A simple technique for trocar site closure after laparoscopic surgery

I. Petrakis,1 V. Sciacca,1 G. Chalkiadakis,2 S. I. Vassilakis,2 E. Xynos2

1 First Department of Surgery, University of Rome “La Sapienza,” Policlinico Umberto I, Viale del Policlinico, I-00161, Rome, Italy2 Department of General Surgery, University Hospital of Heraklion, Post Office Box 1352, Heraklion Crete, Greece

Received: 10 August 1998/Accepted: 13 October 1998

Abstract. Hernias have been reported to occur at trocarsites and small anterior wall defect has been casually iden-tified during laparoscopic surgery. The aim of this article isto describe a simple, fast, and cheap technique for the safeclosure of trocar sites in laparoscopic surgery. Closure isaccomplished with a #0# absorbable suture, which is ap-plied in a pursestring manner using 15 gauge spinal cordneedle. This procedure is also suitable for the laparoscopicrepair of uncomplicated small hernias or fascial defects ofthe anterior abdominal wall; a mesh prosthesis in case thedefect is >2 cm2. This technique allows a secure closure ofumbilical or fascial defects of the anterior abdominal wall.It is a useful method for large trocar sites closure and isrecommended for small uncomplicated hernias or fascialdefects of the anterior abdominal wall. In case of >2 cm2

defects the technique could be an optimal laparoscopic al-ternative for patch tension free repair.

Key words: Hernia — Laparoscopic hernia repair — Tro-car site hernia — Abdominal wall hernia — Umbilical her-nia — Spigelian hernia

Wound-related complications are less common and less se-rious after laparoscopic surgery than after the open ap-proach. Hernias and small anterior abdominal wall defectshave been reported to occur at trocar sites with or withoutinfection. The umbilical region is particularly susceptible tothis problem, because the abdominal wall at this point isvery thin, infections are frequent, and incidentally identifiedhernias are common [3, 4]. Davidoff et al. [1] have reportedwound infection and umbilical herniation after laparoscopiccholecystectomy at rates of 0.4% and 0.6%, respectively.The respective rates reported by Lorimen et al. [2] are 0.8%and 0.4%.

The aim of the technique described herein is to diminish

the incidence of hernia development at trocar sites of$10mm after laparoscopic surgery.

Technique

To begin the procedure, the umbilical trocar is placed in situ in order tomaintain a stable intraabdominal gas pressure. The laparoscope is posi-tioned through an extraumbilical 10-mm trocar site, usually the epigastricone, while an endograsp forceps is inserted through a 5-mm trocar. Acontinuously running nonabsorbable #0# suture is inserted through a 15-gauge needle, which penetrates all subcutaneous layers including the fas-cia, going around the umbilical opening in a 45° angle to create a purse-string. The needle penetrates the fascia at a distance of 0.5–1 cm from thetrocar site (Figs. 1, 2). After the first insertion of the needle, an endograspforceps is used to pull the free suture edge into the abdomen (Figs. 3, 4).Then the needle still holding the suture is reinserted at the next point and,with the use of the forceps, the free intraabdominal edge of the suture islocked through the loop that has been created (Figs. 5, 6). This maneuveris repeated another three times until the pursestring is fashioned. In thefinal step, the suture edge, which is pulled by the last loop, and the needleare withdrawn outside the abdomen close to the site of first insertion of theneedle (Figs. 7, 8), and both edges of the suture are tied up onto the fascia.

Uncomplicated small hernias, including umbilical, Spigelian, or otherfascial defects of <2 cm2, can be safely repaired with the laparoscopicapplication of this suturing technique. If the defect is >2 cm2, a meshprosthesis should be used instead of a pursestring suture. Two 5-mm portsfor grasping and dissecting forceps and one 10-mm port for the scope arerequired. The mesh (ePTFE; Gore-Tex) is placed intraperitoneally andfixed with nonabsorbable #0# sutures using the spinal cord needle. Theneedle is inserted through a tiny skin incision, and the knots of the an-choring sutures are secured to the fascia with every two needle insertions(Fig. 9).

Comments

This simple technique is recommended for the closure oflarge trocar port sites and small anterior abdominal walldefects. It is cheap, safe, and accurate because all defects areclosed under direct vision. It is also tight enough to preventperitoneal fluid leakage in patients with ascites or renalfailure who require peritoneal dialysis. The procedure is notsuitable for large abdominal wall defects, complicated her-nias, recurrent hernias, or as a routine method to repairanterior abdominal wall defects.Correspondence to:I. Petrakis, Via Roma 95, Vasanello (VT), 01030 Italy

Surg Endosc (1999) 13: 1249–1251

© Springer-Verlag New York Inc. 1999

Fig. 1. A 15-gauge spinal cord needle 15 cm in length is inserted through the subcutaneous layers into the abdominal cavity at a 45° angle (cross section:A external,B intraabdominal).

Fig. 2. The needle holding the suture is inserted into the abdominal cavity.

Fig. 3. The free edge of the suture is pulled into the abdominal cavity with the aid of an endograsp.

Fig. 4. The needle is reinserted through the next point.

Fig. 5. The forceps grasps the free intraabdominal edge of the suture through the loop that has been created after the second pass of the needle.

Fig. 6. The suture extremity is pulled through the loop.

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References

1. Davidoff AM, Pappas TN, Murray EA, Hilleren DJ, Johnson RD, Ba-cler ME, Newman GE, Cotton PB, Meyers WC (1992) Mechanisms ofmajor biliary injury during laparoscopic cholecystectomy. Ann Surg215: 196–202

2. Lorimen JW, Smith JR (1995) Intraoperative cholangiography is not

essential to avoid duct injuries during laparoscopic cholecystectomy.Am J Surg 169: 344–347

3. Ponsky JL (1994) The incidence and management of complications oflaparoscopic cholecystectomy. Adv Surg 27: 21–41

4. Wantz GE (1991) Incisional hernias of the abdomen. In: WantzGE (ed) Atlas of hernia surgery.Raven Press, New York, pp 179–216

Fig. 7. The A external andB intraabdominal views of the suturing one step beforecompletion.

Fig. 8. The A external andB intraabdominal views of the suturing at its completion.Both edges of the suture are tied on the fascia.

Fig. 9. Internal view of tension-free fixation of the prosthetic mesh.

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