Different Port Closure Techniques in Laparoscopy Surgery

REVIEW ARTICLE

Different Port Closure Techniques in

Laparoscopy Surgery
1
Majid A Hamood, 2RK Mishra
1
Department of Surgery, Hilla Teaching Hospital, PO Box 294, Babil, Hilla, Iraq
2
Department of Surgery, Laparoscopy Hospital, New Delhi, India

Abstract
Introduction: Any new surgical procedure, face a new technical challenges, although minimally invasive surgery cause evident reduction
of the pain to the patient postoperatively, with better cosmesis, but with time, new challenges appears.
One of challenges is port closure techniques, in order to prevent the trocar site hernias and other complications .
Aims: The aim of this study to review and list different techniques used for closure of the trocar sites.
Methods: A literature search was performed for articles and text books dealing with techniques of closure. The author searched this
subject using Medline and the search engine Google, Springerlink and High wire Press. The following search term were used; port site
closure techniques. Review, All articles reporting techniques with their references were reviewed with some text books.
Results: in this literature review we 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, Owsley retractor, spinal cord
needles, dual hemostat, Veress needle loop technique,suture carrier, Riverdin and Deschamps needles, and Gore-Tex closure device.
Semm's emergency needle with adistal eyelet; the modified Veress needle with a slit made in the retractable brunt tip; dental awl with
aneye; prolene 2/0 on a straight needle aided by a Veress needle; a straight needle armed with suture; Auto stitch (United States
Surgical), a modified Veress needle bearing a crochet hook at the tip. Foley catheter threaded through the port hole forthe elevation of
fascial edge upon traction; fish-hook needle improvised out of a hypodermic needle by bending it 180°; Grooved director; U-shaped
purse-string suture placed in the fascia around the port hole .
Conclusion: Although there are different techniques used to close the trocar site, all of them are effective in closing the defect in the
fascial layers of the abdominal wall, two main groups of techniques were found.
Keywords: Port closure, techniques, complication, laparoscopy surgery.

INTRODUCTION be closed, incorporating the peritoneum into the fascial

closure.10,18-20 Standard suture techniques can be difficult and
Around 200 years ago, endoscopy was first started with the
frustrating, often involving blind closure of the fascial defect.
help of tin tube at the end of which candle was placed to provide
A number of techniques and devices have been developed to
the illumination.1 The modern area of laparoscopy started in
facilitate this fascial closure.
1966 with the development of Hopkin's-Rod system.2 The
introduction of any surgical procedure brings with it new
METHOD
technical challenges. Because laparoscopy offers patients a
reduction in pain and better cosmesis, it is being used more Selected papers were screened for further references. Criteria
frequently today. Laparoscopy allows for more intricate for selection of literature were the number of cases (excluded if
procedures to be performed, but larger ports are required to less than 20), methods of analysis (statical or nonstatical),
execute such complex surgeries.1 Along with larger ports come operative procedure (only universally accepted procedures were
larger abdominal incisions and thus an increase in the possibility selected) and the institution where the study was done
of complications following surgery.3 These complications can (specialized institution for laparoscopic surgery). Textbooks of
include incisional bowel herniation as well as small bowel laparoscopic surgery also were reviewed.
obstruction.4,5 The closure of laparoscopic trocar sites is helpful
in reducing such complications. In 1968, Fear6,7 was the first to RESULTS
report ventral hernia at a trocar site after laparoscopy. Trocar
Port closure techniques could be classified from a technical
complications occur in approximately 1 to 6% of patients.8-16
point of view into two groups:
Herniation associated with laparoscopic trocar sites can occur
with incisions as small as 3 mm.17 It is recommended that all 10 1st group: With laparoscopic visualization (Must be seen
and 12 mm trocar sites in adults and all 5 mm port sites in children through telescope).

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Majid A Hamood

2nd group: Without laparoscopic visualization (must be seen

by surgeon, no telescope).

