A simple and inexpensive technique for closing trocar sites and grasping sutures

NOTES transgastric abdominal wall hernia repair in a porcine model

INTRODUCTION

With approximately 1 million ventral and inguinal hernia repairs performed in the United States each year, even small rates of complications translate into large numbers of patients. Less invasive approaches that potentially lower morbidity deserve consideration, recognizing there are many technical considerations that currently limit their use. We describe a reproducible technique and lessons learned in our laboratory that answer some existing questions with regards to the use of NOTES for hernia repair.

METHODS

A non-survival porcine model with general anesthesia was utilized in all cases. Each animal underwent transgastric peritoneal access with a percutaneous endoscopic gastrostomy (PEG) technique, and the gastrotomy was dilated with a wire-guided balloon dilatation catheter. An Esophageal Z-stent delivery device (Cook Medical, Winston-Salem, NC) was modified ex-vivo to allow us to introduce and protect a 10 x 15 cm lightweight polypropylene hernia prosthetic with pre-placed sutures. Once deployed, the sutures were pulled through the abdominal wall using a looped spinal needle technique in combination with the flexible endoscope. After the four anchoring sutures were tied, proprietary endoscopically placed tacks (Cook Medical) were placed at regular intervals between the sutures to secure the edges of the prosthetic.

RESULTS

Hernia repairs were performed on five animals. In each case, we successfully completed prosthetic delivery and deployment into the peritoneal cavity, anchoring to the abdominal wall with full-thickness abdominal wall sutures, and endoscopically placed nitinol tacks. All prosthetics were deployed flat against the anterior abdominal wall. Operative times ranged from 65 to 120 min.

CONCLUSION

Transgastric abdominal wall hernia repair is feasible, consistent, and reproducible. In particular, the delivery system can successfully deliver the prosthetic across the gastric wall via a transoral route. Survival animal experiments investigating outcomes related to quality of repair, microbiology, adhesions, and visceral closure need to be done. Human studies are not recommended until these issues are formally investigated.

Port closure techniques

BACKGROUND

Laparoscopic trocars do create wounds. This article aims to review and list different techniques used for closure of the fascia incision at trocar sites.

METHODS

A literature search was performed for articles dealing with closure techniques. The author searched this subject in English on Medline by combining the words "trocar" and "hernia," as well as "Deschamps" and "Reverdin." All articles reporting techniques with their references were reviewed.

RESULTS

The articles described many techniques in addition to classical closure using curved needles, including Grice needle, Maciol needles, Endoclose device, Carter-Thomason device, Tahoe ligature device, Endo-Judge device, eXit puncture closure device, Lowsley retractor, spinal cord needles, dual hemostat, suture carrier, Riverdin and Deschamps needles, and Gore-Tex closure device.

CONCLUSION

Three main groups of techniques were found with favor of extracorporeal manipulations under direct visualization. Old methods are sufficient and cost-effective.

Closure of fascial defect at trocar sites after laparoscopic surgery

As laparoscopic surgery evolves, a growing number of different abdominal operations can now be performed. This necessitates the use of multiple large trocars. Herniation through the fascial defect created by trocar entry in laparoscopic interventions has been reported at a rate of 1-6%. We describe a simple closure technique for fascial defects at trocar sites after laparoscopic surgery. To facilitate the closure of the fascial defects of > or = 10 mm trocar entry sites, the surgeon places the upper end of a dissecting forceps through the fascial defect and tilts it so that the abdominal of the peritoneum comes into contact with its flat surface. The assistant retracts the skin and subcutaneous tissue and the "J" needle with the appropriate suture material is then used to take a stitch through the fascia under direct vision. The sharp end of the needle is prevented from coming into contact with any deeper structure as it slides on the flat surface of the dissecting forceps. The stitch is then pulled up to lift the edge of the fascia and the needle is passed from the opposite edge of the fascia in the same manner and then the suture is ligated. The aforementioned technique is easy to perform and facilitates the closure of the fascial defect at trocar sites, and there is no extra cost for the procedure.

Simple technique for proper approximation and closure of peritoneal and rectus sheath defects at port site after laparoscopic surgery

Complex intra-abdominal surgical procedures can now be performed with laparoscopy, and laparoscopic cholecystectomy has become the gold standard in the care of patients with cholelithiasis. This and other surgically challenging procedures involve use of multiple large (10-mm-15-mm) ports. A standard laparoscopic cholecystectomy employs two 10-mm trocar incisions. Development of incisional hernia from these port sites is well recognized unless the rectus sheath is closed properly. This makes proper closure of the incisions for larger ports critical, especially 10-mm to 15-mm ports. However, securing abdominal wall bleeding and closing facial defects through a small incision can be a cumbersome task. We have developed a simple technique using the regular curved needle and sutures for closure of rectus sheath defects through a small port-site incision.