How to perform a suture with a 5-mm trocar by laparoscopy?
Executive Summary
In laparoscopic surgery, the requirement to perform sutures traditionally necessitates the use of 10-mm or 12-mm trocars to accommodate the passage of surgical needles. This technical note describes a specialized "trick" developed by Nohuz et al. (2017) that allows surgeons to perform one or more stitches while utilizing only 5-mm trocars throughout the procedure. By avoiding the transition to larger diameter devices, surgical teams can minimize postoperative complications—specifically trocar-site hernias—and improve patient recovery through reduced incision sizes and decreased scar-related pain. The technique is applicable across various disciplines, including gynecological, digestive, and urological surgeries.
Rationale and Clinical Indications
The primary motivation for this technique is the optimization of outpatient surgery and the reduction of morbidity associated with larger laparoscopic ports.
Limitations of Standard Practice
Standard laparoscopic suturing often requires a 10-mm or 12-mm trocar equipped with a reducer. If a procedure begins with only 5-mm trocars and the need for a suture arises, the surgeon must replace an existing port with a larger device. This increases the complexity of the procedure and the size of the surgical trauma.
Documented Benefits of the 5-mm Approach
Reduced Complications: Trocars with diameters greater than 5 mm are more frequently associated with trocar-site hernias (incisional hernias) and require aponeurotic closure.
Pain Management: Smaller incisions decrease scar-related pain, which facilitates faster recovery and better results in outpatient settings.
Cosmesis: The technique improves the aesthetic outcome for the patient due to smaller surgical scars.
Surgical Applications
The authors cite several specific scenarios where this technique has been successfully utilized:
Gynecology: Suturing the vagina during a hysterectomy; shortening the utero-ovarian ligament (oophoropexy) after ovarian torsion; suturing the ovarian cortex following a cystectomy.
General Surgery: Various applications in digestive and urological procedures.
Technical Execution of the Suture
The procedure involves a specific sequence of removing, loading, and reintroducing the 5-mm trocar to facilitate the passage of a curved needle.
1. Preparation and Loading
Suture Specifications: The technique utilizes 2/0, 0, or 1-gauge sutures (single strand or braided) with a curved needle of 26 mm in length.
Trocar Removal: The 5-mm suprapubic operator trocar is removed under direct visualization to prevent visceral herniation or unintended injury.
Loading: A needle holder is passed through the removed trocar (without its obturator). The needle holder catches the free end of the suture and is withdrawn until the needle is roughly 20 mm from the trocar's end. The holder is then reinserted into the trocar to grip the suture 10 mm from the needle's insertion point.
2. Reintroduction and Insufflation Management
Maintaining Pneumoperitoneum: Because the trocar is briefly removed, gas leaks occur. This is mitigated by the rapid nature of the step (a few seconds) and the use of an insufflator. If necessary, an assistant can obstruct the orifice with a finger to maintain pressure and prevent omental incarceration.
Reinsertion: The needle holder and trocar are reintroduced through the original parietal orifice. It is critical to follow the initial insertion path exactly, especially in obese patients, to avoid creating a "false path."
3. Intracorporeal Suturing
Once the needle holder reaches the peritoneal cavity, the trocar is screwed back into place.
The suture is then performed intracorporeally as per standard surgical practice.
Post-Suture Needle Retrieval
Retrieving a 26-mm curved needle through a 5-mm aperture requires a specific maneuver to prevent the needle from becoming stuck or lost.
The Straightening Maneuver
To ensure safe removal, the curved needle must be made "rectilinear" (straightened) within the abdominal cavity.
Instrumentation: Two needle holders (or one needle holder and one atraumatic/digestive forceps) are placed at each end of the needle.
Execution: The surgeon manipulates the tools to reduce the curvature. This is most effective when the axis of needle flattening corresponds to the axis of its curvature.
Precaution: Instruments should not be placed too distally on the needle to avoid breaking the tip.
Safety Protocol for Retrieval
Conclusion
The technique described provides a safe, efficient, and less invasive alternative to standard laparoscopic suturing. By refining the management of 5-mm ports to include suturing capabilities, surgeons can avoid the increased risks of incisional hernia and postoperative pain associated with larger 10-mm and 12-mm trocars. This approach represents a significant step toward optimizing laparoscopic outcomes and supporting the growth of outpatient surgical procedures.
