Page 34 - World Journal of Laparoscopic Surgery

Different Port Closure Techniques in Laparoscopy Surgery

it to the other side of the trocar, to push it in side the veress
loop, after piercing the abdominal wall, leaving the skin,and
then remove the trocar, and close the wall by knotting (Figs
14A to N).

SECOND GROUP
Port closure should be performed under direct visualization of
the surgeon, which requires good insufflation of the abdomen.
When desufflation is performed, a tactile sense should be used
to close the port. These techniques are applicable during
insufflation or after desufflation. These techniques include the
suture carrier, the dual hemostat technique, the Lowsley
Figs 8A to C: Tahoe surgical instrument ligature device retractor, application of bioabsorbable hernia plug in trocar
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sites. Preliminary placement of fascial stay sutures above and
device is introduced through the 12 mm laparoscopic port. When below the prospective trocar site; Foley catheter threaded
laparoscopically visualized in the abdomen, the right-angle through the port hole for the elevation of fascial edge upon
needle assembly is rotated to the open position, thereby traction; fish-hook needle improvised out of a hypodermic needle
exposing the needle carrier (Fig. 9A). The device is then pulled by bending it 180°; Grooved director; U-shaped purse-string
back up through the port, thereby drawing the needle up through suture placed in the fascia around the port hole. 21
the peritoneum and fascia between the skin and the port. The
skin is pulled away from the tip of the needle to avoid puncture SUTURE CARRIER
of the skin. When the needle is seen coming through the
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subcutaneous fat, a 0-absorbable suture is loaded through the Jorge et al and Li and Chung developed a hook suture carrier
hole in the needle (Fig. 9B). The needle and suture, along with (Figs 10A and B) for closure of trocar wounds, making use of
the entire device, are pushed back down through the port into the vertical rather than the horizontal space. The suture carrier
the abdomen,thereby passing the suture down through the is a hook suture carrier modified from a simple hook retractor
fascial and peritoneal layers. The exit device is then rotated with an eye drilled into the tip through which suture material
180° to the opposite side of the port (Fig. 9C), and the needle can be threaded. The handle is 24 cm long, and the size of the
carrying the suture is again delivered through the fascia and hook approximates the size of the general closure needle (CT
peritoneum. The needle is identified in the subcutaneous tissue, needle; Ethicon, Somerville, NJ, USA). To begin closure, the
and the suture is pulled from the tip of the needle (Fig. 9D). The fascial edge is lifted vertically with a hook retractor, and the
device is returned back in to the abdomen; the needle is closed; suture carrier is partially inserted into the wound to catch the
and the closed device is removed through the port (Fig. 9E). peritoneum and fascia under direct vision, piercing it from the
The port is removed, and the suture is tied, securing the undersurface (Fig. 10A). A suture (such as 0-polypropylene) is
peritoneum and fascia. 24 threaded into the exposed eye of the carrier and brought beneath
Veress needle loop technique; used by RK Mishra, making the fascia. This same suture is then carried to the opposite edge
a loop by passing nylon suture to veress needle and tied it, of the wound using the carrier, executing a stitch from inside
then loadge the vicryl suture to the tip of veress needle, then out. After the suture is disengaged from the carrier, a simple
push the veress needle with the loop, through the abdominal stitch is accomplished with the knot on the surface when tied
wall, with out piercing the skin, 3 mm away from the trocar site, (Fig. 10B).
then remove the veress, leaving the vicryl in side, by putting
your finger on the vicryl, grasp the vicryl by grasper, and pass DUAL-HEMOSTAT TECHNIQUE
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Spalding et al reported the dual-hemostat technique (Figs
11A and B), which is very simple, using two hemostats and a
needle driver with suture and needle. The first hemostat is placed
into the wound, after which the tips are spread open and the
fascia is lifted up away from the underlying abdominal viscera.
The second hemostat is used to retract the overlying
subcutaneous tissue. Then the suture needle is driven through
the fascia to exits between the splayed tips. The procedure is
repeated at the opposite side of the wound.

LOWSLEY RETRACTOR WITH HAND CLOSURE
This technique uses the straight Lowsley retractor (Circon
Figs 9A to E: Exit disposable puncture closure device ACMI, Stanford, CT, USA), a regular needle driver, and a
World Journal of Laparoscopic Surgery, September-December 2009;2(3):29-38 33