Case Report: Application of the Carter-Thomason CloseSure System XL™ to Close Port Sites after Laparoscopic Roux-en-Y Gastric Bypass

Introduction

Herniation into the trocar site is a relatively common complication of laparoscopic surgery with a reported incidence of .23% to 3.1% in the general population.¹ The incidence is higher in obese patients.^2,3

Bariatric patients are especially at risk of developing incisional hernias, because of the thick, fatty preperitoneal space and elevated intra-abdominal pressure. Hand suturing is especially difficult in this patient group. Despite fascial reapproximation, a Richter hernia can still develop.⁴ The following case demonstrates our method of closing trocar sites after laparoscopic Roux-en-Y gastric bypass.

Case Report

A 34-year-old white female, weight 375 pounds with morbid obesity (BMI of 58.9 kg/m²) failed to lose weight after numerous attempts of physician-supervised diets and medical therapy. She had gastroesophageal reflux disease, fatigue during the day due to sleep apnea, and depression.

A laparoscopic Roux-en-Y gastric bypass was performed using six trocars: Four 5 mm trocars were placed (left subcostal, anterior axillary line; left lateral subcostal; right subcostal; and right lateral subcostal). Two 12 mm trocars were placed (left paramedian at the level of the umbilicus and right paramedian, mid-clavicular line).

A 15 ml gastric pouch was constructed. The ante-colic, ante-gastric Roux limb measured 150 cm, and the biliary limb measured 50 cm. Esophagogastroscopy with insufflation of the anastomosis was performed, and no evidence of leaks or bleeding was seen.

A full-thickness closure including the peritoneum and fascia was performed under direct visualization on the 12 mm trocar sites using 0 Polysorb suture and the Carter-Thomason CloseSure System XL™ (Inlet Medical, Inc., Eden Prairie, MN) (Figure 1). Fascial closure was not performed on the 5 mm sites. A subcuticular suture using 4-0 Polysorb, followed by skin glue was used to close the skin at all of the trocar sites.

Figure 1. The elongated instruments in the Carter-Thomason System XL penetrate the thicker abdominal wall and reach the peritoneum to make suture pick up easy.

The post-operative course was uncomplicated. The patient was placed on a clear liquid diet on the first post-operative day after no leaks or obstructions were evident on an upper gastrointestinal series. The patient was discharged in good condition on the second post-operative day. There were no port-site related complications.

At the first outpatient follow-up visit, the patient reported only mild discomfort, controlled by oral analgesics. Her port sites were healing well.

Discussion

We have found that proper instrument selection and meticulous surgical technique are among the most important factors in achieving optimum outcomes with laparoscopic Roux-en-Y gastric bypass.

It is our practice to use the Carter-Thomason CloseSure System XL to perform full-thickness closure of all port sites ³ 10 mm. This closure method is superior to our previous method which involved placing a suture passer device through the wound next to the trocar itself. That method led to inexact suture placement and the inclusion of variable widths of fascia.

The Carter-Thomason CloseSure System XL allows for accurate suture placement with the inclusion of reasonable amounts of fascia. The patient had little discomfort at her incision sites due to the fact that minimal excess tissue was included in the closure (Figure 2). The instruments are ideal for use with obese patients, because their length easily traverses thicker abdominal walls.

Figure 2. The longer Pilot® guide penetrates the thick fat layer and reaches the peritoneum to ensure optimal suture placement.

References

1. Kadar N, Reich H, Liu CY, et al.
   Incisional hernias after major laparoscopic gynecological procedures. Am J Obstet Gynecol 1993;168:1493-1495.
   
   
2. Susmallian S, Ezri T, Charuzi I.
   Laparoscopic repair of access port site hernia after Lap-Band^® system implantation. Obes Surg 2002;12:682-694.
   
   
3. Bonatti H, Hoeller E, Kirchmayr W, et al.
   Ventral hernia repair in bariatric surgery. Obes Surg 2004:14:655-658.
   
   
4. Matthews BD, Heniford BT, Sing RF.
   Preperitoneal Richter hernia after a laparoscopic gastric bypass. Surg Laparosc Percutan Tech 2001;11:47-49.
   
   

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