Page 39 - Journal of Laparoscopic Surgery

WJOLS

Laparoscopic Port Closure Techniques and Incidence of Port-site Hernias: A Review and Recommendations
structures. Parietal defects are covered by mesothelial • Closure techniques that can be performed with or
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stem cells within 5–6 days in case of parietal peritoneum. without visualization (no additional ports)
The total time for repair may take from 8 days–2 weeks.
At sites of peritoneal cautery and suture repair, deep MATERIALS AND METHODS
submesothelial hemorrhage and necrosis prolong the A literature search was performed for the articles related
duration of inflammation, and hence the collagen depo- to port closure techniques in laparoscopic and robotic
sition is delayed, and healing is not seen even after surgeries on Pub Med, Cochrane database, Google
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3 weeks. This delay in healing can be attributed to the Scholar and Clinical key. The keywords used were port-
development of adhesions and port-site hernias. Adhesions site closure, trocar site hernia, laparoscopic hernia and
form when two injured peritoneal surfaces are opposed port-site closure techniques. Prospective and retrospec-
Lamont et al. Surgical insult to tissues results in relative tive case series, randomized trials, literature reviews,
or absolute ischemia which leads to local persistence of and randomized animal studies of trocar hernias on
the fibrin matrix. This is replaced by vascular granulation abdominal wall defects from gynecologic, urologic, and
tissue which consists of macrophages, fibroblasts, and general surgery literature were reviewed.
giant cells. Eventually, the adhesions mature into fibrous
bands often containing small nodules of calcification.
Hence the development of intraperitoneal adhesions is a RESULTS
dynamic process where the surgically traumatized tissues Various techniques and associated hernia rates:
which are in apposition bind through fibrin bridges which
become organized by wound repair process often support- Standard Closure Through Skin Wound 17,18
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ing a rich vascular supply as well as neuronal elements. • This method incorporates direct visualization of the
The fibroblasts contribute collagen which stabilizes the defect through the skin wound After the pneumo-
adhesions and promotes vascular in growth. peritoneum has been released and the port removed.
• The fascial edges are grasped with a Kocher or Allis
Pathogenesis of Hernia Development clamp, and the various layers are sutured together with
After Peritoneal Injury
a simple or figure-of-eight suture (Fig. 1). This tends
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Fear first reported a trocar site hernia in his large series on to be difficult in obese patients with a large breadth
laparoscopic gynecological diagnosis. While this complica- of subcutaneous fat. Every attempt should be made
tion has been recognized for a long time, it’s significance to include all fascial layers and the peritoneum in the
is becoming more important as more and more patients closure. It can be difficult to include the peritoneum
are being treated for this. The term trocar site hernia was when dealing with patients of moderate to high body
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defined by Crist and Gadacz as a hernia developing mass index (BMI). In some cases, the skin incision may
at a cannula insertion site. A port-site hernia following have to be enlarged to permit adequate closure.
laparoscopic surgery is less common compared with an
incisional hernia occurring after open surgery. 12,13 One Port-site Closure using Modified Aptos Needle
study evaluating the risk for a late-onset hernia following Ahmed et al. used the Lasheen needle, which is a
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a variety of open and laparoscopic surgeries reported inci- curved needle with a length which varies from 10 to
dences of an incisional hernia at 1.9 and 3.2 percent at two 15 cm (Fig. 2). It has two sharp pointed ends and a hole
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and five years after laparoscopic surgery, respectively. By at the middle of its length, through which the thread
comparison, the incidence of an incisional hernia for open (No. 0 Vicryl) is passed. The loaded needle was passed
surgery was 8 and 12%, respectively.
in one edge of the port wound at the subcutaneous
pre-fascial plane to come out of the skin about 2 cms
Port Closure Techniques
from the wound edge. At this point, the edge of the
It is recommended that all 10–2 mm trocar sites in adults externalized thread within the wound edge was held,
and all 5-mm port-sites in children be closed, incorpo- and the direction of the needle reversed to come out
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rating the peritoneum into the fascial closure. Shaher through the other wound edge about 2 cm lateral. Now
classified the different port-closure techniques into three the needle direction was reversed, and the needle came
categories: out through the wound itself with the other end of the
• Techniques that use assistance from inside the thread externalized through the trocar wound. In the
abdomen (requiring two additional ports); end, both the ends of the thread were inside the wound
• Techniques that use extracorporeal assistance (requir- edge. The strands were tied, and the knot lay directly on
ing one additional port); and the anterior abdominal sheath (Fig. 3). This study was
World Journal of Laparoscopic Surgery, May-August 2018;11(2):90-102 91