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January/February 2020
Making Laparoscopic Surgery Safer Wound closure devices help guard against the challenges faced by geriatric patients. With the advent of minimally invasive surgery, medicine has been pushing the boundaries to translate procedures that are common in the elderly population from an open to a laparoscopic approach. About one-half of my surgical urology patients are older than 65. Many patients as old as their 80s present with kidney cancers and transitional cell cancers of the renal pelvis and the ureter, requiring robotic laparoscopy for partial or complete nephrectomy or a nephro-ureterectomy. Minimally invasive radical prostatectomy for prostate cancer is done robotically for many patients in their 60s and 70s. Geriatric patients also might have adrenalectomy and sacrocolpopexy, and my colleagues in general commonly perform laparoscopic colon surgeries and hernia repair. Minimally invasive surgeries have benefits for patients of all ages, but may be particularly advantageous for patients who are fragile or have other health problems. Wounds are smaller and faster to heal, so there’s less pain, and patients with diabetes or other conditions that affect wound healing can have an easier recovery. Hospital stays are shorter, and patients benefit from greater mobility after surgery. In some cases, patients spend less time under anesthesia compared with open surgery; this is beneficial for anyone with heart or respiratory problems. There’s also lower risk for major complications such as wound infection, which can take longer to resolve in older adults. Despite the myriad benefits of laparoscopic surgery, port-site closure and healing can be more challenging for older patients than they are for younger groups. This final important step in surgery can have a high degree of surgical difficulty, so there’s been significant effort to develop tools and techniques that make port-site closure both reliably effective and easier for surgeons to perform. By ensuring that wound closure in geriatric patients is consistently free from complications, surgeons can avert problems that may lead to additional surgery. Wound Closure Challenges in Geriatric Patients Diabetes is a common challenge that causes wounds to heal more slowly, with greater risk of infection. A number of older adults also have vascular problems. When patients have peripheral vascular disease and poor vasculature, it certainly impairs their wound healing. Chronic steroid use is another common challenge in geriatric patients who suffer from inflammatory conditions such as rheumatoid arthritis or lupus, who have COPD, or who have had a transplant. Although surgery for cancer typically precedes chemotherapy, neoadjuvant therapy for aggressive cancers can affect wound healing. Finally, because obesity makes port-site closure more difficult, it can add another level of complexity for patients with any of these health problems or medications. Potential Complications After laparoscopic surgery, it can be difficult for the surgeon to suture the tough, connective deep fascia tissue. If closure of that tissue is incomplete, tissues inside the abdomen pushing out against the fascia such as the intestine or omentum can herniate into the laparoscopic port site. Minor cases lead to port site pain. If we don’t see the problem early, it can present a major problem. Most concerning, intestinal herniation in the port site can result in obstruction and emergency surgery. Port-site hernias are identified either by the physician at a follow-up visit or noted by the patients themselves, who see their incision sites are bulging. It can be painful as well. Port-site hernias can happen at any time after a procedure. Some studies suggest they can occur in days to years after surgery, with a typical presentation time of nine months in some studies.1 Patients with a port-site hernia require surgery to repair it. It’s a situation that every patient, doctor, and hospital wants to avoid, and it’s especially undesirable for older patients. By having two surgeries, we add pain, risk, and recovery time, negating some of the benefits of the original minimally invasive procedure. The experience also goes a long way in negating patients’ satisfaction with surgery, no matter how successful that procedure was in meeting its primary goal. Thankfully, we’re always developing new tools and techniques to help get it right the first time. Wound Closure Options The traditional method for closure is to use a curved needle to suture the port site. We find the fascia, suture the sides together, and continue to suture until the wound is closed. This can be challenging because at times it is difficult to locate the needle if the distance between the skin and the fascia is great. In fact, understanding that locating and closing the fascia is our biggest challenge, particularly in overweight or obese patients, the industry has developed wound closure devices to aid this process. One device simplifies the suture “fishing” of the curved needle approach by capturing and holding the suture. The surgeon can simply take the suture and pull it through. This device reduces some time and frustration compared with the curved needle. Another option is a reusable cone-shaped suture guide. The suture needle is fed through the device and then pulled from the other side at the perfect angle to close the fascia and peritoneum. It takes practice to get this method right, but it’s helpful. One more recent addition is an automated suture guide that helps standardize port-site closure. Surgeons insert the device through the port site, load the suture, advance the plunger to complete the first suture, and then load and advance the plunger to create a second suture. The surgeon withdraws the suture guide and detaches and knots the suture. The process eliminates the need to find the fascia and fish for sutures. The single-user device does not require a surgical assistant to help retrieve the suture end. Because the automated guide is very reliable, it can be a welcome option when treating older adults, when health factors have the potential to compromise wound healing. The device works equally well in obese patients and it removes the user variability associated with surgeon experience in port-site closure, making reliable port-site closure accessible to more patients. Reducing the Risks Whenever Possible Thankfully, most cases are tailor-made for wound closure devices. When surgeons use an effective closure device without error, the fascia is closed tightly and hernia is avoided. With older adult patients, avoiding complications and a potential second surgery, this is a welcome approach. — Dieter Bruno, MD, FACS, is a urologist at Peninsula Urology Center in Redwood City, California, and chief medical officer at Dignity Health-Sequoia Hospital in San Francisco. He is a consultant for Medeon Biodesign, maker of the AbClose device.
Reference
COMMON CASE: OBESITY AND DIABETES The Patient: A 72-year-old patient with bladder cancer is referred for partial nephrectomy. At 5’7” and 235 lbs, he has a BMI in the obese range. He also has type 2 diabetes, controlled with insulin. The patient is eager to have the cancer removed but apprehensive about surgery. The explanation of its minimally invasive nature and relatively easy recovery help calm his anxiety. Surgery: Control of the patient’s blood sugar throughout surgery is planned in advance. The robotic partial nephrectomy proceeds without incident, using robotic cameras and arms placed laparoscopically or robotic cannulas to visualize and safely perform the partial nephrectomy. Wound Closure: A wound closure device is used to close the port site. At day one, week one, and one month, there’s no evidence of hernia. Wound healing proceeds according to expectations for someone with diabetes, and there’s no sign of infection (redness, pain, leakage of fluid, fever, or chills). Recovery and Outcomes: The patient can stand and walk in the hospital at day one. He rates his postoperative pain as high. He is prescribed narcotic pain pills for the first three to five days. The patient is discharged at five days for recovery at home. Because he has no evidence of wound infection or hernia, he can begin chemotherapy for renal cancer immediately. — DB
COMMON CASE: CHRONIC GLUCOCORTICOID STEROID USE The Patient: A 78-year-old patient with bladder prolapse is referred for sacrocolpopexy. The patient also has rheumatoid arthritis and has been taking prednisone daily for 12 years. The patient has seven children and previous unrelated minor surgeries. She expresses comfort in visiting the hospital and confidence in the procedure. Surgery: Robotic sacrocolpopexy is very straightforward and proceeds according to expectations. Wound Closure: The port site is sutured using a wound closure device. There’s no evidence of hernia or infection during any postoperative evaluations in the hospital or later in the doctor’s office. The wound takes slightly longer to heal than it would without glucocorticoid use, but the healing is complete and trouble-free. Recovery and Outcomes: At day one, the patient can stand and walk. She rates her postoperative pain as medium. Pain is treated with narcotic pain pills, with pain scale ratings monitored by the nurse. She remains at the hospital for three nights, leaving after the catheter is removed and she can urinate normally. Potential postoperative pain/weakness and use of pain medication could increase fall risk. It’s important to ensure that older adult patients are released to a caregiver for recovery. — DB |
