LAS VEGAS – Surgeons have developed a simple new suture technique using two S-retractors to close laparoscopic and robotic surgery ports without sacrificing visualization.
"This method involves minimal training and surgical skill, is quick to perform, and requires no additional instrumentation and no additional cost to the institution, surgeon, or patient," Dr. Homayara Aziz said at the 41st AAGL Global Congress.
No fewer than 29 original methods have been described in the literature for fascial closure, but many use assistance from inside the abdomen or extracorporeal assistance, and require additional ports. Others can be performed without an additional port, but may or may not provide direct visualization when securing the abdominal wall fascia and peritoneum.
Illustration by John Nyquist, MS, FAMI, CMI
A schematic of the closure technique.
With the new technique, devised at the State University of New York at Buffalo, the needle does not enter the peritoneal cavity blindly, where the bowel or other visceral organs may be present, Dr. Aziz said. Instead, the S-retractor functions as a barrier to protect the contents of the abdominal cavity, reducing the risk of visceral injuries.
The S-retractor also provides direct visualization of the different abdominal layers, exposing the needle tip during its course through the fascia. Because there is no needle tip in the intraperitoneal cavity, the procedure is safer, she said.
The two-step process starts with the surgeon inserting an S-retractor through the incision into the peritoneal cavity and then lifting the abdominal layers with the bottom of the retractor, creating a barrier between the fascia and the visceral contents. The assistant uses a second S-retractor to retract the skin, fat, and muscle in the opposite direction to expose the fascia. The surgeon then uses a needle suture to grasp the fascia, Dr. Aziz explained.
The first retractor is then rotated 180 degrees in the peritoneum by the surgeon to allow for work on the opposite side of the fascia. The second retractor, used by the assistant, is also moved to the opposite side of the abdominal wall layers to expose the fascia.
The surgeon again continues to grasp the opposite side of the fascia with the suture. The two ends are tied and the fascia is closed. If the fascial defect is greater than 10 mm, the surgeon may continue the same technique for another interrupted suture, figure of 8, or running closure, said Dr. Aziz, now a clinical instructor of obstetrics, gynecology, and reproductive science at the University of Maryland, Baltimore.
She reported on a prospective, consecutive case series involving 100 private and clinic patients in which this method was used over a 3-year period for fascial closure of total laparoscopic hysterectomies; bilateral or unilateral salpingo-oophorectomy where the port site was more than 12 mm to remove the specimen using an endocatch bag; and any robotic surgery where the ports are generally more than 8 mm.
There were no intraoperative incidents, nor was there added operative time or need to access costly instruments, she said.
No bowel injuries or port-site hernias were reported during a mean follow-up of 6 weeks post surgery and at 12-month annual follow-up.
"Closure of the fascia should remain simple, easy, cost-effective, and quick to apply," Dr. Aziz said. "It should also be safe and without any complications, and this technique described here fulfills all of these criteria."
The technique takes 5 minutes or less to learn, and has been used on at least 200 additional patients at both institutions since the current analysis was performed, Dr. Aziz said in an interview. "Many of my attendings at SUNY Buffalo call it ‘the Aziz technique’ and [it] has gained much popularity."
Dr. Aziz reported no relevant conflicts of interest.