TZT by rotating the needle “counterclockwise”; for right-handed people - in the 12-3 o’clock sector on the dial, for left-handed people - in the 3-6 o’clock sector on the dial; the manipulations are repeated 20 to 40 times; At the second stage, training is conducted on the formation of a nodal interrupted intracorporeal suture (NIS) with an intracorporeal surgical knot (ICSK): - watch a video film with IKS with IHU; - watch the teacher’s demonstration of the implementation of the IKS with the IHU on the TZT; - on the TOT, the THSh fabric is stitched with a needle with a 20-40 cm long braided absorbent thread, the thread is straightened; repeat 10 to 20 times; - perform the formation of a “horseshoe” from the long end of the thread (LET) on the TOT to prepare the thread for the formation of loops; repeat the manipulations 10 to 20 times; - perform the formation of a triple loop from the DKN on the TOT, wrapping the thread around the ID by rotating the instruments in a clockwise direction relative to the ID; repeat the manipulations 20 to 30 times; - perform the formation of a triple loop from the DKN on the TOT, wrapping the thread around the ID by rotating the instruments counterclockwise relative to the ID; repeat the manipulations 20 to 30 times; - perform the formation of a triple loop from the DKN on the TZT, wrapping the thread around the ID by rotating the instruments in clockwise and counterclockwise directions relative to the ID; repeat the manipulations 20 to 30 times; - perform the formation of a double loop on the TZT in a counterclockwise or clockwise direction, grab the short end of the thread (SEFT) and pull it through the double loop; repeat the manipulations 10 to 20 times; - the TZT is used to stitch the THSh fabric with a needle with a braided absorbable thread; double and triple loops are formed from the DKN; the short end of the thread (SET) is captured and pulled through the loop, followed by tightening the loop and cutting off the long end of the thread with the needle (DKN), leaving a thread end 6-8 cm long; the manipulations are repeated 10 to 30 times; - perform the formation of single loops one by one from different ends of the thread on the TZT; repeat the manipulations 30 to 50 times; - a double and two single loops of braided absorbable thread are formed on the TZT, the manipulations are repeated 10 to 20 times; - a double and two single loops are formed on the TZT using a braided non-absorbable thread, and the manipulations are repeated 10 to 20 times; - on the TZT, stitching is performed with a needle with a braided absorbable thread and the formation of the IHU; a video recording of the performance is performed and viewed; - on the TZT, stitching is performed with a needle with a braided absorbable thread and the formation of the IHU with correction of errors identified during viewing of the video recording; repeated 2-5 times; - on the TZT, stitching is performed with a needle with a braided absorbable thread and the formation of the IHU; a video recording of the performance is performed and viewed; At the third stage, training is conducted on the formation of a continuous intracorporeal suture (CICS) with an intracorporeal Aberdinius knot (IAK): - watch a video film with NIKSH and IAU; - watch the teacher demonstrate the implementation of the NICS; - perform the formation on the TZT by stitching the fabric with a needle and making a double and two single loops in different directions from the DKN, while the double loop is formed above the place of stitching the fabric, the KKN is pulled through it and tightened; then single IHU are formed clockwise and counterclockwise, repeated 10 to 20 times; - using the formed IHU on the TZT, a continuous seam is formed with 5-7 stitches; the seam line is located along the diagonal line parallel to the ID, in the direction from 10 o'clock to 5 o'clock on the dial; repeat 5 to 10 times; - form 4 loops for the Aberdeen knot (AU) using the formed stitches; repeat the manipulations 5 to 10 times; - on TOT, the manipulations of forming 4 loops for the Aberdeen knot are repeated 10 to 15 times; - on the TZT, the manipulations of forming 4 loops for the Aberdeen knot are repeated 10 to 15 times; - on the TZT, repeat the manipulations of forming 4 loops for the Aberdeen knot with the suture line positioned in the direction from 9 o'clock to 3 o'clock on the dial; repeat the manipulations 5 to 10 times; - on the TZT, repeat the manipulations of forming 4 loops for the Aberdeen knot with the suture line positioned in the direction from 3 o'clock to 9 o'clock on the dial; repeat the manipulations 5 to 10 times; - on the TZT, the manipulations of forming 4 loops for the Aberdeen knot are repeated 10 to 15 times, video recording and viewing of the performance are conducted; - on the TZT, the manipulations of forming 4 loops for the Aberdeen knot are repeated with correction of errors identified during viewing of the video recording; repeated 2-5 times; At the fourth stage, training is conducted on the formation of a nodal interrupted intracorporeal suture with a sliding knot: - watch a video demonstrating the technique of performing an intracorporeal sliding knot (ICS); - watch the teacher demonstrate the technique of performing ISU; - the fabric is stitched onto the TOT with a needle with a braided absorbable thread, two oppositely directed loops are made from the active end of the thread (AEFT), an intracorporeal sliding half-knot (ISHK) is formed and the passive end of the thread (PET) is held so that the ISHK is at a distance of 2-4 cm from the edges of the fabric being stitched; repeat 10 to 20 times; - the ISPU is tightened on the TOT; with the branches of the instrument in the non-dominant hand (HP), the ISPU is lowered in the direction of the wound, not reaching the tissue by 1-2 cm and checking the degree of its tightening; then the ISPU is lowered onto the tissue until the edges of the wound are aligned as required; repeat 5 to 10 times; - on the TOT, two to four loops are formed on alternating ends of the thread, securing the ISPU; the threads are cut, leaving ends of 6-8 mm; - at TOT, the set of movements for forming the ISU is repeated from 5 to 10 times; - on the TZT, a set of movements is performed to form the ISU from 5 to 10 times; - on the TZT they perform a set of movements to form the ISU, make a video recording of the formation of the ISU, and watch the video recording; - on the TZT they perform a set of movements to form the ISU with the correction of errors identified during viewing of the video recording; - on the TZT, a set of movements is performed to form an ISU with a braided non-absorbable thread, repeated 5 to 10 times.