FIRST GROUP
The manipulation of this group is performed from inside the
abdomen under direct visualization, the maximum safety in
avoiding visceral injuries. These techniques include Maciol
needles, the Grice needle, catheter or spinal needles, the
endoclose device, and the Gor-Tex device, Reverdin, Deschamps
needles, Semm's emergency needle with adistal eyelet; the
modified Veress needle with a slitmade in the retractable brunt
tip; dental awl with aneye; prolene 2/0 on a straight needle
aided by a Veress needle; a straight needle armed with
suture;Autostitch (United states surgical), a modified Veress
needle bearing a crochet hook at the tip, veress needle loop
technique.29
Grice needles Used by Stringer et al,16 A Grice needle (Figs
1A and B) was inserted at an angle along the side of a lateral
trocar. Under direct laparoscopic visualization, the needle was
placed through both the peritoneum and the fascia. Within the
abdomen, the suture was grasped and removed from the Grice
needle with a grasper inserted from the opposite trocar. The
Grice needle then was removed and reinserted opposite the Figs 2A to C: (A) Maciol suture needle set (B and C)
previous puncture, again at an angle along the trocar. The suture Maciol needles
was regrasped with the Grice needle and pulled out of the
abdomen. After complete removal of the trocar, the suture was
tied under direct laparoscopic visualization.
Maciol needles. Contarini6 reported using Maciol needles
(Core Dynamics, Inc. Jacksonville, FL, USA, Maciol needles
(Fig. 2A) are a set of three needles: Two black handled
introducers, one straight and one curved, and a golden-handle
retriever. The introducer needle (needle with an eye) is used to
pass the suture through the abdominal wall into the peritoneal
cavity from the subcutaneous tissue (Fig. 2B). The retriever
needle (needle with a barb) is next passed into the abdomen on
the opposite side of the defect to retrieve the suture, then pulled

Figs 3A to C: Vein catheter, spinal cord needle, and angiocath needle

back through the tissue (Fig. 2C). The procedure is performed

under direct laparoscopic visualization before trocar withdrawal
and does not require any enlargement of the skin incision.
Vein catheter, angiocath needle, and spinal cord needle.
Nadler et al. 22 used a venous catheter (Fig. 3A). direct
laparoscopic visualization to secure the abdominal wall fascia
and peritoneum, (Fig. 3B). A continuously running
nonabsorbable 0-polypropylene suture is inserted through a
15 gauge needle, which penetrates all subcutaneous layers
including the fascia, going around the umbilical opening at a 45
degree angle to create a purse string. The needle penetrates the
fascia at a distance of 0.5 to 1 cm from the trocar site. After the
first insertion of the needle, an endograsp forceps is used to
Figs 1A and B: Grice needle pull the free suture edge into the abdomen Then the needle, still

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 Different Port Closure Techniques in Laparoscopy Surgery

holding the suture, is reinserted at the next point and, with the
use of the forceps, the free intra-abdominal edge of the suture
is locked through the loop that has been created. This maneuver
is repeated another three times until the purse string is fashioned.
In the final step, the suture edge, which is pulled by the last
loop, and the needle are withdrawn outside the abdomen near
the site of first needle insertion, and both edges of the suture
are tied up onto the fascia, angiocath needle to perform the
same closure technique (Fig. 3C). The large 10 mm trocar is
removed, and the pneumoperitoneum is maintained in all
abdominal trocar wounds 10 mm or larger simply by placement
of a gloved finger over the top of the wound. A 14 gauge
angiocath needle with the sheath removed is preloaded with a
50 cm length of 0- braided polyglactin suture. The angiocath
and suture are inserted through all fascia layers on one side of
Figs 4A to C: Endoclose suture device
the laparoscopic wound with laparoscopic visualization.
Carefully, the needle and suture are placed in the exact middle
of one side of the trocar wound. The surgeon or surgical
assistant grasps the suture through a previously made 5 mm
port. The needle is removed, and the suture is pulled a short
distance (10-15 cm) into the abdominal cavity. A 5 mm grasping
instrument is inserted directly through the subxiphoid or any
large trocar wound, and the suture is grasped. The 5 mm grasping
instrument and suture are removed from the abdominal cavity.
The four steps are repeated by passing another preloaded
angiocath needle and suture through the midpoint of the other
side of the trocar wound. The suture is brought out through the
same trocar hole. The ends of the suture are tied together with
several square knots. The knot is reduced into the peritoneal
cavity by pulling on one or both ends of the tied suture. The
knot may be removed by pulling it through the fascia, thereby
leaving a single strand of suture for closure of the fascia. The Figs 5A and B: The Gore-Tex suture passer
fascia is then closed, and the suture is tied under direct vision
through the laparoscope.23 distended by the pneumoperitoneum, the laparoscope is used
Endoclose suture device. This is a disposable endoclose to view the trocar site to be closed. The end of the trocar should
device (Tyco Auto Suture International, Inc. Norwalk, CT, USA) still be visible within the peritoneal cavity.
with a spring-loaded suture carrier (Fig. 4A) is loaded with a 0- The suture is loaded into the Gore-Tex Suture Passer, then
absorbable suture and introduced into the abdomen between passed through the subcutaneous tissue and fascia on one
the edge of the skin and the port.The suture is released and side of the trocar (Fig. 5A). The suture is released from the
dropped in the abdominal cavity, after which the device is passer by pushing down on the handle, then grasped
removed (Fig. 4B). The spring-loaded suture carrier is then intraperitoneally with a blunt grasper. The suture passer is then
passed through the fascia and peritoneum 180° degree from the removed and inserted through the subcutaneous space and
original insertion site between the skin incision and the port. fascia on the opposite side of the trocar. The suture is placed
With the assistance of a 5 mm grasping forceps through a back in the jaw of the suture passer and locked into position by
secondary port, the suture is reloaded onto the opened notch pulling back on the handle (Fig. 5B). The suture is then removed
in the endoclose needle (Fig. 4C). The device and suture are by pulling the passer out. Next, the trocar may be removed and
brought out of the abdomen. The port is removed, and the the suture tied down.
suture is tied to approximate the fascia and peritoneum.23,24
CARTER-THOMASON DEVICE
THE GORE-TEX SUTURE PASSER
The Carter-Thomason close-sure system (Inlet Medical, Inc.,
Chapman25 used the Gore-Tex suture passer (WL Gore and Eden Prairie, MN, USA) is of two parts (Figs 6A and B): The
Associates, Phoenix, AZ, USA), which is a reusable trocar Pilot guide and the Carter-Thomason suture passer. Closure of
closure device. With the trocar still in place and the abdomen the port incision requires four easy steps: (1) use the suture

