ASSESSMENT OF PORT SITE CLOSURE OUTCOMES USING HAND SUTURING AND CARTER–THOMASON NEEDLE TECHNIQUE IN LAPAROSCOPIC PROCEDURES.

Laparoscopic surgery has revolutionized modern surgical practice by offering a minimally invasive approach associated with reduced postoperative pain, shorter hospital stays, improved cosmetic outcomes, faster recovery, and earlier return to routine activities.1 Over the past few decades, laparoscopic procedures have become the preferred approach for a wide range of abdominal and pelvic surgeries including cholecystectomy, appendicectomy, hernia repair, gynecological procedures, and diagnostic interventions. Despite the advantages of minimally invasive surgery, complications related to trocar insertion and port site closure remain clinically significant and may adversely affect postoperative outcomes.2. Port site closure is a critical step in laparoscopic surgeries, particularly for trocar sites measuring 10 mm or larger. Inadequate closure of fascial defects may lead to complications such as port site hernia, wound infection, hematoma formation, bowel entrapment, chronic pain, and poor cosmetic appearance.3,4 Port site hernia is one of the most important long-term complications and may result in bowel obstruction or strangulation requiring emergency surgical intervention. The incidence of port site hernia varies depending on trocar size, obesity, wound infection, operative duration, and the technique of fascial closure used during surgery.5

Conventional hand suturing is the most practiced method for port site closure. Although widely accepted, hand suturing can be technically challenging in obese individuals, deep abdominal walls, or difficult anatomical locations.6,7 Accurate visualization and approximation of fascial edges may be difficult, increasing the risk of incomplete closure and postoperative complications. Conventional closure techniques may also prolong operative time and require greater tissue handling, which can contribute to postoperative pain and wound-related morbidity.8. To overcome these limitations, several port closure devices and techniques have been developed to facilitate safe and effective fascial closure. Among them, the Carter–Thomason needle closure system has gained increasing popularity. The Carter–Thomason technique utilizes a specialized suture passer and guide system that enables direct visualization and secure fascial closure with minimal tissue trauma.9 The method is considered technically easier, especially in obese patients and deep trocar sites, while also reducing the risk of visceral injury and incomplete fascial approximation.10

 

The Carter–Thomason needle technique may offer several advantages over conventional hand suturing. These include shorter closure time, reduced operative difficulty, lower postoperative pain, decreased wound complications, and improved cosmetic results.11 Despite these proposed benefits, the technique is not universally adopted in routine laparoscopic practice, partly due to limited comparative studies evaluating its efficacy and safety in different patient populations. The findings may help identify a safer, technically easier, and more effective closure method that can improve patient outcomes and reduce postoperative morbidity in laparoscopic surgeries.

 

AIMS AND OBJECTIVES

•              To compare the efficacy, safety, and postoperative outcomes of hand suturing versus Carter–Thomason needle closure of port sites in laparoscopic surgeries.

This prospective comparative study was conducted in the Department of General Surgery at Sree Mookambika Institute of Medical Sciences over a period of 12 months from January 2025 to December 2025. Informed written consent from all patients willing to participate in the study. A total of 110 patients undergoing elective laparoscopic surgeries were included in the study. Patients were randomly allocated into two groups consisting of 55 patients each. Group A underwent conventional hand suturing for laparoscopic port site closure, while Group B underwent closure using the Carter–Thomason needle closure technique.

 

Patients aged between 18 and 70 years undergoing elective laparoscopic procedures such as laparoscopic cholecystectomy, appendicectomy, hernia repair, and diagnostic laparoscopy with at least one port size measuring 10 mm or more were included in the study. Both male and female patients who provided informed consent and were fit for surgery under general anesthesia were considered eligible for participation.

 

Patients with previous abdominal wall hernia, prior major abdominal surgery involving the port site region, immunocompromised status, uncontrolled diabetes mellitus, coagulopathy, severe obesity with body mass index greater than 40 kg/m², pregnancy, emergency laparoscopic procedures, conversion to open surgery, and patients unwilling to participate were excluded from the study. Patients with pre-existing wound infection or connective tissue disorders affecting wound healing were also excluded.

