Ultrafine suture materials (4-0 to 7-0) are essential in reconstructive urogenital surgery, nerve repair, and tubal procedures due to their minimal tissue trauma and precise approximation. However, handling these delicate sutures intraoperatively poses significant challenges, particularly in minimally invasive and NOTES (Natural Orifice Translumenal Endoscopic Surgery) procedures, where operative space is severely limited and only 5 mm laparoscopic instruments are available. Commercially available knot pushers are typically designed for suture sizes ≥ 3-0, limiting their applicability in ultra-fine suture scenarios and often requiring improvisation. To address this gap, we developed a simple, self-made knot pusher, the “Ney-Pusher,” which allows secure placement of slipknots with sutures as fine as 7-0.

Between March 2018 and March 2026, 164 patients underwent urogenital procedures using ultra-fine suture materials (3-0 to 5-0). Procedures included laparoscopic ureteral reconstructions, ureteral neoimplantations, pyeloplasties, bowel and vascular sutures, and transurethral or transanal NOTES interventions for fistula repair. The Ney-Pusher was constructed from a 4×10 mm strip of suture packaging, bent into a V-shape, and secured within the laparoscopic needle holder. The suture was guided medially through the V, enabling precise positioning of slipknots, including von-Leffern and Roeder loops, directly onto target tissues.

All targeted anatomical structures were securely approximated without suture breakage, tissue trauma, or loose knots. The mean time per individual knot placement was 2 minutes. The device is immediately available intraoperatively using commonly present materials, reducing the need for additional instruments and simplifying workflow.

The Ney-Pusher demonstrates that ultra-fine sutures can be handled safely, efficiently, and reproducibly in restricted operative environments. Its use allows precise knot placement while minimizing material waste, potentially lowering complication rates related to knot failure or tissue tearing. The device’s simplicity and adaptability make it particularly valuable in laparoscopic and NOTES procedures, where standard instruments may be insufficient.

By providing full control over suture placement, the Ney-Pusher facilitates time-efficient, secure knotting of sutures from 3-0 to 7-0. Compared to traditional intracorporeal knotting, it offers superior handling, material conservation, and operative reliability, representing a practical and cost-effective solution for ultrafine suture applications in minimally invasive surgery.