Port-Site Closure: A New Problem, An Old Device

Abstract

Objective:

Trocar-site incisional hernias and their complications are reported in 1% to 6% of patients. Such hernias are attributed to the difficulty of applying standard suturing techniques to wound closure. We report our experience with a simple device, the Deschamps ligature needle.

Methods:

The Deschamps needle has a handle and a tip (sharp or blunt), with an opening to pass suture. The blunt tip is very effective for closing trocar sites. Disposable needles are obviously sharp, but can bend on the needle holder and break in a deep, small incision. The Deschamps needle is a rigid, noncutting instrument that can be forced through fascia and peritoneum (around the surgeon's fingertip) avoiding loss of pneumoperitoneum. A full-thickness closure is accomplished. We perform closure under direct vision through the scope. Tactile sense is provided by the surgeon's finger. The last trocar site is closed in the same manner without the scope.

Results:

We have used the Deschamps needle since 1992 in all (1400) laparoscopic procedures. We close 10-mm and 5-mm trocar sites and have not observed wound dehiscence or hernias at these sites.

Conclusion:

The Deschamps needle is effective in preventing incisional hernias and wound dehiscence. It is cost-effective. Disposable, single-use devices vary in price from $30 to $75 each. The Deschamps needle is sold in Italy at approximately $35 each. Considering that it may have been in the trays of most operating rooms for years (as in our case), and the number of procedures performed, we conclude that the real cost of this instrument is almost negligible

CASE REPORT

With the wide diffusion of laparoscopic surgery for many abdominal procedures, trocar site incisional hernias have become more frequent (1% to 6%),¹ along with their related complications (bowel or omentum incarceration and Richter's hernia).² Most complications occur with 10-mm trocars, but some have occurred at 5-mm trocar sites.³ The occurrence of these complications has been attributed to the difficulty in applying standard suturing techniques for wound closure. Every surgeon who has performed traditional closure of fascia and peritoneum has found that closure of all layers in small, deep wounds is sometimes impossible, frequently unsafe, and never quick and easy. This is especially true in obese patients.

Immediately after the appearance of these reports of trocar site complications in gynecologic, urologic, and general surgery literature, many authors began to publish papers regarding original techniques and new devices to obviate the problem.

Some have suggested that a Foley catheter,⁴ spinal needle,⁵ hypodermic needle,⁶ or urologic instrument⁷ could solve the difficulties in closing trocar sites; others developed new devices.^{8, 9} The “debut” of numerous different approaches to closing trocar sites could have been controversial and disorientating to some, but Elashry and associates¹⁰ in 1996, published a perspective, randomized trial that compared many of these techniques. Their final statement concluded that the preferred method of trocar site closure was one that utilized a new, disposable instrument.

The commercial “explosion” of companies producing laparoscopic devices has amplified the problem. Several companies have developed safer and smaller trocar tips while others have focused on developing new, disposable (and frequently expensive) wound closure instruments.

At the beginning of our laparoscopic experience in 1990 we faced the problem of how to close trocar sites as did many of our colleagues. We struggled, we were frustrated, we doubted, and sometimes we renounced the techniques then available.

Although we experienced only two uncomplicated umbilical hernias at trocar sites in our initial period (both following wound infections), we were very concerned about this problem. Then one day the chief nurse of our operating room came with an old instrument from the “forgotten storeroom.” This instrument was a Deschamps needle (Figure 1), which was extensively used in the past for “en masse” ligature of pedicles. As shown in Figure 2, it has a handle and a tip, sharp or blunt, with a hole to pass a suture. It is probably present, and maybe forgotten, in most of the operating rooms in Europe. The blunt type is very effective, in our experience, for the closure of trocar wounds. Disposable needles although obviously sharp, can bend on the needle holder, and can sometimes break in a deep, small incision. The Deschamps needle is a rigid, noncutting instrument that can be forced through the fascia and peritoneum in and out, turning (bending) around the finger tip of the surgeon. Loss of pneumoperitoneum is thus avoided (Figures 3A, 3B, 3C, 3D) and a full thickness closure of the trocar sites is accomplished. Several techniques are available that are suitable for use in 5 mm incisions and in the deep fascial wounds of obese patients. The closure is performed under direct vision through the scope, and the tactile feedback provided by the surgeon's finger allows quick, safe passage of the needle. The last trocar site, after removing the scope, is closed in the same manner, facilitated by maintenance of the pneumoperitoneum. No omentum or bowel is included in the suture, because passage of the instrument is “felt” by the surgeon's finger.

Figure 1.

Deschamps needle.

Figure 2.

Deschamps needle, handle and tip.

Figures 3A, 3B, 3C, 3D.

Deschamps needle passes through the fascia and peritoneum in and out around the finger tip of the surgeon.

Since 1992, we have used the Deschamps needle in all of our laparoscopic procedures, even when only 5-mm trocars were used. To date, we have had no cases of wound dehiscence or herniation in approximately 1400 procedures.

Concerning financial matters, disposable, single-use devices have a price that varies from $30 to $75 per unit, and reusable instruments, frequently sold in a set of various sizes, can cost up to $2,500. The Deschamps needle is sold in Italy at an average cost of $35 each. This means that $140 is the total expense for a complete set.

When one considers that the Deschamps needle has been on the trays of most operating rooms for many years (as in our case) and when one considers the total number of procedures already performed, the real impact of this instrument on surgical costs is inconsequential. We conclude that the Deschamps needle is a safe, cost-effective, readily available device to accurately close fascial defects that arise from the use of trocars and cannulas in laparoendoscopic surgery.