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Aim of the studyLiver retraction during laparoscopic fundoplication is important for obtaining an optimal space. Several methods have been developed, but the risks and benefits are unclear. We compared three different approaches and evaluated their safety and utility.MethodsForty-three neurologically impaired patients who underwent laparoscopic fundoplication between 2005 and 2018 were classified into three groups: A, snake retractor method, n = 18; B, crural suture method, n = 13; C, needle grasper method, n = 12. Patients’ characteristics and outcomes were reviewed.Main resultsThe liver retraction time was significantly shorter in group C than in A or B (p < 0.05). The operative times were shorter in groups B and C than in A. There were no significant differences in the liver enzyme levels. The liver enzyme levels increased temporarily but improved within a week. The C-reactive protein levels were significantly lower in group B than in A or C (p < 0.05).ConclusionsThe most convenient method was the needle grasper method, as the other two approaches create conflict with the operator’s forceps. The crural suture method damages the liver less, but requires higher surgical skill levels. It is important to select the appropriate method according to the operator’s skill and the patient’s size and deformity.

Port site herniation is one of the serious complications of laparoscopic surgery, which decreases its benefits. Closure of a fascia defect at the port site is an important problem of laparoscopic surgery, especially in obese patients. To evaluate needle grasper fascia closure. We closed the port site fascia using a percutaneous organ-holding device (needle grasper) in laparoscopic cholecystectomy patients. This study included 334 patients who underwent laparoscopic cholecystectomy between January 2015 and January 2017 in our hospital. Patients were divided into 2 fascia closure groups: group 1 with a standard simple suturing technique and group 2 with a needle grasper to close the port site. Patient demographics, operative details, and postoperative outcomes were collected and evaluated. There were 243 female and 91 male (total 334) patients with the mean age of 49.18 ±13.15 years. Only 1 patient in the BMI > 30 kg/m group of patients had port site hernia development with the needle grasper technique at the end of the 8-month follow-up period. The port site hernia incidence was higher in group 1 than group 2 (p < 0.001), but there was no significant difference in terms of operation duration between the two groups (p < 0.001, p = 0.709, respectively). In patients with a BMI > 30 kg/m , both operation duration and port site hernia incidence were higher in simple suture closure than in the needle grasper technique (p < 0.001, p = 0.016, p = 0.005). The needle grasper technique is easy, simple, safe, fast, and effective for fascia closure of port sites. This method can also be applied in obese patients easily, safely and in a short time.

The two-port laparoscopic appendectomy technique (TPLA) lays between the conventional three-port trocar procedure and single-port laparoscopic appendectomy surgery. During TPLA, the appendix is suspended with stitches, resulting in perforation risk and difficulty in exploration. We used a needle grasper in TPLA to hang and manipulate the appendix. Thirty-four patients (10 female, 24 male) who underwent TPLA between February 2015 and November 2015 were analyzed retrospectively for patient demographics, duration of operation, laparotomy or conventional laparoscopy necessity, drain use, complications, and hospital stay periods. The needle grasper was inserted at the right under the abdominal quadrant (McBurney point) without an incision to hang and manipulate the appendix. The mean age was 25.19 ±8.464 years; the mean body mass index (BMI) was 23.50 ±3.246 kg/m(2). ASA scores were 1 and 2. The operations were completed without any additional trocar in 34 patients. The mean operation time was 57.03 ±3.814 min. There were no intraoperative complications in any patients. Three patients required a drain; all were discharged after drain removal. Thirty-one patients were discharged on the 1(st) postoperative day; three patients with drains were discharged on the 2(nd) day. The mean hospital stay period was 1.18 ±0.535 days. Using the needle grasper, the appendix was held and suspended and the mesoappendix was cauterized and skeletonized successfully in TPLA. Inserting a needle grasper into the abdominal cavity at the McBurney point to manipulate the appendix helps and does not leave a visible scar.

During single-incision laparoscopic cholecystectomy (SILC), the gallbladder is suspended with stitches, resulting in perforation risk and difficulty in exploration. We used the needle grasper in SILC to hang and manipulate the gallbladder. Sixty-five patients (43 female, 22 male) who underwent SILC between December 2013 and December 2014 were analyzed retrospectively for patient demographics, duration of operation, laparotomy or conventional laparoscopy necessity, drain use, complications, and hospital stay periods. To place the SILC port (Covidien, Inc.), the needle grasper was inserted at the right upper abdominal quadrant without an incision to hang and manipulate the gall-bladder. The mean age was 47.9 ±13.068 years; the mean body mass index (BMI) was 26.94 ±3.913 kg/m . ASA scores were 1, 2, and 3. Two patients with high BMI with additional trocar use were excluded. The operations were completed without any additional trocar in 59 patients. The mean operation time was 89 ±22.41 min. Eighteen patients required a drain; all were discharged after drain removal. One patient needed re-hospitalization and percutaneous drainage and was discharged on the 9 day. Fifty-three patients were discharged on the 1 post-operative day. Eleven patients with drains were discharged on the 2 day, and 1 was discharged on the 7 day. The mean hospital stay period was 1.26 ±0.815 days. The main difficulty of SILC is to manipulate hand tools because the triangulation principle of laparoscopy use is not possible in SILC. Inserting a needle grasper into the abdominal cavity at the right subcostal area to manipulate the gallbladder helps and does not leave a visible scar.

Surgical needles are usually held using dedicated grasping instruments. When the tissue to be penetrated is resilient, or the grasping force is low, the needle can swivel, causing it to deviate from the intended path, resulting in suboptimal tissue approximation. Needle swivel is particularly prevalent when needles are not held transversely in the jaws, but it is difficult to maintain a transverse grasp during surgery. An improved swivel-resistant grasper design is proposed. Conventional and swivel-resistant graspers were tested to quantify the benefits of the swivel-resistant design. Needles secured in the grasper were repeatedly distracted until swiveling occurred. The torque required to swivel the needles was statistically analyzed. The swivel-resistant grasper offers greatly improved resistance to swivel (p = 0.01) when the needle is not held transversely. The four-point contact afforded by the modified needle graspers imparts improved needle retention and resistance to swivel.

The search for tiny bits of broken pediatric minimal access surgery (MAS) instruments in an operative field is akin to the search for a needle in a haystack. With the extension of MAS to the pediatric age group, instruments are becoming smaller and equitably more prone to breakage. When breakages occur, retrieval, especially in the pediatric abdominal cavity, can be challenging. Inability to do so would affect patient safety and also lead to a web of medico legal and ethical issues. We present two cases of intraoperative breakage: An eyeless 3-0 polyamide suture needle and a 2-mm grasper blade both of which were successfully retrieved and fortuitously escaped becoming retained surgical items.