Jagpreet Deed, MBBS, MS, DNB, MRCS, General, surgery1, Vinay Sabharwal, MBBS, MS, General, Surgery2, Ajay Chauhan, MBBS, DNB, General, Surgery3. 1Zulekha hospital, 2Jeewan Mala Hospital, 3BL Kapoor Memorial Hospital
OBJECTIVE:Port closure with routine general surgery instruments is difficult due to limited space, inadequate retraction and difficulty of working in depth. Specialized port closure devices and needles are usually used for port closure, which have their own risk of injury to viscera or vessels of abdominal wall. We describe a technique of port closure using routine open surgery instruments.
TECHNIQUE:Back of thumb forceps is introduced in the depth of the port to reach intraperitoneally. It is then turned towards lower lip of the wound and is used to lift the abdominal wall inferior to the lower lip, by its stout body. The volume of forceps takes the viscera and omentum away from edge of the sheath to prevent any injury to vital structures. Small Langenbeck retractor is used for skin retraction, to clearly expose the lower edge of the sheath, for its closure. For taking an ‘inside-out’ bite, the needle tip is passed a millimeter within the inferior edge of the sheath tissues. At this point the forceps is withdrawn out of the field which helps by making more space available by the pull of Langenbeck retractor below. Hence, ample space is available for the needle to pass a distance into sheath- be rotated- and tip delivered 1 cm inferior to the edge- to be picked by another instrument. (Notable difference here: if the forceps is kept in position in the tract, it (1) reduces the compliance of tissues so that sufficient sheath cannot be exposed by pull of Langenbeck, needed for adequate bite from edge of sheath, (2) hard surface of the forceps does not allow needle to rotate (3) overcrowding of instruments reduces the working space).
Having dealt with lower edge of sheath, the forceps is again introduced through the port tract and this time it is turned upwards. The abdominal wall superior to upper edge of sheath is lifted by the forceps and the skin is retracted with small Langenbeck to expose the sheath underneath. For taking a ‘outside-in’ bite the needle tip is placed 1cm superior to upper edge of sheath. At this point the Langenbeck is removed from the field. The needle is rotated, passed though the sheath and tip withdrawn from below the superior edge of sheath. (Notable difference here: if the Langenbeck retractor is kept in position without removing it, (1) its hard surface does not allow rotation of needle, (2) its presence further reduces the limited working space (3) it is no longer needed after needle tip has been placed appropriately over the sheath). Finally, a self inverting knot is tied after checking for any prolapsing viscera or omentum.
RESULTS: Since 2009, all laparoscopic procedures are completed with port closure by technique described above. For 3102 laparoscopic procedures, the average time for each port closure is 1minute 7 seconds. There have been no major or minor complications.
CONCLUSIONS:It is a safe, inexpensive, easily reproducible and simple technique for port closure. Randomized controlled trials are needed for further evaluation