Methods of Port closure in Laparoscopy

Author : Dr.Amol Nikam, MB, DGO (Mum), PG-ART (UK)
NIKAM HOSPITAL, Sawarde, Ratnagiri (Maharashtra)

Abstract:

Introduction:As the new methods of surgical diagnosis and treatment are coming out day by day,minimal access surgery is there to stay and its success is better access,better cosmesis and mobilization and cure.But port closure techniques has big role to play in its success and cosmesis.

Aims:The objective of this review article is to study various methods of port closure in Laparoscopic surgery.
Material and Methods:Various literature search over Google,PubMed,Journals of Laparoendoscopy,Articles of Urology sites.All articles with reported techniques were reviewed with some textbooks. 

Keywords:

Port closure,laparoscopy,Veress Needle.

Introduction:

Laparoscopy has opened a fresh era of diagnosis and treatment since last fourty years that has benefitted a lot of patients and brought down the complications in surgeries.The development of any new surgical method brings along with it new technical challenges.

The complications due to laparoscopic surgery are drcreasing on account of technology and also the training programmes that surgeons undergo.They mainly occur when attempting to gain access in the abdomen and or misuse of instruments during surgery.There are many methods for closing laparoscopic ports.Inadequate port closure might occur into a port site hernia.There may be wound infection ,herniation of small bowel,entrapment of omentum and incarcerated Richter's hernia [16]. Along with larger ports come larger abdominal incisions and so an increase  in the possibility of complications following surgery [17].Whether surgeon is totally new or expert,a systematic procedure for closing the tiny incisions after any laparoscopic surgical treatment is essential.

Therefore several methods have already been described over last five decades.We shall be comparing and studying these methods.

Methods and Materials:

Literatures available over internet,various journals of laparoscopy,PubMed and textbooks of laparoscopic surgeries.The criteria for variety of materials was 40 - 50 port data and closures mainly available in last 10 - 15 years.

Results :

The comparative study of each and every procedure was evaluated.There are many methods explained by various surgeons.

1.Maciol suture needle technique:

Contarini [1] reported using Maciol needles(Core Dynamics,Jacksonville,FL),are a collection of three needles,two black handed introducers,one straight and one curved plus a golden handled retriever.The introducer needle (which possesses an eye) is utilized to successfully pass suture from sidemargin of abdominal wall into peritoneal cavity.The retriever needle is passed is passed from opposite sidemargin of the port in the peritoneal cavity.This needle possesses a barb in the tip which catches the suture and takes it all out through other side.This treatment is conducted under direct vision (laparoscope).

2.Grice Needle Technique:

Used of by Stringer et al [2],a needle having a hollow shaft,laterally disposed,elongate handle at a proximal end and an elongate inner shaft disposed within the outer shaft.The inner shaft includes a cutting edge with the distal end and extends from the outer shaft on the proximal end,terminating in a spring loaded push button.A lateral notch is formed inside the inner shaft proximal of the cutting edge.A suture could be placed in the notch so the instrument grips the suture between outer shaft and inner shaft when the push button is released.Thus the suture may be delivered into the abdomen with this needle and may be retrieved from the opposite end.

3.Vein Catheter,Angiocath needle and Spinal Needle:

Vein Catheter enables you to position the suture in and retrieve via a loop from some distance aroud canula, Nadler et al [3].Thus three to four times repeat insertion and retrieval makes suture into purse string fashion and also the port is closed. Similarly 14 guage angiocath needle using the sheath removed is preloaded with 50 cm length of no.polyglactin suture is passed from one side of trocar wound.The needle and 10-15 cm suture is pulled inside with 5 mm grasper.Then needle is removed from same trocar 10mm wound.Such steps repeated four times and ends of all the sutures are tied together with square knots.

4.Endoclose Suture Device:

This is a disposable endoclose device(Auto Suture Co.,Norwalk,CT) using a springloaded suture carrier.

5.The Gore-Tex Suture Passer:

Chapman4 has explained this piece of equipment.It is actually a suture passer needle.

6.Carter Thomson Device:

It is also known as Carter Thomson Needle Point Suture Passer or CTNSP (Inlet Medical,Inc,Eden Prairie,MN).It includes two parts.The pilot guide and suture passer. This process was created especially for bariatric and obese patients5.

7.Endo-Judge Device:

It  is a 14 guage hollow J shaped needle that serves as a carrier for suture material plus a device for performing fascial closure.

8.Two mm Trocar Technique:

This can be explained by Reardon [6]. A 2 mm trocar and sleeve are introduced alongside the port whose entry site will be closed.

9.Five mm trocar technique:

Rastogi and Dy [4] designed a simple technique utilizing the regular curved sutures and needle for closure of peritoneal and rectus sheath defects with the port site.Using a 5 mm telescope they inspect the defect from your inside after which pass a hemostat with the incision.Under direct telescopic vision the peritoneum and rectus sheath are grasped at the upper and lower edges and pulled throughout the incision,facilitating the passage of needle. Chatzipapaset [7] designed a similar closure technique using standard sutures with straight needles,a 5 mm laparoscopic grasper plus a 4 mm hysteroscope.

