Page 47 - Journal of Laparoscopic Surgery

WJOLS

Laparoscopic Port Closure Techniques and Incidence of Port-site Hernias: A Review and Recommendations
They did not report data relating to laparoscopic trocar non-bladed trocars and concluded that it helps in the
hernias. creation of ports with the smallest dissection without
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One randomized trial conducted an intraoperative eval- bleeding or cutting the muscle fibers. This splitting
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uation of laparoscopic closure techniques. Elashry et al. of abdominal wall musculature by trocar allows the

studied the closure of 95 twelve-mm trocar port-sites in surgeon to forego closure of small fascial defects. Blade-
32 patients and compared the Carter-Thomason (CT-NP) less 12 mm visual entry trocars have also been shown to
needlepoint suture device (CooperSurgical, Inc, Trumbull, produce no intraoperative bowel or vascular injuries, no
CT) with the Maciol suture needle set (Specialty Surgical mortality and extremely low rate of trocar site hernia of
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Instrumentation, Nashville, TN), eXit disposable puncture 0.2%. Single-incision laparoscopic surgeries are finding
closure device (Progressive Medical, St. Louis, MO), the greater acceptance among the surgeons and patients due
Endoclose device (Covidien Surgical, Norwalk, CT), a to better cosmetic outcomes. These depend heavily on
14-gauge angiocatheter, Lowsley retractor (CS Surgical the 12 mm ports, for visualization and instrumentation.
Inc, Slidell, LA) with hand-sutured closure, and standard A study suggests that single incision laparoscopic surgery
hand-sutured closure. They found that the CT-NP device has a higher incidence of port-site hernia when compared
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was faster (mean time 2.5 minutes) and had secure closure to conventional laparoscopy. Studies have also shown
confirmed digitally and endoscopically. They, however, a higher incidence of port-site hernia in cases of single
did not follow their patients for hernia development. This incision robotic procedures. 55
study was underpowered, and hence no definitive conclu- With the multitude of port entry and closure tech-
sions could be made about the benefit of one closure type niques, it will be an uphill task for the surgeon to famil-
over another in hernia development. iarize with all the techniques. Every entry technique
comes with its own set of advantages and disadvantages.
Patient Presentation Similarly, the closure techniques also have their pros and
cons. It is prudent on the part of the surgeon to decide
The incidence can be said to be underestimated, as upon the preferred technique. The bladeless, blunt and
the patients present only if they are symptomatic. The radially dilating trocars have been proven to be superior
real incidence, however, can be established only if an in various studies. 51-53
abdominal CT-scan will be done for each patient oper- All the 10 mm and 12 mm ports should ideally be
ated with a laparoscopic approach, which is overbur- closed otherwise the morbidity associated with the port
dening to the patient as well as the health-care system. site hernia will adversely affect the expected benefits of
The usual hernia contents are omentum and to a lesser the intended minimally invasive surgery.
degree, small bowel. Regarding the port closure, the authors would like to
Richter’s hernia occurs when a part of the bowel wall present a few recommendations, after reviewing various
that is the antimesenteric border, herniates through the articles on entry and closure techniques, which would
port-site. The incidence of Richter’s hernia was about help to minimize the risk of port site hernia development.
47.50% in early onset hernias in one study and they typi- • Obese patients pose a problem due to the thickness
cally present with nausea, vomiting, pain and abdominal of the abdominal wall and long needle carriers may
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distention. Computed tomography and gastrointestinal be needed to secure proper closure.
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contrast studies have been used to aid the diagnosis of • Ports which are 10 mm and higher, either midline or
trocar site hernias. 49
lateral, must be closed at the level of fascia. 29,56
• The use of minimal necessary ports. Neudecker et al.
Whether to Close or Not
had shown that port site complications were increased
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A study by Singal et al. a total of 200 non-obese patients, with increased number of ports.
who were posted for various laparoscopic procedures, • Port closure should incorporate both fascia and peri-
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were prospectively studied. They were divided into two toneum.
groups and with group A receiving only skin closure • The 5 mm ports may generally be closed at skin
without fascial closure and group B receiving both level but in case of enlargement of the fascial and/
fascial and skin closure, of the 10 mm port. The 5 mm or peritoneal defect during the surgery, mostly due
ports were closed only with skin closure. They found to more time-consuming procedures or those which
no significant difference between the groups in terms require extensive manipulation must be closed at
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of port-site hernia, bleeding and infection rates. Blunt fascial level too.
10 mm trocars were used in all the patients. Bladeless • The midline port sites in all patients must be closed
trocars have been shown to atraumatic, and they split, using standard methods through the skin wound
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rather than cut the muscle fibers upon entry. Liu used particularly if it is enlarged due to tissue retrieval.
World Journal of Laparoscopic Surgery, May-August 2018;11(2):90-102 99