 

Detailed demographic data including age, sex, body mass index, comorbidities, diagnosis, and type of laparoscopic surgery performed were recorded. Preoperative clinical evaluation and routine laboratory investigations were carried out in all patients. All surgeries were performed under standard aseptic precautions and general anesthesia by experienced surgeons familiar with both closure techniques. Pneumoperitoneum was created using standard laparoscopic techniques, and trocar ports were inserted according to the surgical procedure performed.

 

In Group A, port site closure was performed by conventional hand suturing using absorbable suture material with direct fascial approximation. In Group B, closure was performed using the Carter–Thomason needle closure device under direct visualization to facilitate fascial closure with minimal tissue handling. The duration required for port site closure was recorded from insertion of the closure instrument or suture needle until completion of fascial closure. Intraoperative difficulty during closure, need for additional assistance, and accidental tissue injury were also documented.

 

Postoperative assessment included evaluation of pain using visual analog scale scores at 24 hours, wound infection, seroma formation, hematoma, port site hernia, and duration of hospital stay. Patients were followed up at regular intervals during the postoperative period for assessment of wound healing and detection of late complications such as port site hernia. Cosmetic outcome and surgeon satisfaction regarding ease of closure were also evaluated.

 

The collected data were entered into Microsoft Excel and analysed using Statistical Package for Social Sciences (SPSS) software version 25. Quantitative variables were expressed as mean and standard deviation, while qualitative variables were presented as frequency and percentage. Chi-square test and Student’s t-test were used for comparison between groups wherever appropriate. A p-value of less than 0.05 was considered statistically significant.

Majority of patients belonged to the 31–50 years age group accounting for 56 (50.9%) cases. Female predominance was observed with 64 (58.2%) patients. Both study groups were comparable with respect to age and gender distribution, and no statistically significant difference was observed (p > 0.05). (Table 1).

 

Table 1: Age and Gender Distribution of Study Participants

 

Laparoscopic cholecystectomy was the most performed procedure constituting 50 (45.5%) cases followed by laparoscopic appendicectomy in 32 (29.1%) patients. The distribution of surgical procedures was similar in both groups without statistically significant difference. (Table 2).

 

Table 2: Distribution According to Type of Laparoscopic Surgery

 

The mean duration of port site closure was significantly lower in the Carter–Thomason group compared to the hand suturing group (p < 0.001). Intraoperative difficulty and need for additional assistance were significantly more common with conventional hand suturing, indicating better technical feasibility of the Carter–Thomason technique. (Table 3).

 

Table 3: Comparison of Operative Parameters.

Postoperative wound complications were comparatively higher in the hand suturing group. Patients undergoing Carter–Thomason closure experienced significantly lower postoperative pain scores (p = 0.02), suggesting reduced tissue trauma and improved patient comfort. (Table 4)

 

Table 4: Postoperative Complications in Both Groups

 

Intraoperative difficulty increased significantly with increasing body mass index (p = 0.01). Overweight and obese patients demonstrated greater technical challenges during port site closure, particularly in the hand suturing group. (Table 5).

 

Table 5: Correlation Between BMI and Intraoperative Difficulty

 

Patients undergoing Carter–Thomason port closure had significantly shorter hospital stay compared to the hand suturing group (p = 0.02). Reduced postoperative pain and fewer wound complications may have contributed to earlier recovery and discharge. (Table 6).

 

Table 6: Correlation Between Closure Technique and Hospital Stay

 