10.Tahoe Surgical Instrument Ligature Device:

It  is disposable device (TSI Co.San Juan,PR).Initially the laparoscopic canula is taken off.A suture is put in the hollow delivery Tahoe needle without extention past the distal end from the needle.The product is introduced in the abdomen,thereby securing the suture from the closed metal loop.The full system is withdrawn through the abdomen,thus delivering the tow ends in the suture onto the abdominal wall.The suture is tied,approximating the peritoneum and fascia [8].

11.Exit disposable puncture closure device:

It is additionally called EDPC Device (Progressive Medical,St.Louis,MO).A 10 mm instrument with arecessed right angle needle that could be exposed by rotating a dial towards the top of the instrument.The product is introduced throughout the 12 mm laparoscopic port. The closure is completed by loading these devices with suture and then getting and again rotating 180 degrees thus taking out another end and the suture is tied, securing the peritoneum and fascia [8].

12.Veress Needle Loop Technique:

Invented by Dr.R.K.Mishra, creating a loop by passing nylon suture to veress needle and tied it, then loadge the vicryl suture for the tip of veress needle, then push the veress needle with all the loop, from the abdominal wall, without having piercing your skin, 3 mm from the trocar site, then remove the veress, leaving the vicryl in side, by putting your finger around the vicryl, grasp the vicryl by grasper, and pass it to the other part in the trocar, to push it in side the veress loop, after piercing the abdominal wall, leaving your skin layer,and after that remove the trocar, and close the wall by knotting [9].

13. Suture Carrier:

Jorge et al [10] and Li and Chung designed a hook suture carrier for closure of trocar wounds, using the vertical as opposed to the horizontal space. The suture carrier can be a hook suture carrier modified from your simple hook retractor with an eye drilled in the tip whereby suture material can be threaded. The handle is 24 cm long, and the dimensions of the hook approximates the size of the general closure needle (CT needle; Ethicon, NJ and Somerville USA).

14.Dual Haemostat Method:

Spalding et al [11] reported the dual-hemostat technique , which is simple, using two hemostats. The 1st hemostat is put in the wound, and after that the ideas are spread open as well as the fascia is lifted up from the underlying abdominal viscera. The second hemostat can be used to retract the overlying subcutaneous tissue. Then your suture needle is driven through the fascia to exits between your splayed tips. The procedure is repeated on the opposite side of the wound.

15.Lowsley Retractor with Hand Closure:

This technique uses the straight Lowsley retractor(Circon,USA),a consistent needle driver along with a 0 no.absorbable suture on a curved needle [12].The closed straight Lowsley retractor is passed with the 12 mm port and into the peritoneal cavity.The blades of your Lowsley retractor are next opened maximally to 180 degrees.The port then is taken out from the abdomen after the shaft of the Lowsley retractor,leaving simply the retractor from the wound.The retractor as well as the port are pulled upwards.The fascia is tented towards skin surface and exposed.A standard hand sutured closure with no.absorbable suture is performed5.

16.Port Plug Technique:

Within this technique making use of the bioabsorbable hernia plug hernin in trocar site,the unit was implanted in the umbilical trocar (10 mm) implantation of the bioabsorbable hernia plug device with the safe port possible in all cases [13].

17.Langenback Retractor Method:

Once the intra-abdominal part of the laparoscopic procedure is completed, gas is let out.The 10 mm ports are retained and used to elevate the abdominal wall by angling them to 0 degrees. Langenbecks retractors are  used to retract the skin around the port to expose the underlying fascia. An appropriate stitch, according to the surgeon’s preference, is used to insert a good bite onto the rectus sheath, and the same method is repeated on the other side. In this particular method, the stitch goes through the peritoneum and both anterior posterior fascial Layers (i.e.,fullthickness). The surgeon can easily see and feel the total thickness nature of your stitch.We use a J-needle with 0 - (PDS Summersville and Ethicon, NJ) and would rather take offset stitches at the opposite corners for maximal approximation [14].

18.Closure with Two Langenbecks Retractors:

Within this method another Langenbeck retractor is utilized to retract your skin layer, exposing the fascia. Then, using a J-needle with PDS, you take a stitch through the corner, which is away from the retractor. Then, alter the direction of the Langenbeck’s retractor and take another bite from the opposite corner. Applying this technique, one may avoid struggling to stitch the fascia. It will probably be very helpful in obese patients. Other retractors could be substituted instead of the Langenbeck’s [14].

