Endoscopic suturing without extracorporeal knots: A laboratory study

Background: To eliminate cumbersome extracorporeal knotting, we designed a new endoscopic suturing device, the Eagle Claw V. The efficacy of the new device was tested on the Erlangen model and was compared with the initial extracorporeal knotting version (Eagle Claw II). Methods: Segments of porcine splenic arteries were placed on the mucosal surface of the anterior wall of a pig stomach. The two ends of the artery were brought out through the gastric wall and were connected to a two-channel manometer. The Eagle Claw V has a curved needle with a detachable tip. After puncturing the tissue, the needle tip was engaged into a catching cartridge, where the suture had been embedded in a tightening mechanism. The suture could be tightened by simply pulling the end. The Eagle Claw V was used to plicate the splenic arteries mounted on the stomach. Suturing was considered secure if the suture could withstand endoluminal pressure greater than 200 mm Hg that lasted at least 10 seconds. Results: Eleven of 15 stitches (73.3%) gained secure plication of the vessels. The suturing time (mean ± standard deviation 2.93 ± 0.80 minutes) was significantly faster than that of the Eagle Claw II (9.38 ± 1.51 minutes). The device consistently achieved penetration of the muscular layer, and 4 of 15 sutures included the serosa. The 4 failures were because of suture breakage in two, thread entanglement in one, and cartridge dislodgement in one. Conclusions: The present prototype represents significant improvements in the ease of operation and the security of the suture, bringing the technique closer to clinical use for a variety of applications.