A new technique of fascial closure for laparoscopic incisions

Objective

To develop a technique and instrumentation for closure of 10 mm and larger laparoscopic incisions with a single instrument under direct laparoscopic vision, ensuring complete fascial and peritoneal closure.

Materials and Methods

The Carter-Thomason Needle-Point Suture Passer uses a 2.7 mm diameter grasping tool with a single-action jaw. The grasping mechanism is designed with a cone-shaped grasping tip honed to a fine need-point for easy passage through tissue.

The needle-point suture passer introduces the suture through the muscle, fascia, and peritoneal layers under direct laparoscopic vision. The needle-point grasper drops the suture, is withdrawn, and is passed to the opposite site of the fascial opening, where it picks up the suture and is withdrawn, grasping the suture through the peritoneal layers, fascia, and muscle. The surgeon ties the suture below the sin to achieve a mass closure of the layers. The appropriate suture for closure of this layer is 0 Vicryl.

The last 100 mm or 12 mm trocar is site is closed by placing a 5 mm laparoscope through the 5 mm incision and viewing the remaining 10 mm or 12 mm site.

A specially designed conical needle guide is used to maintain pneumoperitoneum and to identify the position of the fascial layer.

Results

Over 400 incisions in 200 laparoscopic procedures have been closed since March 1993 without complication. Eight percent of the 400 sites involved 12 mm incisions. The remaining 20% of sites involved 10 mm incisions. The operative time for closing the incisions under direct or laparoscopic view was less than 1 min per incision, a reduction in the amount of time that the author required previously to close laparoscopic incisions of 10 mm and larger by the conventional technique of isolating the fascia.

The instrument and described technique also have been used to ligate a lacerated inferior epigastric vessel with successful ligation obtained in less than 5 minutes. In addition, the instrument has been used to perform intraabdominal suture ligation, such as ligation of the infundibulovpelivc ligament.

Discussion

The complications of operative laparoscopy include trocar site-related injuries, such as incisional hernias and laceration of vessels. Prevention of incisional herniation and omental entrapment requires peritoneal, fascial, and muscle layers. Mass closure of the layers provides additional security.

The greatest risk of herniation is in the heavy patient with a very thick layer between fascia and skin, which makes it difficult to identify the fascial layer using standard techniques with standard instrumentation. Use of a fascial closure device that allows complete mass closure under direct laparoscopic visualization is a great benefit to the laparoscopic surgeon, even for difficult patients.

Conclusion

The Carter-Thomason Needle-Point Suture Passer allows for complete and secure closure of the fascial, muscle, and peritoneal incision during laparoscopy, thereby reducing the risk of incisional hernia during the postoperative recovery period.