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Majid A Hamood

passed into the abdomen until the olive is visible below the
peritoneum. The instrument is then positioned in a plane
perpendicular to the trocar incision to expose the needle and
pass it through the peritoneum and fascia until it exits the skin
incision.The end of the suture is grasped and tagged with
ahemostat. The needle is dropped back into the olive, and the
instrument is rotated 180°. The olive is again dropped to expose
the needle, which is again passed through the peritoneum and
fascia. After removal of the Endo-Judge, the suture is tied,
creating a secure, airtight fascial and peritoneal closure.
The 2 mm trocar technique. Reardon et al.24 A 2 mm trocar
and sleeve are introduced adjacent to the port whose entry site
will be closed. A monofilamentheavy-gauge suture with the
needle removed is passed through the lumen of the 2 mm sleeve.
The 2 mm sleeve is then removed over the suture, after which
Figs 6A to F: Carter-Thomason device
the 2 mm trocar and sleeve are reintroduced through the
opposing fascial edge 180° from the original insertion site. The
passer to push suture material through the Pilot guide, fascia,
trocar is removed, and a 2 mm grasper is passed through the
muscle, and peritoneum into the abdomen, then drop the suture
sleeve and used to retrieve the intra-abdominal end of the suture.
and remove the suture passer) (Fig. 6C), (2) push the suture
passer through the opposite side of the pilot guide and pick up
THE 5 mm TROCAR TECHNIQUE
the suture (Fig. 6D), (3)pull the suture up through the
peritoneum, muscle, fascia, and guide (Fig. 6E), and (4) remove Rastogi and Dy25 developed a simple technique using the
the Pilot guide and tie (Fig. 6F). Designed specifically for regular curved needle and sutures for closure of peritoneal and
bariatric and obese patients. The suture passer and Pilot guides rectus sheath defects at the port site. Using a 5 mm telescope,
have been lengthened to reach through the peritoneum in the they inspect the defect from the inside, and then pass a hemostat
larger patient to provide full-thickness closure in this at-risk through the incision. Under direct telescopic vision, the
group.23 peritoneum and rectus sheath are grasped at both the upper
and lower edges and pulled through the incision,facilitating the
ENDO-JUDGE DEVICE passage of the needle. Chatzipapaset et al.9 developed a similar
closure technique using standard sutures with straight needles,
The Endo-Judge wound closure device (Figs 7A to F), a 14 a 5 mm laparoscopic grasper, and a 4 mm hysteroscope.
gauge hollow J-shaped needle that serves as a carrier for suture
material and adevice for performing the fascial closure. The
TAHOE SURGICAL INSTRUMENT LIGATURE DEVICE
suture is mounted on a reel at the proximal end of the device
and fed to the hollow needle until it is delivered out the needle It is disposable. Initially, the laparoscopic cannula is removed.
tip. The plastic oval shield (olive) at the J-portion of the needle A 0-absorbable suture is placed into the hollow delivery Tahoe
maintains pneumoperitoneum and prevents injury to underlying needle without extension beyond the distal end of the needle
structures. Reverdin and Deschamps needle can also be used (Fig. 8A). The device is introduced into the abdomen after the
same way to close the port (Figs 13A and B). It is controlled by needles are first inserted through the two holes on an
asliding ring located on the shaft of the instrument. The device introduction disk. The needle tips are then guided to pierce the
should be used under direct visualization. The Endo-Judge is fascia on either side of the port site. The lock is released, and
the handle is depressed until the metal retrieval loop is extended
and encompasses the tip and distal shaft of the delivery needle.
The suture is fed into the delivery needle until it lies several
inches beyond the distal end of the delivery needle and through
the retrieval loop (Fig. 8B). The handle is released, allowing the
retrieval loop to retract, thereby securing the suture in the closed
metal loop. The entire device is withdrawn from the abdomen
(Fig. 8C), thus delivering the tow ends of the suture onto the
abdominal wall. The suture is tied, approximating the peritoneum
and fascia.24

