LAPAROSCOPY REIN AND CUSHION: Strategies in single incision laparoscopy surgery and natural orifice surgery.

FIGURE 1

Operative laparoscope with a working channel use in single port laparoscopy.

With the goal of decreasing pain, hospital stay, infections, peritoneal post-surgical adhesions, incisional hernias and improving cosmetic results, gynecologists pioneered single port laparoscopy sterilizations [1]. Dr. Marco Pelosi from Bayonne, New Jersey, performed single port hysterectomies in 1991, but the technique failed to gain acceptance due to difficulties in triangulation. (Figure 1)

The introduction of Minilaparoscopy Assisted Natural Orifice Surgery and Natural Orifice Transluminal Endoscopy Surgery (NOTES) has brought new instruments, innovations, and strategies that will facilitate these procedures as well as enhance Single Incision Laparoscopy Surgery.

FIGURE 2

The SILS™ Port is a flexible laparoscopic port that can accommodate up to three instruments use in a single incision laparoscopy.

Specifically, the laparoscopy rein is a strategy that follows the trend in pursuit of techniques that reduce the size and number of the abdominal wall entrances. The damage to the abdominal wall is reduced. The objectives are pain reduction and improved cosmetic results, hernia prevention in the fascia, and adhesions prevention in the peritoneum. The entry size of the rein is the diameter of one Keith needle.

BULLET POINT 1

Triangulation and strong traction is sometimes difficult to achieve in laparoscopy without additional ports and is often difficult in Single Incision Laparoscopy and Natural Orifice Transluminal Endoscopic Surgery. A simple inexpensive and easy to assemble laparoscopic rein may solve many of these problems.

The concept of securing specimens or tools, traction, triangulation, retraction and exposure with leashes, reins and marionettes were previously described in laparoscopy [2-6]. The laparoscopy leash, was originally used to secure specimens, was modified by Dr. Geisler for use in mobilization during laparoscopic myomectomy as a marionette, and by Dr. Puntambekar et al. to hitch the uterus in oncological surgeries when dilatation of the cervix is not indicated. (For techniques, see also http://www.obgmanagement.com/article_pages.asp?AID=9492.)

FIGURE 3

Uterine mobilization during single port laparoscopy.

To achieve peritoneoscopy with less abdominal wall damage Dr. Fausto Davila presented in the SAGES annual Congress in 1999 a study on cholecystectomy with a single port, aided by percutaneous needles and leashes, he coined the procedure “without a trace” [7]. He later designed a rein that consisted of an endo suture with 6 cm straight needle of 2-0 polypropylene and a silastic embolus of a small syringe plunge tied as stoppage near the end. The rein was used instead of the leash. The rein was used successfully during procedures done via an operative laparoscope as a single port and in natural orifice transvaginal endoscopic surgeries in Mexico [8]. Figure 3.

FIGURE 4

View of the original rein from a transvaginal flexible endoscope during a Minilaparoscopy Assisted Natural Orifice Surgery cholecystectomy

The Figure 4 shows a transvaginal cholecystectomy with one rein at the fundus of the gallbladder as an anchor, the rein is externalized close to the right costal edge. (Figure 4)

The rein was recently used in Single-Incision Laparoscopic Cholecystectomy by doctors Edgar J. Figueredo, Andrew S. Wright, Saurabh Khandelwal and Brant K. Oelschlager from the Center for Videoendoscopic Surgery, University of Washington Medical Center, Seattle, Washington USA.

The use of the syringe plunge as a stoppage required specific protocol authorization for its utilization in peritoneoscopy. A large Hem-o-lok clip (Weck, Raleigh, NC) is approved for use in laparoscopy for clip and tissue approximation. According to doctors Daniel A. Tsin, Fausto Davila, Guillermo Domniguez and Andrea Tinelli, a modified rein that uses a Hem-o-lok as a stoppage will simplify the use of the rein in the USA [3].

The rein could be introduce into the abdomen via a 5 mm or larger port or via the working channel of an operative laparoscope by grasping the rein 2 cm from the needle, pushing the holder and the needle through the cannula or operative laparoscope. Once into the abdomen the needle is passed through the designated target and is re-grasped. The needle is placed perpendicular to the parietal peritoneum for percutaneous extraction. The needle is pushed through the full thickness of the abdominal wall and grasped outside the skin with a Kelly clamp. The needle holder is removed from the port. As the extraction continues, the stoppage will enter the cannula. Some port models need a valve opening for the passage of the Hem-o-lok in and out. As we continue to pull, the Hem-o-lok reaches its target. The needle is exteriorized. The rein is held as a marionette with a Kelly clamp at a distance of 10 cm to 15 cm from the skin. The rein is cut above the clamp and the needle end is disposed. The rein could be used as a marionette, or the Kelly clamp could be repositioned and held in place at the skin level to anchor the target. For removal, grab the spring end of the Hem-o-lok and withdraw completely via a 5 mm or wider port.

The tensile strength of the 2-0 polypropylene or nylon rein is about 4 Kg. Rein traction is different from the leash, it has only one abdominal wall entrance, and the force is applied directly to the stoppage and indirectly to the target, thereby diminishing the chances of tearing [9].

In rare occasions with a friable target, a cushion is made with a piece of Surgicel or Teflon. The cushion is placed over the target, and the rein enters first through the cushion and then the target. The cushion will reduce the pressure of the Hem-o-lok over the target [10]. The surgeon must be careful in removing the cushion before completion of the surgery.

BULLET POINT 2

When needed use a cushion to reduce the pressure.

The rein with or without a cushion could be used in laparoscopy, single incision laparoscopy or natural orifice surgery for triangulation, strong traction and exposure. There is no need for additional ports, and can be used as an alternative to the leash, marionettes or the hitch in gynecological as well as other general surgery and urological procedures.

References:

References.
1. C.R. Wheeless. A rapid, inexpensive and effective method of surgical sterilization by laparoscopy. J Reprod Med .1969 ;3 : 65-69
2. Tsin DA, Davila F, Dominguez G, Manolas P. Secured independent tools in peritoneoscopy. JSLS. 2010 ;14(2):256-258
3. Tsin DA, Davila F, Dominguez G, Tinelli A. Laparoscopy Rein and a Backward Needle Entrance. J Laparoendosc Adv Surg Tech A. 2011 Jun 1. [Epub ahead of print]
4. Tsin DA,Colombero LT. Laparoscopic Leash: A simple technique to prevent specimen loss during laparoscopy. Obste Gynecol . 1999;94:628-629
5. S. P. Puntambekar, A. M. Patil, N. V. Rayate, S. S. Puntambekar, R. M. Sathe, and M. A. Kulkarni, “A Novel Technique of Uterine Manipulation in Laparoscopic Pelvic Oncosurgical Procedures: “The Uterine Hitch Technique”,” Minimally Invasive Surgery, vol. 2010, Article ID 836027, 5 pages.
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9. Tatum Tarin, M.D.,* Simon Kimm, M.D.,* Benjamin Chung, M.D., Rajesh Shinghal, M.D., and Jeffrey Reese, M.D. Comparison of Holding Strength of Suture Anchors on Human Renal Capsule. J. ENDOUROLOGY. 2010;24:293-297
10. Gaujoux S, Kingham TP, Jarnagin WR, D'Angelica MI, Allen PJ, Fong Y. Single- incision laparoscopic liver resection. Surg Endosc. 2011; 5:1489-1494.