Majority of patients in the current study belonged to the 31–50 years age group, accounting for 56 (50.9%) cases, reflecting the high utilization of laparoscopic procedures among middle-aged individuals. Female predominance was observed in 64 (58.2%) patients, largely due to the greater number of laparoscopic cholecystectomies performed in women. Similar demographic distributions have been reported by Chaudhary G et al.11 who found comparable gender, BMI, and procedure characteristics between the Carter–Thomason and hand suturing groups. Likewise, Jeon Y et al.12 observed comparable baseline characteristics while evaluating trocar-site closure techniques. In the present study, port-site closure time was significantly lower in the Carter–Thomason group (4.8 ± 1.2 minutes) compared to the hand suturing group (8.1 ± 1.7 minutes). The reduction in closure time may be attributed to easier fascial access, improved visualization, and reduced tissue manipulation. Similar findings were reported by Chaudhary G et al.11 who demonstrated significantly shorter closure times with the Carter–Thomason technique (4.37 ± 1.69 minutes) compared to hand suturing (5.20 ± 1.30 minutes). Likewise, Ranjani CM et al.13 reported a significantly shorter closure time with the Veress needle technique (4.8 ± 1.2 minutes) compared to conventional suturing (6.2 ± 1.5 minutes). Further supporting these observations, Jeon Y et al.12 found that the EZ-Close™ device significantly reduced closure time compared to hand suturing, particularly in overweight and obese patients. Similarly, del Junco M et al.14 demonstrated shorter closure times with the EFx closure system compared to the Carter–Thomason device in a cadaveric model, emphasizing the ongoing evolution of port closure techniques aimed at improving efficiency. Intraoperative difficulty was encountered less frequently in the Carter–Thomason group compared with conventional hand suturing. Difficult fascial approximation was particularly noted in overweight and obese individuals due to increased abdominal wall thickness. These findings correlate with the observations of Jeon Y et al.12 who reported that closure devices maintained procedural efficiency even in patients with higher body mass index and greater abdominal wall thickness, conditions that commonly challenge conventional closure methods.

 

Postoperative pain was comparatively lower among patients who underwent Carter–Thomason closure. Pain scores greater than 5 were observed in only 12.7% of patients in the Carter–Thomason group compared with 30.9% in the hand suturing group. Reduced tissue trauma and minimal fascial manipulation likely contributed to improved postoperative comfort. Similar findings were reported by Ranjani CM et al.13 who demonstrated significantly lower postoperative pain scores in patients undergoing device-assisted closure. Likewise, Shetty A et al.15 reported reduced postoperative discomfort with the Carter–Thomason method. Previous studies evaluating the Carter–Thomason device have also noted lower postoperative pain and improved patient satisfaction when compared with conventional suturing techniques. Wound-related complications were more frequent among patients undergoing conventional hand suturing. Wound infection occurred in 14.5% of patients in the hand suturing group compared to 5.5% in the Carter–Thomason group. Seroma formation was observed in 10.9% and 3.6% of patients respectively, while port-site hernia occurred only in the hand suturing group. These findings are consistent with the study by Chaudhary G et al.11 who reported a lower incidence of port-site infection in the Carter–Thomason group, although the difference did not reach statistical significance. Similarly, Ranjani CM et al.13 observed higher rates of wound infection and wound dehiscence in the hand suturing group. Shetty A et al.15 also concluded that Carter–Thomason closure was associated with fewer wound and bowel-related complications compared with conventional closure methods.

 

The absence of port-site hernia in the Carter–Thomason group in the present study further highlights the effectiveness of secure fascial closure. Comparable findings were reported by Chaudhary G et al.11 who observed no port-site hernias during follow-up in either study group. Long-term evidence supporting device-assisted closure has been provided by Muñoz-Leija MA et al.16 who reported lower rates of secondary surgery for port-site hernia in patients undergoing Carter–Thomason closure compared with conventional closure or non-closure techniques. Their findings reinforce the importance of meticulous fascial closure for trocar sites measuring 10 mm or greater. Hospital stay was significantly shorter among patients managed with Carter–Thomason closure. Hospital stay exceeding three days was observed in 43.6% of patients in the hand suturing group compared with only 20.0% in the Carter–Thomason group. Faster recovery, reduced pain, fewer wound complications, and earlier mobilization likely contributed to earlier discharge. Similar trends have been reported by Shetty A et al.15 who noted improved postoperative recovery and fewer complications with Carter–Thomason closure. Reduced morbidity associated with device-assisted closure techniques has consistently translated into enhanced postoperative outcomes and shorter recovery periods across several studies.