EXIT DISPOSABLE PUNCTURE CLOSURE DEVICE

A 10 mm instrument with arecessed right-angle needle that can
Figs 7A to F: Endo-Judge device be exposed by rotating a dial at the top of the instrument. The

32
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 Different Port Closure Techniques in Laparoscopy Surgery

it to the other side of the trocar, to push it in side the veress

loop, after piercing the abdominal wall, leaving the skin,and
then remove the trocar, and close the wall by knotting (Figs
14A to N).

SECOND GROUP
Port closure should be performed under direct visualization of
the surgeon, which requires good insufflation of the abdomen.
When desufflation is performed, a tactile sense should be used
to close the port. These techniques are applicable during
insufflation or after desufflation. These techniques include the
suture carrier, the dual hemostat technique, the Lowsley
Figs 8A to C: Tahoe surgical instrument ligature device retractor, application of bioabsorbable hernia plug in trocar
sites.28 Preliminary placement of fascial stay sutures above and
device is introduced through the 12 mm laparoscopic port. When below the prospective trocar site; Foley catheter threaded
laparoscopically visualized in the abdomen, the right-angle through the port hole for the elevation of fascial edge upon
needle assembly is rotated to the open position, thereby traction; fish-hook needle improvised out of a hypodermic needle
exposing the needle carrier (Fig. 9A). The device is then pulled by bending it 180°; Grooved director; U-shaped purse-string
back up through the port, thereby drawing the needle up through suture placed in the fascia around the port hole.21
the peritoneum and fascia between the skin and the port. The
skin is pulled away from the tip of the needle to avoid puncture SUTURE CARRIER
of the skin. When the needle is seen coming through the
subcutaneous fat, a 0-absorbable suture is loaded through the Jorge et al26 and Li and Chung developed a hook suture carrier
hole in the needle (Fig. 9B). The needle and suture, along with (Figs 10A and B) for closure of trocar wounds, making use of
the entire device, are pushed back down through the port into the vertical rather than the horizontal space. The suture carrier
the abdomen,thereby passing the suture down through the is a hook suture carrier modified from a simple hook retractor
fascial and peritoneal layers. The exit device is then rotated with an eye drilled into the tip through which suture material
180° to the opposite side of the port (Fig. 9C), and the needle can be threaded. The handle is 24 cm long, and the size of the
carrying the suture is again delivered through the fascia and hook approximates the size of the general closure needle (CT
peritoneum. The needle is identified in the subcutaneous tissue, needle; Ethicon, Somerville, NJ, USA). To begin closure, the
and the suture is pulled from the tip of the needle (Fig. 9D). The fascial edge is lifted vertically with a hook retractor, and the
device is returned back in to the abdomen; the needle is closed; suture carrier is partially inserted into the wound to catch the
and the closed device is removed through the port (Fig. 9E). peritoneum and fascia under direct vision, piercing it from the
The port is removed, and the suture is tied, securing the undersurface (Fig. 10A). A suture (such as 0-polypropylene) is
peritoneum and fascia.24 threaded into the exposed eye of the carrier and brought beneath
Veress needle loop technique; used by RK Mishra, making the fascia. This same suture is then carried to the opposite edge
a loop by passing nylon suture to veress needle and tied it, of the wound using the carrier, executing a stitch from inside
then loadge the vicryl suture to the tip of veress needle, then out. After the suture is disengaged from the carrier, a simple
push the veress needle with the loop, through the abdominal stitch is accomplished with the knot on the surface when tied
wall, with out piercing the skin, 3 mm away from the trocar site, (Fig. 10B).
then remove the veress, leaving the vicryl in side, by putting
your finger on the vicryl, grasp the vicryl by grasper, and pass DUAL-HEMOSTAT TECHNIQUE
Spalding et al27 reported the dual-hemostat technique (Figs
11A and B), which is very simple, using two hemostats and a
needle driver with suture and needle. The first hemostat is placed
into the wound, after which the tips are spread open and the
fascia is lifted up away from the underlying abdominal viscera.
The second hemostat is used to retract the overlying
subcutaneous tissue. Then the suture needle is driven through
the fascia to exits between the splayed tips. The procedure is
repeated at the opposite side of the wound.

