Laparoscopic Port Closure Technique

INTRODUCTION
Minimal access surgery is a routine surgical practice due
to its minimal invasive and associated advantages. It has a
lot of advantages but not devoid of complication, one of the
major concerned complication is the trocar site herniation
(TSH). TSH is a serious complication often requiring
emergency repair. If unattended, TSH can lead to small
bowel strangulation and incarceration.
The literature says that preventative measures should
be taken to avoid the occurrence of herniation at the portal
site. Fascial closure has been recommended as a means of
TSH prevention. One study reported a statistically higher
frequency of hernia at 12 mm port site where the fascia was
left open (8%) compared with those that were closed (0.22%)
following laparoscopy. There is a consensus that all the
port site ≥10 mm should be closed due to an increased risk
of herniation. For smaller ports, fascial closure may not be
necessary, except when manipulated extensively.
Trocar site herniation is also associated with other
technical factors other than the port site. Port location is
another factor. There are many reports suggesting that
umbilical sites are at greater risk of herniation when
compared to lateral port sites. This is due to weakness
of the fascia and absence of supporting muscle in the
area. Stretching or even extending the incision of a
port site during specimen extraction has a great risk
hernia development. Factors such as high body mass
index (BMI) are patient-related risk factors that are
associated with TSH. Here it is related to increase intra-
abdominal pressure and increase abdominal wall thickness.
Studies show that wound infection is a predisposing factor
to hernia development. Therefore, closure of fascia is
necessary for umbilical ports, ports sites that are stretched
or enlarged for specimen retrieval, and trocar sites in obese
patients.
Minimally invasive laparoscopic surgery has
revolutionized the way surgery is performed for an
increasing number of patients. Incisional hernia can occur
after any abdominal surgery and laparoscopic surgery is
not immune to this complication. The hernia that follows
laparoscopy usually occurs through the larger ports (size
>10 mm), especially the umbilicus. Fig. 1: Typical port closure needle.
Laparoscopic Port
ClosureTechnique
Predisposing factors include:

■ Previous laparoscopies

■ Extensive manipulation during surgery

■ Increased intra-abdominal pressure

■ Obesity

■ Use of sharp cutting-tip trocars

■ Rapid abdominal deflation at the end of surgery

■ Poor port removal techniques and defective closure of
the abdominal fascia

■ Wound extension

■ Male sex

■ Infection of the wound

■ Pre-existing umbilical defects

■ Postoperative chest infections

■ Pre-existing diseases such as diabetes mellitus

■ Connective tissue disorders

■ Job profile of the patient (weight lifting).
Among all these factors, the single most important factor
remains the improper closure of the fascial defects at the
port sites and not using proper port closure instruments
(Figs. 1 to 3). The diagnosis is often delayed because most
cases present late, and treatment might be instituted along
other lines. Computed tomography scans are helpful in its
diagnosis and will facilitate prompt treatment to avoid the
grave consequence of bowel gangrene.
Prof. Dr. R. K. Mishra

166 SECTION 1: Essentials of Laparoscopy
Fig. 2: Laparoscopic port closure Cobbler’s needle. Fig. 3: Incisional hernia development due to improper closure of
port should be repaired later by mesh.
Fig. 4: The tip of telescope should be introduced in and cannula is
pulled over telescope to prevent suction of omentum or bowel.
While surgical techniques and instrumentation have
made significant advances, it is usual that the surgical
incision is closed using invasive suturing techniques or
by the use of tapes or by the use of topical cyanoacrylate
skin adhesives (TCAs) for closure of surgical wounds. The
incidence of incisional hernia occurring at the port sites after
laparoscopic surgery lies between 0.02 and 3.6% and usually
remainsunreported,untilthedevelopmentofcomplications.
Any port closure technique should have following
characteristics:

■ Effective (strong and secure) surgical wound closure

■ Faster wound closure

■ Better scar cosmesis

■ Occlusive microbial wound dressing

■ Less tissue trauma, reduced inflammatory reaction

■ No requirement for suture/staple removal

■ Easy to use/simple learning curve

■ Reduced risk of needlestick injury—safety and costs

■ Cost effective.
WITHDRAWAL OF INSTRUMENTS AND PORTS
Once the surgery is finished, all the instruments should
be removed carefully under vision. All the accessory ports
should be removed and the gas is removed by releasing the
valve of 10 mm cannulas. The primary port should be taken
out in the end (Fig. 4).
If last port is suddenly withdrawn, sudden suction effect
of cannula can pull the omentum or bowel inside the port
wound, the chance of port-site hernia and adhesion is much
higher in this case. It is a good practice to insert some blunt
instrument or telescope inside the abdomen while removing
the last cannula out over that instrument, to prevent
inadvertent entrapment of omentum or bowel.
The access technique will result in breach in continuity
of abdominal wall which need to be repaired at the end of
surgery. All the 10 mm or >10 mm port should be repaired
properly to prevent any future possibility of hernia. The
rectus sheath should be sutured with Vicryl. Only one stitch
is required in middle which will convert 10 mm wound into
5 mm. The 5 mm port wounds are not necessary to repair.
Laparoscopic Port Closure Instruments
Various types of port closure instruments are available. The
suture passer is a convenient instrument for port closure.
It is used to pass the thread on the side of cannula and then it
is tied externally (Figs. 5A to D).
Port Closure Needle
This is a simple instrument just like cobblers and it can be
effectively used for closing the port. The tip of the instrument
isbluntandtheneedlefacestowardthefascia,sothechances
of injury to the bowel are less with the use of this instrument
(Fig. 6).

167
CHAPTER 12: Laparoscopic Port Closure Technique
C
A B
D
Figs. 5A to D: Port closure with the help of suture passer.
Fig. 6: Port closure needle. Fig. 7: Aneurysm needle.
Aneurysm needle can also be used for closing fascia.
The advantage of this needle is that eye is at the tip and due
to rigid structure there is no risk of bending or rotation of
needle (Fig. 7).
After closing the rectus sheath, the skin can be closed
by intradermal, skin stapler or any of the surgical skin glues
TCAs available (Fig. 8).
New Laparoscopic Port Closure Instruments
Weck®
EFx Shield Fascial Closure
System (Figs. 9A and B)
The Weck®
EFx Shield Fascial Closure System from Teleflex
is the only shielded port closure device, providing enhanced
sharps protection for uniform and consistent performance.

Fig. 8: Closure of skin wound by skin stapler.
A B
Figs. 9A and B: Weck®
EFx Shield Fascial Closure System.
Figs. 10A and B: NeatClose automated port closure device.
B
A
The EFx Shield®
System is designed with speed and safety in
mind. An array of enhanced features includes:

■ Unique shielded wing design for enhanced sharps
protection

■ Intuitive wing deployment

■ Innovative suture retrieval system for unassisted fascial
closure.
NeatClose Automated Port Closure
Device (Figs. 10A and B)
NeatStitch of Israel has come up with an automated port
closure device known as NeatClose, where it also picked
up both the Food and Drug Administration (FDA) and
European approvals in the process. It is marketed to be an
alternative to manual port closure, making it a speedy and
efficient manner to help laparoscopic surgeon save time
and money by lowering intraoperative costs. This system
lets surgeons produce a watertight seal quickly, and it goes
without saying that this would go a long way in aiding the
recovery of a patient, never mind that one does not have
Wolverine’s healing factor. When inside the operating
cavity, the surgeon can squeeze the handle leavers in order
to release a couple of blunt needle guides, where said guides
are specially positioned in a perpendicular manner to the

169
port plane. With the activation button pressed, it will release
the needles from the guide, via the tissue and back to the
NeatClose cartridge. Once the system is pulled outside the
port, you can be sure that a safe and efficient airtight seal is
created, hence aiding the recovery of a patient for surgery
quickly. Now we are still waiting for a painless method
without the need for anesthesia.
Carter-Thomason CloseSure System—Port-site
Closure (Figs. 11A and B)
Closing any trocar site is a simple, fast and safe procedure
with the Carter-Thomason CloseSure System. The cone-
shaped Pilot®
Guide correctly angles the suture passer to
achieve full-thickness closure. It closes the port including
fascia and peritoneum (preventing Richter’s hernias)—
while maintaining pneumoperitoneum. The guide’s unique
design ensures precise placement of the suture passer for
consistent, reproducible results on any body type.
VersaOne™ Fascial Closure System (Figs. 12 and 13)
Port-site hernias are serious complications across
procedures and are a burden on patients, clinicians, and
health systems. Appropriate port-site closure is considered
to be one of the most critical factors for the prevention
of port-site herniation. The VersaOne™ Fascial Closure
System is a novel all-in-one device that serves as a trocar
and fascial closure device to deliver consistent port-site
closure and suture placement. The unique system
features a special cannula that allows for defect closure
without the need of additional devices.
As a result, the VersaOne™ Fascial Closure System:

■ Provides procedure efficiency

■ Eliminates the need to remove the trocar before closing

■ Makes reinsufflation unnecessary—pneumoperitoneum
can be maintained throughout the procedure

■ Enables tissue layers to remain aligned.
B
A
Figs. 11A and B: Carter-Thomason CloseSure System—port-site closure.
Fig. 12: VersaOne™ Fascial Closure System with its trocar. Fig. 13: VersaOne™ Fascial Closure System demonstrating
insertion of suture.