The present study concludes that the Carter–Thomason needle closure technique is a safe, effective, and efficient method for laparoscopic port site closure compared to conventional hand suturing. The technique significantly reduced port closure time, intraoperative difficulty, postoperative pain, wound complications, and duration of hospital stay. Accurate fascial approximation achieved with the Carter–Thomason method also contributed to lower incidence of port site hernia and improved postoperative recovery. Although both techniques were effective for port closure, the Carter–Thomason technique demonstrated superior overall outcomes and technical convenience. Routine use of this method may improve surgical efficiency and reduce postoperative morbidity in laparoscopic surgeries.

 

FINANCIAL SUPPORT AND SPONSORSHIP

Nil.

CONFLICTS OF INTEREST

There are no conflicts of interest.

1.       Alkatout I, Mechler U, Mettler L, Pape J, Maass N, Biebl M et al. The development of laparoscopy—a historical overview. Frontiers in surgery. 2021 Dec 15;8:799442.

2.       Gadacz TR. Update on laparoscopic cholecystectomy, including a clinical pathway. Surgical Clinics of North America. 2000 Aug 1;80(4):1127-50.

3.       Gaunay GS, Elsamra SE, Richstone L. Trocars: site selection, instrumentation, and overcoming complications. Journal of Endourology. 2016 Aug;30(8):833-43.

4.       Hamood MA. Different port closure techniques in laparoscopy surgery. World Journal of Laparoscopic surgery. 2012 Apr 1;2(3):29-38.

5.       Owens M, Barry M, Janjua AZ, Winter DC. A systematic review of laparoscopic port site hernias in gastrointestinal surgery. The surgeon. 2011 Aug 1;9(4):218-24.

6.       Shaher Z. Port closure techniques. Surgical endoscopy. 2007 Aug;21(8):1264-74.

7.       Arifuzaman M, Samreen A. Laparoscopic port closure techniques and incidence of port-site hernias: a review and recommendations. World Journal of Laparoscopic Surgery. 2018 Dec 1;11(2):90-102.

8.       Latona JA, Tannouri S, Palazzo F, Pucci MJ. Fundamentals of sutures, needles, knot tying, and suturing technique. InFundamentals of General Surgery 2018 Feb 26 (pp. 39-64). Cham: Springer International Publishing.

9.       Hamood MA. Different port closure techniques in laparoscopy surgery. World Journal of Laparoscopic surgery. 2012 Apr 1;2(3):29-38.

10.    Ng WT. A full review of port-closure techniques. Surgical endoscopy. 2007 Oct;21(10):1895-7.

11.    Chaudhary G, Vohra A, Bariya M, Garchar R, Shrimali UV, Fafal JN et al. Comparison between hand suture and carter-thomason needle closure of port sites in laparoscopy. Int J Acad Med Pharm. 2025;7(6):256-9.

12.    Jeon Y, Song S, Han KW, Lee DH, Baek JH. Evaluation of a novel trocar-site closure device in laparoscopic surgery. JSLS: Journal of the Society of Laparoscopic & Robotic Surgeons. 2020 Jul;24(3):e2020-00033.

13.    Ranjani CM, Anish P. A comparative study between hand suture and veress needle technique closure of port sites in laparoscopic surgeries. Int J Acad Med Pharm. 2026;8(1):761-5.

14.    del Junco M, Okhunov Z, Juncal S, Yoon R, Landman J. Evaluation of a novel trocar-site closure and comparison with a standard Carter-Thomason closure device. Journal of Endourology. 2014 Jul;28(7):814-8.

15.    Shetty A, Adiyat KT. Comparison between hand suture and Carter-Thomason needle closure of port sites in laparoscopy. Urology journal. 2014 Jul 1;11(4):1768.

16.    Muñoz-Leija MA, Rosales-Vázquez JG, Rosales-Pérez G, Álvarez-Valdés G. Four Techniques for Closing Laparoscopic Ports in Obese Patients. JSLS: Journal of the Society of Laparoscopic & Robotic Surgeons. 2026 Mar 17;30(1):e2025-00121.