Alexander J Shope, BS, Joshua S Winder, MD, Jonathon Bliggenstorfer, BS, Randy S Haluck, MD, Eric M Pauli, MD. Penn State Hershey Medical Center
Transfascial suture passers (TSPs) are a common open and laparoscopic tool used to assist in port site closure or mesh securement. Commercially available TSPs have a wide array of distal tip configurations, mechanical actions, and shaft diameters. We assessed the insertion force of various TSPs in a novel ex-vivo porcine model. We hypothesized that TSPs with smaller diameter and a closed distal tip would require less insertion force.
A custom designed support structure held a 3D-printed platform (Fortus 400mc, Statasys) suspended from a digital tensiometer. Uniform sections of porcine abdominal wall including skin, subcutaneous fat, and rectus muscle were sequentially secured to the platform. Nine TSPs were tested: Novapass straight and curved (Cook Inc), Gore suture passer (W.L.Gore), Weck-EFx (Teleflex Medical), Omniclose (Unimax), Artisan Port Closer (Artisan Medical), Carter-Thomason (Cooper Surgical), Endo-Close (Covidien), and a Reverdin needle (Amity Impex). After a standard skin incision, TSPs were passed through the abdominal wall at three locations both without and with 0 prolene suture under the following scenarios: native abdominal wall and abdominal wall with underlay ePTFE or composite ePTFE/polypropylene mesh. Insertion force was recorded in newtons (N) ± standard deviation.
Force measurements can be seen in Table 1. When passed without suture through the abdominal wall, smaller diameter TSPs required less force [1.50N±0.17 for 1.52mm diameter compared to 9.68N±1.5 for 2.82mm diameter (p=0.00072)]. When passing through mesh or while holding suture, diameter was not the only contributor to force; distal tip design and suture holding location played a contributory role. Through composite mesh, the solid tipped Gore TSP required less force than the hollow tipped Unimax [3.87N±0.25 vs 7.88N±0.20 (p=0.00026)]. However, through the same mesh while holding suture, Unimax TSP required less force that the Gore [8.57N±0.83 vs 13.67N±2.70 (p=0.035)]. Overall, smaller diameter TSPs required less force than the larger TSPs when passed through ePTFE empty [Gore 2.95N±0.83 vs. Carter-Thomason 16.07N±2.10 (p=0.0005)] or through ePTFE mesh with suture [Gore 8.37N±2.59 vs. Carter-Thomason 19.12N±1.10 (p=0.003)].
When passed without suture through the native abdominal wall, TSP diameter plays the greatest role in the force required for transfacial penetration. When passed through the abdominal wall/underlay mesh or passed while holding a suture, the distal tip shape, the mechanism of suture holding and the shaft diameter all contribute to the forces necessary for transfascial penetration. These factors should be considered when choosing a TSP for intraoperative use.