Fig. 14: Remove the stylet from the cannula. Fig. 15: Pass a suture material through the cannula from the tip.
Fig. 16: Take suture out from the other end. Fig. 17: Tie the loop and hide the knot in the cannula.
There are a number of methods of post site closure
but there is no gold standard. Use of traditional suturing
techniques are difficult due to blind closure of the fascial
defect. Varying degrees of success are achieved by modified
hand suturing techniques. Finding the rectus sheath and
suturing through the layers of a thicker abdominal wall
through a relatively small hole is challenging particularly
in the obese. In such cases, we need special instrument for
efficientclosureoftheportsite.Veressneedleisaninstrument
that is commonly used for creating pneumoperitoneum but
it has been used to close the port site efficiently under vision.
VERESS NEEDLE TECHNIQUE OF
PORT CLOSURE
In 1983, Janos Veress of Hungary developed a specially
designed spring-loaded needle. Interestingly, Veress did not
promote the use of his needle for laparoscopy purposes. He
used Veress needle for the induction of pneumothorax. But
now Veress needle is the most important instrument today
to create pneumoperitoneum. Veress needle consists of an
outercannulawithabeveledneedlepointforcuttingthrough
tissues. Inside the cannula of Veress needle is an inner stylet,
stylet is loaded with a spring forward in response to the
sudden decrease in pressure encountered upon crossing the
abdominal wall and entering the peritoneal cavity.
TECHNIQUE OF PORT CLOSURE BY VERESS
NEEDLE (FIGS. 14 TO 25)
Occlude the port site with a finger so that the pneumo-
peritoneum is maintained and pass the Veress beside the
fingerthroughallthelayersexcepttheskinandsubcutaneous
tissue under vision. Maintenance of pneumoperitoneum is
important as it is very difficult to close the port if vision is
compromised.
Minimal access surgeries are the present and future of
surgical procedures and no surgery is complete without port
site closure. There are a lot of methods to close the port-site
but no gold standard. This procedure with the Veress needle
is safe, efficacious, and cost-effective.
One of the preventable complications is port-site
incisional hernia (PIH), which could develop at any port
site, most frequently at the midline, possibly because of
the absence of supporting muscle. The incidence of PIH
is variable from center to center, depending on several
factors including surgical technique and of course surgical
experience.

171
Fig. 18: Insert the suture material (that should close the port site) into
the cannula tip about 2 cm deep and bend it so that it stays in place.
Fig. 19: Now Veress needle is ready for port closure.
Fig. 20: Veress needle inserted with loop and tying
suture on one side.
Fig. 21: Retract the Veress and the suture is automatically
retained inside.
Fig. 22: Insert the Veress from the other side of the defect. Fig. 23: Entangle the suture in the loop of the Veress.
The trocar diameter, trocar design, pre-existing fascial
defects, tissue retrieval from the port site, and some
operation and patient-related factors, direction of the port
insertion, use of drain are the risk factors for development
of PIH. In obese and bariatric patients because of larger
preperitonealspaceandelevatedintra-abdominalpressure,
the risk of formation of trocar site hernia is greater. Size of
the port is another major risk factor and it is advisable to
close the hole >5 mm at the fascia level.
The meticulous closure of the laparoscopic ports is
important to prevent and reduce the chances of formation
of PIH. Port-site closure by Veress needle is an efficient

Fig. 24: Tighten the loop and retract the Veress along with the suture
and tie the knot outside.
Fig. 25: Thus, the port site closed under vision and is safe procedure.
and safe technique done under vision and there is no need
to buy additional equipment to close the port site thus
cost effective.
The hernia may become evident at any time following
laparoscopic surgery and the patient may either have an
uncomplicated hernia, or may be afflicted with a variety of
complications such as evisceration of the bowel or omentum
and it may become a cause of significant morbidity.
Meticulous closure of the fascia, avoidance of unnecessary
wound extension, the use of nonabsorbable sutures when
faced with defects >2 cm in size, completely defining the
extent of any pre-existing hernia and repairing this at
the time of port-site closure, are recommended to minimize
the incidence of port-site hernia after laparoscopic surgery.
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