26. Port Site Closure Methods and Hernia Prevention

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1 26. Port Site Closure Methods and Hernia Prevention Chandrakanth Are, M.D. Mark A. Talamini, M.D. Laparoscopic port site hernias have been frequently reported (incidence of 0.02% 5% with an average of 1%) since the first case was documented in 1968 by Fear et al. Larger port size and increasing numbers of ports required to perform more complex laparoscopic procedures are likely to increase the incidence of port site hernias (PSH). PSH tend to develop more frequently at umbilical and midline port sites due to the thinness of the umbilical skin and weaknesses in the linea alba. The presence of an undetected umbilical hernia when the port site is near the umbilicus can also increase the incidence of a PSH in that location if both the port site and the preexisting umbilical hernia are not closed with a formal herniorrhaphy. About one-quarter of PSH are umbilical. Overlapping muscle and fascial layers explains the reduced incidence of PSH at lateral port locations. Closure of the fascial defect does not completely prevent the development of PSH, although the incidence is higher if a fascial closure is not attempted. PSH have been reported through port sites of all sizes (including 5 mm). However, more than 90% of PSH occur through trocar sites 10 mm or larger. Patients usually present within 2 weeks of surgery, although some cases have been reported years after the initial surgery. The development of unremitting pain, fever, or other gastrointestinal complaint after laparoscopic surgery requires immediate investigation. The contents of these hernias are usually small bowel or omentum or, on rare occasions, large bowel. The spectrum of symptoms range from no symptoms to pain due to omental infarction or small bowel obstruction. Richter s hernia is very common among PSHs due to the small size of the fascial defect. The insidious nature of Richter s hernia can lead to significant morbidity. PSH should be suspected in all patients with bowel obstruction up to 1 year after laparoscopic surgery. A computed tomography (CT) scan can be helpful in making the diagnosis. Comorbid conditions that can increase the incidence of PSH include diabetes mellitus, wound infection, and obesity. Laparotomy or repeat laparoscopic surgery is required to repair the PSH. Adhesiolysis and bowel resection are also necessary in up to 10% of the patients. The associated morbidity of these iatrogenic hernias underscores the importance of preventing the condition. Every attempt should be made to keep the incidence less than the expected 1% by closing the fascia and the peritoneum. Trocars used for laparoscopic surgery usually range between 5 and 15mm. Port sites (PS) 10mm or greater should be closed if at all possible. Current consensus is not uniform about the management of PS less than 10mm. In this chapter, we detail the indications, various methods, and techniques to ensure proper port site closure to minimize the occurrence of PSH.

2 A. Methods 26. Port Site Closure Methods and Hernia Prevention 289 The ideal method of closure should be quick, easy to perform without enlarging the skin incision, safe, inexpensive, and provide adequate closure of fascia and peritoneum. Several methods and instruments are available to help close the trocar sites. The more commonly used techniques are described below. The ideal method for each patient depends on the incision characteristics, the body habitus, and the surgeon s preference. Standard Closure (Via Skin Wound) This method entails direct visualization of the defect through the skin wound once the pneumoperitoneum has been released and the port removed. Usually, the fascial edges are grasped with a Kocher or Allis clamp and the various layers are sutured together with a simple or figure-of-eight suture. This can be difficult in obese patients with a large breadth of subcutaneous fat. Every attempt should be made to include all fascial layers and the peritoneum in the closure. It can be very difficult to include the peritoneum when dealing with patients of moderate to high body mass index (BMI). In some cases, the skin incision may have to be enlarged to permit adequate closure; in this case, the morbidity of an incisional hernia outweighs the benefit of a small skin incision. Although this method is a reasonable alternative, in the author s opinion, one of the laparoscopically visualized methods of suture placement is preferred. Laparoscopic Direct Visualization Fascial Closure Methods There are a number of fascial and peritoneal closure methods that permit accurate placement of sutures under direct laparoscopic visualization. The goal of all these methods is a subcutaneous knot that well approximates the peritoneal and the fascial wound. These methods are carried out with the pneumoperitoneum intact. The sutures can be placed either with the port in place (by working adjacent to the port) or after the port has been removed. In the latter case, the surgeon usually plugs the hole with the second or third finger to prevent gas desufflation while carefully inserting the suture passer, needle, or other device through the skin wound adjacent to the finger. The laparoscope is used to visualize the port wound in question and the passage of the suture bearing instrument directly observed. By moving the laparoscope to different ports it is possible to use this method for all ports that require closure. The advantages of this type of method when compared to the standard open method described in the section above include (1) more accurate placement of suture under direct vision, (2) possible decrease in operative time, (3) elimination of the possible need to extend the skin incision, and (4) suture placement may be technically

