Exiting the Abdomen and Closure Techniques

Laparoscopic surgery has reduced overall complication rates and minimized postsurgical recovery time; however, attention must be paid to the closure of laparoscopic ports on completion of the operative procedure. The rate of port site complications after conventional laparoscopic surgery is approximately 21 per 100,000 cases. Complications include infection, dehiscence, trocar site hernia (TSH) of small bowel, entrapment of omentum, and incarcerated Richter hernia. The incidence of TSH is 0.23% at 10-mm port sites and 1.9% at 12-mm port sites. This incidence increases to 6.3% for obese patients, defined as having a body mass index (BMI) greater than 30. The current recommendation is that 10- and 12-mm port sites require fascial closure in all patients to prevent TSH. In children, port sites larger than 5 mm require fascial closure. Several closure techniques have been described to reduce TSH complications, including hand closure and closure device techniques.

Hand Closure

Hand closure of fascia offers advantages for the nonobese patient with minimal subcutaneous fat. This technique incorporates the fascia, but not the peritoneum, into the closure, and it may potentially result in increased procedure time, wound infection, wound dehiscence, and ascitic fluid leak when compared with other closure techniques. For prevention of injury to the underlying viscera, only the anterior fascia is reapproximated. To perform this closure, use two Army-Navy retractors to retract the skin and two Kocher clamps on either side of the fascia to facilitate exposure. Close the fascial layer with a 2-0 polyglycolic acid suture. A UR-6 tapered needle allows easy rotation to catch the fascia. Care should be taken to ensure no bowel is involved during passage of the suture. Passing the suture under direct laparoscopic visualization from an adjacent trocar is paramount.

To date, two needles have been designed specifically for closure of trocar ports: the TN needle (Ethicon Endo-Surgery, Cincinnati, Ohio) and the J needle (Ethicon Endo-Surgery). The TN needle is attached to a single-armed, 27-inch polydioxanone suture or coated polyglycolic suture in the 2-0 or 0 size. When using the TN needle, position it perpendicular to the fascial edge and roll up through the fascia. The J needles are double armed on an 18-cm strand of polydioxanone or coated polyglycolic suture in the 2-0 or 0 size. Insert the J needle parallel to the fascial edge and rotate 90 degrees through the edges of the fascia ( Fig. 11-1 ).

Closure Device Techniques

Device closure systems include the Carter-Thomason device, the Endo Close device, and the Weck EFx device ( Fig. 11-2 ).

Carter-Thomason Device (See )

The Carter-Thomason CloseSure System (Cooper Surgical, Trumbull, Conn.) consists of two components: a 5-mm or 10/12-mm, cone-shaped pilot guide and a single-action (only one arm moves; the other is fixed) hinged jaw at the end of a suture passer. This construction enables three degrees of freedom:

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Translational or in-and-out movement
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Rotational movement
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An end-effector jaw that allows it to grasp the suture

The closure technique begins with insertion of the cone-shaped pilot guide into the port site defect. Manipulate the pilot guide so that the plane of the guide channel holes are perpendicular to the fascial defect. Open the hinged jaw by retracting on the spring-loaded thumb handle. Place the end of a 2-0 polyglycolic acid suture within the hinged jaw and release the handle. The suture is now held within the jaw. Place the suture-loaded needle grasper, under direct visualization, through the guide channel. Pass through the fascia and peritoneum, entering the abdomen close to the camera. This optimizes visualization for finding and grasping the suture end during the second pass. Once the suture passer enters the abdomen, and one is comfortable with the suture position, retract the thumb handle to open the hinged jaw and disengage the suture. Close the jaws. Withdraw the device through the guide channel. Place the suture passer on the opposite side of the Carter-Thomason pilot guide, and enter the abdomen again. Open the hinged jaw by retracting the thumb ring and grasp the loop of suture previously left on the first pass. Use a grasper through another laparoscopic port to aid in passing the suture loop to the hinged jaw if having difficulty. Once the suture is secured within the jaws, withdraw the suture passer. Now both ends of the suture are outside the abdomen and can be secured with mosquito clamps to prevent inadvertent removal of the suture. Reinsert a trocar to maintain the pneumoperitoneum. Close the other ports in similar fashion. Once the surgeon is ready to exit the abdomen, the surgeon can remove the trocar and tie the ends of the suture together to complete the fascial closure.

Another technique that can be useful at times is the placement of the suture via digital guidance. The index finger of the nondominant hand occludes the abdominal wall defect to prevent loss of pneumoperitoneum and can be used to elevate the abdominal wall during closure. This finger also palpates the edge of the fascia to guide proper needle placement.

Endo Close Device

The Endo Close (Medtronic, Minneapolis, Minn.) works in a similar fashion to the Carter-Thomason device. It consists of a disposable, spring-loaded blunt stylet with a hook that retracts into a sheath as a 14-gauge needle is pushed through the abdominal wall. This device has two degrees of freedom: translational (in and out) and rotational. Begin the technique by depressing the top button to open the hook, and place a 2-0 polyglycolic acid suture into the notched portion. Release the top button, which draws the hook inward and anchors the suture at the tip of the device. Insert the Endo Close through one side of the trocar site, incorporating both the fascia and peritoneum. Once the suture is within the abdomen, depress the button to drop the suture. Remove and reinsert the Endo Close device on the opposite side of the incision and depress the button to expose the notched end of the stylet. Keeping the hook exposed, snare or place with a grasper through another port the loop of suture into the device. Withdraw the device and suture together through the incision. This now leaves two free ends of suture outside of the abdominal cavity, and a knot can be tied to complete the fascial closure when suitable.

Weck EFx Device (see )

The Weck EFx Endo Fascial Closure System (Teleflex Medical, Research Triangle Park, North Carolina) is the newest system. It consists of two components: the EFx device and a suture passer. To use the device, load the suture passer with a size 0 suture. Pass the device into the defect. Twist the device handle to the unlock position, and pull the handle to open the approximation wings inside the abdomen. Manipulate the device so that the wings are perpendicular to the abdominal defect. Lock the device to stabilize it. Insert the previously loaded suture passer through the lateral guide channels down through the silicone depth control pads. The suture placement is now 1 cm lateral to the defect. Visually ensure the suture is captured by the pad. Remove the suture passer, load the other end of the recently placed suture, and repeat the aforementioned steps on the opposite guide. Unlock the device, press down on the ring handles to close the approximation wings, and remove the device from the port site. The surgeon is then able to tie the suture. The Weck EFx Closure System offers unassisted delivery and retrieval of sutures and uniform 1-cm closure in varying abdominal thickness and is reported to be a more efficient method to capture all fascial layers to complete the fascial closure. Literature comparing use of the Weck EFx with the Carter-Thomason device on 72 trocar defects found mean fascial closure times of 1.6 minutes and 2.23 minutes, respectively.

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