A multidisciplinary evidence-based guideline for minimally invasive surgery: part 2—laparoscopic port instruments, trocar site closure, and electrosurgical techniques

Abstract

Minimally invasive surgery (MIS) is practiced by different surgical disciplines applying similar basic techniques. In 2007, the Dutch Health Care inspectorate indicated the need for a guideline including multidisciplinary agreements for MIS aiming towards better patient care and safety. A multidisciplinary guideline development group was founded consisting of general surgeons, gynecologists, an anesthesiologist, and an urologist. All members were authorized by their scientific professional associations. Clinically important aspects were identified and discussed. The best available evidence on these aspects was gathered by systematic review. Recommendations for clinical practice were formulated based on the evidence and a consensus of expert opinion. The guideline was externally reviewed by members of the participating scientific associations and their feedback was integrated. Identified important topics were: laparoscopic entry techniques, intra-abdominal pressure, laparoscopic port instruments, electrosurgical techniques, prevention of trocar site herniation, patient positioning, anesthesiology, perioperative care, patient information, multidisciplinary user consultation, and complication registration. The text of each topic contains an introduction with an explanation of the problem and a summary of the current literature. The current available evidence on safety aspects in minimally invasive surgery is limited. Few conclusions could be deduced from evidence-based data. This underscores the need for larger studies with adequate design and methodology to define conclusions of importance. Above all, the development of this multidisciplinary guideline facilitated a rich discussion, which resulted in a very complete and implementable guideline. This is the second of three papers on the multidisciplinary guideline for minimally invasive surgery, in which we present our literature reviews, conclusions, and practical recommendations for the use of specific port instruments, port site closure, and electrosurgical and ultrasonic techniques.

The “Flip-Flap” Technique for Laparoscopic Port-Site Closure—Description of a Novel, Cost-Effective Technique with Review of Literature

“… 2 13 14 The closure of port sites with smaller diameters should be considered in pediatric patients, after excessive port manipulation and when predisposing risk factors are present. 15 The ideal method of port-site closure, however, remains debatable.…”

Safety and Efficacy of Trocar Port-Site Closure Using a Biological Plug Closure in Laparoscopic Bariatric Surgery: a Prospective Study

“…Surgical methods of closing trocar sites, such as various suturing techniques, show a high rate of herniation, bleeding, pain, and nerve trapping among patients [13]. Various procedures have been investigated to minimize port-site complications during or after laparoscopic surgery, including specialized instruments and suturing techniques [5,[11][12][13][14][22][23][24][25]. However, despite the availability of preexisting suturing methods and materials developed for port-site closures, the incidence of failure and complications (pain, infection, herniation, neuroma) following laparotomy incisions remains significant [25].…”

“…Blood transfusions and other standard supportive treatments may successfully avoid the need for reoperation to control bleeding in the majority of patients [31,32,[34][35][36]. Herniation and epiploic entrapment require direct suturing through the skin incision or under laparoscopic vision [4,11,13,14,21].…”

“…Trocars are used in laparoscopic procedures to provide a portal for the placement of surgical instruments. Typically, three to four or more trocars of different sizes ranging from 5 to 15 mm in diameter are used in abdominal surgery [11,12]. Although generally safe, laparoscopic surgery is not without complications.…”

“…Although generally safe, laparoscopic surgery is not without complications. The greater the trocar diameter, the higher the reported incidence of port-site complications such as bleeding, herniation, pain, infection, epiploic entrapment, and neuroma [1,4,5,[11][12][13][14][15][16][17][18][19][20].…”