3 290 C Are and M A Talamini easier. Numerous devices have been designed for this purpose including the Grice method, the Carter-Thomson Needle-Point suture passer, the Maciol suture needle, and the Endoclose suture carrier. These suture placement methods can also be used to control bleeding from abdominal wall vessels injured during port placement or surgery. Using a Spring-Loaded Needle or Suture Passer Needle Several of these devices consist of a needle with a plastic or metal oversheath. The needle is notched or has a groove within which the suture is intended to lie. The spring-loaded sheath is retracted to expose the notch or groove. When released, the sheath returns to its neutral position, which covers the notch, thus entrapping the suture. An alternative design is a laparoscopic suture passer that has a spring-closed handle. Commonly, these instruments have a jawed needle tip that has a conical shape. One jaw of the tip has a groove that is meant to hold the suture. To open the device to release or grasp a suture, it is necessary for the surgeon to forcibly spread the hands apart, thus overcoming the spring on the handle. Regardless of which type of device is used, the method is similar (Figure 26.1A D). The device is loaded with a suture by retracting the outer plastic sheath or by opening the jaw of the instrument. Once the suture is locked in the suture notch, the plastic sheath is released or the spring-closed handle is released, thus securing the suture. The tip of the needle is directed at a angle through the abdominal wall adjacent to the fascial defect. Once the tip is inside the peritoneal cavity, the suture is released by either opening the instrument jaws or retracting the sheath. A grasper introduced through another port is used to grasp the intraperitoneal end of the suture and thus prevent the suture from being pulled back out of the abdomen when the suture passer is withdrawn. The empty suture passer is inserted through the opposite side of the fascial defect, 180 from the initial insertion site. Once inside the peritoneal cavity, the free intraperitoneal end of the original suture is grasped. Placing mild tension on the suture by pulling on the extraabdominal component of the suture material can facilitate reloading the needle. Next, the suture passer is withdrawn from the abdomen. The two ends of the suture that are now outside the abdominal cavity can either be tied or tagged with a clamp and a second interrupted suture placed. Alternatively, the process can be repeated with the same suture to create a figure of eight. Angiocatheter Technique This method utilizes a 14-gauge angiocatheter that is universally available and is inexpensive. At the end of the procedure, with the trocar in place, a 14- gauge angiocatheter is inserted into the subcutaneous tissue between the skin

4 26. Port Site Closure Methods and Hernia Prevention 291 A B Figure (A) Suture containing suture passes is inserted into the abdomen. (B) Intraabdominal instrument grasps suture and suture passer is withdrawn. edge and trocar. The angiocatheter is inserted at an angle of 30 away from the trocar to capture as much fascia as possible. Under laparoscopic direct visualization, the angiocatheter is inserted completely into the abdominal cavity. A pre-tied loop of suture is inserted through the plastic cannula after removing the metal needle. With the help of a laparoscopic grasper introduced through another port, the loop is drawn further into the abdomen and held in place while the plastic cannula is withdrawn. The angiocatheter is then inserted on the opposite side of the trocar site (180 ) in similar fashion. One end of a second long suture

5 292 C Are and M A Talamini C D Figure Continued (C) Empty suture passer is inserted back into abdomen on opposite side. (D) Suture has been passed to the suture passer that is being withdrawn from the abdomen. is now introduced into the peritoneal cavity via the cannula, after which it is passed and then pulled a good distance through the looped end of the first suture. After removing the plastic cannula, the loop-ended suture is then pulled out of the abdomen, hopefully carrying the other suture with it. The nonlooped second suture that has now been passed into and out of the abdominal wall can then be tied. The knot will lie in the subcutaneous tissue. This method can be used to suture all ports under direct vision and also to control abdominal wall bleeding. While sharing the benefits of the Grice needle, it has the added advantage of being inexpensive (about $3). The only disadvantage of this approach is that the standard angiocatheter may not be long enough for obese patients. In this case, 16- or 18-gauge spinal needles can be used.

