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INTRODUCTION "A stitch in time saves nine…." The Critical Nature of Suturing for Flexible Endoscopic Surgery by Lee L. Swanstrom, MD Bariatric Times. 2013;10(11 Suppl B):B4. AUTHOR AFFILIATION: Dr. Swanstrom is from the Division of GI/MIS Surgery, The Oregon Clinic, Portland Oregon; and is Innovations Director, Institut Hospitalo Universitaire, Strasbourg, France. ADDRESS FOR CORRESPONDENCE: Lee L. Swanstrom, MD, 4805 NE Glisan, Suite 6N50, Portland, OR 97213; Phone: (503) 281-0561; Fax: (503)-2810575; E-mail lswanstrom@orclinic.com FUNDING AND DISCLOSURES: No funding was provided. Dr. Swanstrom is on the scientific advisory board for Apollo Endosurgery, Inc. and has received education and research grants from Olympus and Boston Scientific. T he fields of surgery and interventional endoscopy come closer and closer to an inevitable overlap, if not merger: surgery, due to its increasing reliance on videoscopic perception and its patient-driven move toward less access trauma; and endoscopy, due to its increasing ability to replicate or replace surgical procedures. The obvious and unavoidable overlap will require evolution on the part of practitioners as well metrics to measure competence and expertise in both disciplines. In surgery, the ability to place a stitch and tie a secure knot has been the hallmark physical attribute of the skilled surgeon for many millenniums. The inaugural ritual for medical students and residents today is suturing on a pig's foot or throwing knots around the bedpost of a call room. This is despite the fact that most surgeries no longer require suturing in the face of clips, glues, and staples. The same is true for laparoscopic surgery. Program directors insist that residents and fellows practice suturing (not cutting or retraction or tissue handling) on a pelvic trainer. The Fundamentals of Laparoscopic Surgery (FLS) exam, which is a high-stakes cognitive and manual skills test required for board certification, has, as its most discriminating task, the laparoscopic placement of a stitch and tying of a knot. This is included in the FLS despite the fact that, once again, most common laparoscopic procedures (e.g., gallbladders, hernias, colectomy, appendectomy) do not involve suturing and, even for those that do, there are multiple devices that render the manual placement of a stitch unnecessary. I believe there are three reasons for this. First, tradition certainly still carries weight and many surgeons will suture where they could have clipped or stapled for the pure aesthetic pleasure it carries. Suturing also demands bimanual dexterity and good eye/hand coordination and as such offers a measurable metric for surgical skill. Finally, no matter how good staplers, suturing machines, or glues are, they are not universally applicable and, in a tight situation, it will be a surgeon skilled with needle and thread who salvages a procedure or corrects a complication. 4 It is, therefore, perhaps the most salient sign that endoscopy has moved into the realm of surgery that we have today, the ability to suture endoscopically. One of the highest priorities of the international natural orifice transluminal endoscopic surgery (NOTES) movement was achieving robust and secure enterotomy closure, and suturing naturally came to the forefront.1 Industry responded with enthusiasm, sensing suturing might represent a disruptive paradigm shift in endoscopy. Multiple devices were trialed including the following: Tissue Apposition System (TAS [Ethicon, Inc., Blue Ash, Ohio, United States]), flexible Endo Stitch™ (Covidien, Norwalk, Connecticut, United States), and advanced bimanual operating platforms that could suture with standard surgical suture, such as the DDES (Boston Scientific, Natick, Massachusetts, United States) and Endo Samurai (Olympus, Tokyo, Japan).2 Unfortunately, none of these devices reached commercialization due to the global economy, an unclear marketing pathway, and sabotage by the FDA. Despite these contrary forces, and serving as an indication of the need for endoscopic suturing, two companies have commercially available suturing devices on the market, Apollo Endosurgery (Austin, Texas, United States) and USGI Medical (San Clemente, California, United States). The USGI device is currently marketed only as a bariatric procedure device. The Apollo OverStitch™ Endoscopic Suturing System is approved and marketed as a general suturing device. Currently, the OverStitch™ Endoscopic Suturing System (Apollo Endosurgey, Inc.) is the only device on the market that permits general endoscopic surgery. This is sufficient to have enabled a variety of creative uses: suturing stents in place, closure of fistulas and leaks, full thickness resections, and others. It is the start of a new future for interventional endoscopy. REFERENCES 1. 2. Rattner D, Hawes R, Swanstrom LL, and the ASGE/ SAGES working group on NOTES. ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery; White Paper October 2005. Gastrointest Endosc. 2006;63(2):199–203. Sclabas G, Swanstrom LL. Secure closure methods in NOTES. Surg Innovation. 2006;13(1):2–330.