More recently, a first generation of device-based solutions has come
to the market. Some have been associated with promising results with
respect to TSH prevention. ( 9, 20, 21) However, a major issue associated with closure devices is post-operative pain. One study reported a
5 percent incidence of clinically significant pain associated with fascial
closure of port sites in the lower abdomen following laparoscopic
gynecologic surgery. ( 22) This pain was attributed to nerve entrapment
by the implanted sutures used for approximation of the defect. Surgical
intervention to release the fascial stitch was effective in alleviating pain.
The authors of that study concluded that careful re-approximation of
fascial edges, avoiding an excessively tight closure, may decrease the risk
of nerve compression. It has been reported that over-tightened sutures
can lead to tissue necrosis and excessive tissue overlap, which results in
reduced tensile strength in the healed tissue. ( 23)
Achieving the balance of effective approximation without excessive
tension can be difficult when using devices that provide “closed loop”
approximation. A recently developed next generation fascial approxima-
tion device called neoClose facilitates a different type of approximation.
This approximation method, referred to as Vector X Closure (Figure 2),
is facilitated by the delivery of two absorbable AutoAnchors into the ab-
dominal wall. These are used by the surgeon to approximate the tissue
on either side of the incision site. This type of approximation is intend-
ed to reduce tension at wound sites compared to more traditional closed
loop methods (Figure 1). On this basis, the risk of nerve compression
provide closed loop approximation. Minimizing wound tension during
approximation is also expected to contribute to a suitable environment
for optimal wound healing. ( 24)
With increasing emphasis on procedural safety and cost-effectiveness in
today’s OR, surgical teams are faced with the challenging task of reducing
post-operative complications. Solutions that enable safer surgery, faster
recovery time and better outcomes are required. For laparoscopic surgery,
this will include technologies that lead to reduced post-operative pain and
a lower risk of herniation. The advent of technologies that offer a consistent
positive outcome will be a welcome benefit for both patient and surgeon.
1. Owens, M., Barry, M., Janjua, A. Z. & Winter, D. C. A systematic review of laparoscopic port site hernias in gastrointestinal surgery. Surg. J. R. Coll. Surg. Edinb. Irel.
9, 218–224 (2011).
2. Swank, H. A. et al. Systematic review of trocar-site hernia. Br. J. Surg. 99,
3. Kadar, N., Reich, H., Liu, C. Y., Manko, G. F. & Gimpelson, R. Incisional hernias
after major laparoscopic gynecologic procedures. Am. J. Obstet. Gynecol. 168,
4. Lajer, H., Widecrantz, S. & Heisterberg, L. Hernias in trocar ports following abdominal laparoscopy. A review. Acta Obstet. Gynecol. Scand. 76, 389–393 (1997).
5. Romagnolo, C. & Minelli, L. Small-bowel occlusion after operative laparoscopy:
our experience and review of the literature. Endoscopy 33, 88–90 (2001).
6. Yamamoto, M., Minikel, L. & Zaritsky, E. Laparoscopic 5-mm trocar site herniation and literature review. JSLS J. Soc. Laparoendosc. Surg. Soc. Laparoendosc.
Surg. 15, 122–126 (2011).
7. Azurin, D. J., Go, L. S., Arroyo, L. R. & Kirkland, M. L. Trocar site herniation
following laparoscopic cholecystectomy and the significance of an incidental preex-
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* Boodman S., ” The Pain of Wrongsite Surgery,” Washington Post, June 20, 2011. † ChloraPrep® is a registered trademark of CareFusion Corporation.
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