Today’s options make challenging cases easier and reduce the risk of hernia.
By Dieter Bruno, MD, FACS
Urologist, Peninsula Urology Center, Redwood City, California
A surgeon can perform a complex laparoscopic procedure exceptionally well, but if the patient develops a port-site hernia postoperatively, that will be the enduring impression of their surgery.
Port-site hernias can occur in any case, but they happen most commonly when patients are obese, elderly, or diabetic. The surgeon struggles to suture the deep fascia, and incomplete closure of that tough connective tissue results in the contents of the abdomen bulging and pushing on weaker layers. Patients see the bulge and sometimes feel pain, so we have to go back in and do a second procedure to repair the hernia, with all the added cost, hospital time, and anesthesia. In the worst cases, a piece of the intestine can bulge through the hole, causing an obstruction that requires emergency surgery.
Put simply, nothing can substitute for suturing the port right the first time.
Our Options for Port Closure
As an urologist, I need to close ports after a number of procedures, including laparoscopic adrenalectomy or hysterectomy, as well as robotic hysterectomy, partial nephrectomy, prostatectomy, pyeloplasty, and sacrocolpopexy. But port closure is the same, regardless of the procedure or the specialty.
In selecting a method for port closure, we look for options that address our toughest challenges. The most pressing problem is the difficulty of finding and accessing the fascia in large patients. Secondly, at the end of the case, we don’t want to make any errors as a result of fatigue. To my mind, that means the closure method should be very straightforward and efficient.
Some surgeons used a curved needle to close the port, but it’s difficult to get the layer we want with this method, and we need to fish for the sutures as we work. Another option that simplifies the process is the Endo Close device (Medtronic), which captures and holds the suture so the surgeon can pull it through the other side. With the Carter-Thomason CloseSure System (CooperSurgical), a reusable conical guide ensures that we angle the suture passer correctly for closure of the fascia and peritoneum. We feed the suture through the device, and then grab it and pull it from the other side. This can be difficult, so it requires some practice.
Another option called AbClose (Medeon Biodesign) standardizes how we suture and close the fascia by mechanizing the toughest aspects of port-site closure. A single surgeon or less experienced resident can safely and reliably close the fascia each time, regardless of the patient’s weight or other challenges.
The ultimate goal in working toward development of an elegantly simple port-site closure device is to reduce the risk of hernias so fewer patients face the added risks of additional surgeries. Surgery should meet its goals, not open patients to further problems. When we can close ports correctly every time, the wound closure device becomes an unsung hero in the OR that allows patients to focus on getting better, instead of on wound complications.
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