LOWSLEY RETRACTOR WITH HAND CLOSURE

This technique uses the straight Lowsley retractor (Circon
Figs 9A to E: Exit disposable puncture closure device ACMI, Stanford, CT, USA), a regular needle driver, and a

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Majid A Hamood

Figs 10A and B: Suture carrier

Figs 12A and B: Lowsley retractor with hand closure

Figs 11A and B: Dual-hemostat technique

0-absorbable suture on a curved needle.13 The closed straight

Lowsley retractor is passed through the 12 mm port and into
the peritoneal cavity (Fig. 12A). The blades of the Lowsley
retractor are next opened maximally to 180°. The port then is
removed from the abdomen along the shaft of the Lowsley Figs 13A and B: Reverdin and Deschamps needle
retractor, leaving only the retractor in the wound. The retractor
and the port are pulled upward. The fascia is tented toward the trocar site after laparoscopy may arise from failure to
skin surface and exposed. A standard hand-sutured closure reapproximate fascial wound edges ,infection, premature suture
with 0-absorbable suture then is performed (Fig. 12B).23 disruption, a bulge at a previous port site should immediately
raise suspicion.23
PORT PLUG TECHNIQUE Hernia at trocar ports is classified into three types:
1. The early-onset type (i.e., occurring immediately after the
In this technique using the bioabsorbable hernia plug hernin in
operation, with small-bowel obstruction (especially Richter
trocar site,the device was implanted in the umbilical trocar
hernia) frequently developing, (2) the late-onset type (i.e.,
(10 mm) implantation of the bioabsorbable hernia plug device
occurring several months after the operation, mostly with
by the safe port possible in all cases.28
local abdominal bulging and no small-bowel obstruction
developing [laparocele]), and (3) and the special type (i.e.,
DISCUSSION
indicating protrusion of the intestine and/or omentum).20
The port site hernias are found with incidence of 0.23% at the The Richter hernia usually presents days later, and the
10 mm port site and 1.9% at the 12 mm port site. This incidence patients experience a delay in diagnosis due to persistence
markedly increases to 6.3% for obese patients with a body mass of bowel function leading to significant morbidity.This
index (BMI) greater than 30.10, 12,14 This incisional hernia at a complication of minimally invasive surgery is rare, but

34
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 Different Port Closure Techniques in Laparoscopy Surgery

Fig. 14A Fig. 14D

Fig. 14B Fig. 14E

Fig. 14C Fig. 14F

Fig. 14: Contd...

World Journal of Laparoscopic Surgery, September-December 2009;2(3):29-38 35

Majid A Hamood

Contd...

Fig. 14G Fig. 14J

Fig. 14H Fig. 14K

Fig. 14I Fig. 14L

Fig. 14: Contd...

36
JAYPEE
 Different Port Closure Techniques in Laparoscopy Surgery

Fig. 14M Fig. 14N

Figs 14A to N: Veress needle technique for port closure

potentially dangerous. The usual presentation involves remaining lateral ports, further ensuring that the bowel is
crampy abdominal pain with nausea and vomiting. Treatment not implicated in the repair, and that homeostasis has been
is by reduction of the bowel that is incarcerated, followed achieved,35 at the end the perfiction of the clouser technique
by repair of the fascial defect. Although some authors have proliferated and improvements are continuously being
advocate open repair or local exploration combined with made. Practising surgeon should be congnisant of the full
laparoscopy, the laparoscopic approach is acceptable range of techniques while familiarizing themselves with the
treatment at the time of diagnosis, as long as the incarcerated useful ones deemed simple, safe and effective.36
bowel is not compromised or frankly ischemic.30 The The comparisons among these techniques are beyond the
following risk factors for the development of trocar-site aim of this illustrative review, applying a tighter closure of the
hernias have been identified: The trocar diameter, the trocar skin incision may control the leak of the ascetic fluid in patient
design, pre-existing fascial defects, and some operation and with ascitis, but for a short-time. The tight closure of fascia will
patient-related factors. 11 Many authors believe that prevent ascitic fluid leak.6 For closure of the skin, transcutaneous
inserting the 10 mm lateral trocar in an oblique fashion or as closure with absorbable material seems to be the most suitable
a Z-tract will reduce hernia formation by putting the external technique.37
and internal fascias at different levels, 8-31 so It is
recommended that all 10 and 12 mm trocar must be closed.
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