6 26. Port Site Closure Methods and Hernia Prevention 293 Use of a Heavy Spatulated Needle This method utilizes a 110-mm heavy spatulated suture needle (5/8 circle). The suture is placed under direct vision. With the port in place, the needle is inserted perpendicular to the abdominal wall, about 1 2 cm from the skin edge. The laparoscope is used to directly view the needle as it enters the peritoneal cavity. The needle is pushed through the abdominal wall on the opposite side of the port site, again 1 2cm from the skin edge. This step can be facilitated by levering or bending the port so that it is almost parallel to the abdominal wall. Once the needle has been passed, the port is removed and both ends of the suture are lifted to make them taut. A nerve hook is then inserted into the subcutaneous tissue and an attempt is made to entrap the suture, after which the hook is removed. The goal of this maneuver is to redirect the suture end out through the subcutaneous fat layer. After retrieving both ends in this manner the suture can be tied; the knot will lie in the subcutaneous fat. By rotating the camera between the different trocars, all port sites can be sutured. Using a Suture Carrier This approach uses a hook suture carrier, which is a 24-cm-long modified hook retractor with an eye drilled into its tip. The fascial edge is lifted vertically and the suture carrier is passed into the abdomen via the open wound. Under direct laparoscopic visualization, the end of the hook is then pulled up through the peritoneum and fascia (from the inside out) such that the tip reenters the wound via the subcutaneous fat. The suture is then threaded into the eye and the carrier is withdrawn back into the abdomen pulling the suture with it. With one end of the suture still loaded in the eye, the instrument and the hook s tip are turned to the opposite side of the wound, and then the hook is driven up through the peritoneum and fascia, again from the inside out, into the wound via the subcutaneous tissue once again. This brings the two ends of the suture into the subcutaneous tissue. Alternatively, after the first pass, the suture is unloaded from the hook, and the carrier without a suture is passed from inside out again on the opposite side of the wound. The external free end of the suture is then passed through the hook tip and the carrier withdrawn into the abdomen. Both ends of the suture now lie in the abdominal cavity. This method is used if the surgeon chooses to bury the knot. B. Recommendations Regarding Port Wound Closure Although several approaches have been described here, it should be noted that there are several other methods as well. The choice of method will depend

7 294 C Are and M A Talamini on the individual patient characteristics (such as body habitus, number and size of ports), the surgeon s preference, and available resources. Regardless of the specific approach, the authors recommend that the following principles be adhered to in regard to closure of port wounds. Admittedly, it is not possible to provide supporting published data for each of these recommendations. 1. All ports greater than 10mm (midline and lateral) should be closed at the fascial level. 2. It is advised that 5-mm ports may need to be closed if the peritoneal and/or fascial defect has enlarged significantly during the procedure as a result of lengthy or extensive manipulation during the procedure. This is more likely to be necessary when the port is located in the midline. 3. Enlarging the incision to allow proper closure should take precedence over obtaining a good cosmetic result. 4. Port closure should include fascia and peritoneum. 5. In thin patients, midline port sites can be closed using standard methods via the skin wound. 6. Where possible, it is advised to view the abdominal side of each wound during fascial closure via the laparoscope. C. Tips to Avoid Port Site Hernia 1. Use the minimum number of ports needed. 2. Use ports of the smallest possible diameter. 3. Avoid violent or severe levering or torquing of the ports as this can enlarge the fascial defect. 4. Attempting to insert the ports in a Z -shaped fashion with some subcutaneous travel may help reduce herniation. 5. Desufflate the abdomen carefully when removing ports. If this is not done, escaping CO 2 can draw the bowel or omentum into the port sites (chimney effect) or the wound utilized for specimen removal. 6. After completion of surgery and before closure of ports, shake the abdomen to dislodge any bowel stuck in the port sites. 7. The fascial defects should be closed before the patient wakes up. Coughing and gagging can make closure very difficult. 8. Palpate the abdomen before closure to identify any unrecognized or preexisting hernia defects that may require repair. 9. Presence of incidental paraumbilical or umbilical hernias dictates enlarging the incision and performing a formal umbilical herniorrhaphy. This sometimes may require placement of a mesh patch. 10. Obese patients can pose a problem due to the thickness of the abdominal wall. Long needle carriers may be needed to secure proper closure.

8 D. Conclusions 26. Port Site Closure Methods and Hernia Prevention 295 In summary, every attempt should be made to ensure the proper closure of port sites. Otherwise, the morbidity associated with a port site hernia will negate the expected benefits of the intended minimally invasive surgery. E. Selected References Ammori BJ, Morias JC. A simple method of closure of a laparoscopic trocar site. J R Coll Surg Edinb 1996;41: Fear R. Laparoscopy, a valuable aid in gynaecologic diagnosis. Obstet Gynecol 1968;31: Garzotto MG, Newman RC, Cohen MS, Rout R, Grice OD. Closure of laparoscopic trocar sites using a spring-loaded needle. Urology 1995;45: Li P, Chung R. Closure of trocar wounds using a suture carrier. Surg Laparosc Endosc 1996;6: Nadler RB, McDougall E, Bullock AD, Ludwig MA, Brunt LM. Fascial closure of laparoscopic port sites; a new technique. Urology 1995;45:

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