19.Port Closure with Tissue Adhesives:

These are mainly utilized for closing the wound of skin incision taken for laparoscopy.They can be used direct closure of 5 mm trocar port wounds.Octyl-Cynoacrylate Tissue adhesive (OCT) is a liquid monomer that polymerize on exposure to tissue fluid,thereby forming a strong bond when placed on moist skin.It really is available as Dermabond (Ethicon, Commonville, NJ).
N-butyl 2-Cynoacrylate,Histocryl(Braun,Germany),LiquiBand Surgical S is also utilized to close the ports after laparoscopy .They have shown 4 times more tensile strength than OCT [15]. OCT adhesive strips can also be are extremely effective,especially in children [29].

20. Deschamps ligature needle:

The Deschamps needle carries a handle plus a tip (sharp or blunt), with the opening to pass suture. The blunt tip is incredibly effective for closing trocar sites. Disposable needles are obviously sharp, but can bend on the needle holder and break in a deep small incision. The Deschamps needle is a rigid, noncutting instrument that could be forced through fascia and peritoneum (across the surgeon's fingertip) avoiding lack of pneumoperitoneum. An entire-thickness closure is accomplished. We perform closure under direct vision throughout the scope. Tactile sense is supplied from the surgeon's finger. The final trocar website is closed in a similar manner with no scope [27].

Discussion:

Many authors feel that inserting the 10 mm lateral trocar in a oblique fashion or as a Z-tract will reduce hernia formation by putting the internal and external fascias at different levels,18-24 so It is recommended that all 10 and 12 mm trocar should be closed. The development of nonbladed obturators with integrated stability sleeves allows for development of a muscle-splitting dilated laparoscopic port site with minimal abdominal wall defects after elimination of trocar sleeves, [25,26] may play a role.
Osama Elashry et al in 1996 studied 95 port sites using various port closure devices [6].


The investigation concludes that CTNSP system is faster and 100% successful of other methods. Shaher Z in 2007 studied different techniques of port wound closure.He determined that three main teams of techniques were found with favour of extracorporeal manipulations under direct visualization.Old methods are sufficient and price-effective [5].

Di Lorenzo N in 2002 studied Deschamps needle in 1400 laparoscopic procedures.The investigation concluded that it must be great at preventing incisional hernias and wound dehiscence.Also, it is cost effective [27].

Ahmed Lasheen in 2013 used a double tip needle(Lasheen needle) in 100 patients successfully and noted this technique as effective,safe,an easy task to perform,less invasive,much less time consuming and virtually costless [28].

Romero P et al [29] studied tissue adhesives, Dermabond with adhesive strips, Steri-strips in 49 children in 2011, learned that steri-strips were best closure method.

The ideal port closure method needs to be effective ,fast,simple to use and cheap.The learning curve ought to be short.The product should provide precise anatomical closure and enable for closure under direct endoscopic control. Moreover ,the device must not cause any significant problems including bleeding or skin dimpling.Port site hernias can be found with increasing incidence specially in canulla sites with diameter 10 mm or more [16].CTNSP device allowed endoscopically controlled mass closure of your abdominal wall layers without the closure related complications (bleeding or gas leakage) or necessity for revision.MSN technique, Grice needle Technique, Vein catheter,Angiocath,Endoclose suture device, Gore-Tex suture passer,Veress Needle loop technique, etc they all are mainly based upon principle of putting suture within the abdomen and retrieving out of other end in the port except Port Plug Technique, Tissue Adhesives and Staplers which require very a shorter time.Therefore they are fast and efficient ways of port closure.Then come Exit disposable puncture closure device,which requires no port removal or auxillary grasper.But research has revealed which it has highest failure rates also.The needle is found not far from the shaft from the laparoscopic canula,such that many times, it fails to acquire a broad enough bite of fascia and peritoneum to effect a secure closure.

The price of different devices which are either disposable or reusable varies widely.Overall the lowest priced method is varess needle technique explained by Dr.R.K.Mishra which necessitates the same veress needle which had been used for pneumoperitoneum.Then comes Angiocath technique which is easily available in every single operating room.Our prime purchase expense of the reusable closure devices should be balanced against the longevity of the instrument and recurring sterilization and cleaning costs.CTNSP , MSN , Lowsley veress and retractor needle are reusable devices. The training curve for Macicol Needle, CTNSP, EDPC, TSIL is far more as each method is different and uses their own instrument or primary insertion instrument.The tissue adhesives,staplers cannot be useful for 10 mm port closure.The least learning curve is made for veress needle technique.It really is obvious that putting a veress needle in abdomen is step one for laparoscopy.Therefore everyone learn this technique really quick.

Conclusion:

The various methods of port closure in laparoscopy concludes that there are very good techniques which require a learning curve to get them effective,time saving and also cost effective.Depending upon the needs of conditions the most effective method of port closure will be used by surgeons.So far the veress needle technique of Dr.R.K.Mishra is best in the view of effectivity,faster closure time and cheapest of all the methods.

Aknowledgements:

I would like to thank my teacher Dr.R.K.Mishra, Dr.J.C.Chauhan and Worldlaparoscopy hospital for helping me in this article.

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