Page 36 - World Journal of Laparoscopic Surgery

MK Medha
through the port-hole for elevation of fascial edge for trac- 2. The late-onset type, which occurs after few months
tion, fish-hook needle improvised out of a hypodermic of laparoscopic surgery, mostly with local abdominal
needle by bending it to 180°, and a U-shaped purse-string bulge and no small bowel obstruction.
suture placed in the fascia around port-hole. 3. The special type, which indicates protrusion of intes-
tine and/or omentum. 10
Suture Carrier The Ritcher hernia usually presents few days later
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Jorge et al and Li and Chung developed this carrier and patient experiences delay in realizing its occurrence
making use of vertical rather than horizontal space. It is a due to normal bowel function, which causes significant
hook suture carrier modified from a simple hook retractor morbidity. It is a rare complication but a dangerous one.
with an eye drilled into the tip through which suture can be The usual symptoms include crampy abdominal pain
threaded. Its handle is 24 cm long and size approximated with nausea and/or vomiting. Treatment is reduction
to the size of general closure needle (CT needle, Ethicon, of the bowel which is incarcerated followed by repair of
etc.). To start closure, the edge of fascia is lifted vertically the fascial defect. Some authors advocate open repair of
with a hook retractor and the suture carrier is partially hernia or local exploration combined with laparoscopy,
inserted into the wound to catch peritoneum and fascia but the minimally invasive approach is an acceptable
under direct vision, piercing it from the undersurface. Then treatment at the time of diagnosis but only as long as
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0-polypropylene suture is threaded into the exposed eye of the incarcerated bowel is not ischemic. Risk factors
carrier and brought beneath the fascia. Then the suture is for the development of trocar-site hernia are diameter of
passed from the edge of opposite wound with carrier and the trocar-site, trocar design, preexisting fascial defects,
5
taking a single stitch from in to out. Then a simple stitch some surgeries, and patient-related factors. Many
is taken with knot on the surface of port-wound. authors believe that inserting a 10 mm trocar in an
oblique fashion or Z-tract will reduce hernia formation
Dual-Hemostat Technique by putting the external and internal defects at different
21
Spalding et al used this technique using two hemo- levels. So it is recommended that all 10 and 12 mm size
stats and a needle holder with suture and needle. First trocar wounds must be closed. At the end, the perfection
hemostat is placed into the wound. Then the tops are of all closure techniques has proliferated and improve-
spread open and the fascia is lifted away from underlying ments are continuously being made. But the surgeon must
viscera. Then second hemostat is used to retract overlying be familiarized with the useful port-closure techniques
subcutaneous tissue. Then the suture needle is passed which he/she feels comfortable with, easy to perform,
through the fascia to exit between the splayed tips. This simple, safe, and effective. 25
procedure is repeated at the opposite side of wound also. The comparisons among all these techniques are
beyond the aim of this literature review. It is suggested
Port Plug Technique that tighter closure of the skin incision may control the

In this method the bioabsorbable hernia plug is used leak of ascetic fluid in patients with ascites, but only for
in the trocar site with the help of bioabsorbable hernia a short time. The tight closure of fascia may prevent the
14
plug device. 22 ascitic fluid leak. For the closure of skin, the transcuta-
neous closure with absorbable suture material seems to
DISCUSSION be the most suitable technique. 26
Incidence of port-site hernia is about 0.23% at the 10 mm
port-site and 1.9% at the 12 mm port-site. This incidence REFERENCES
drastically gets increased to 6.3% when patients are obese 1. Saleem I. Minimal access surgery the port site complication.
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trocar sites and grasping sutures. J Laparoendosc Adv Surg
to reapproximate fascial wound edges of the big trocar Tech A 1999 Feb;9(1):81-85.
wounds, infection, and premature suture disruption. A 3. Brody F, Rehm J, Ponsky J, Holzman M. A reliable and efficient
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trocar-site hernia. 23 4. Felix EL, Harbertson N, Vartanian S. Laparoscopic her-
Hernia at trocar-sites is classified into three types: nioplasty: significant complications. Surg Endosc 1999
Apr;13(4):321-322.
1. The early-onset type, which occurs immediately 5. Holzinger F, Klaiber C. Trocar-site hernias: a rare but poten-
after laparoscopic surgery and with a small bowel tially dangerous complication of laparoscopic surgery.
obstruction. Chirurg 2002 Sep;73(9):899-904.
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