Closing a 12 mm Umbilical Port Site in a Purulent Abdomen

Goal: close the anterior rectus sheath/fascia fully, without catching bowel, and without narrowing the umbilical ring unnecessarily.

Steps and rationale:

1. Improve exposure first. Ask for the laparoscope to be redirected to view the underside of the defect from inside - this is the single best protection against needle-stick injury to bowel and against an inadequate bite. If the surgeon cannot oblige immediately, do not place blind deep bites.
2. Identify the layers. Skin, Scarpa's fascia, anterior rectus sheath. The 12 mm defect is a fascial defect; the peritoneum/transversalis does not require separate closure.
3. Grasp and elevate the fascia with two Kocher or Allis clamps so the needle is driven away from underlying viscera.
4. Suture choice: a slowly absorbable suture of adequate caliber (e.g., 0 polyglactin or 0 polydioxanone) on a large curved needle, placed as a figure-of-eight or as two to three interrupted simple sutures, taking generous bites (~1 cm from the edge) with a bite-to-bite ratio near 1:1.
5. Close the defect completely but do not strangulate tissue; the hernia risk persists for the life of the patient, and 10-12 mm port sites are the classic source of trocar-site hernias.
6. Account for the needle with the circulator before moving to skin.

Reasoning principle: the failure mode here is not a bad knot, it is a blind deep bite and an inadequate fascial bite - both preventable by getting the fascial edges under direct vision.

Classification: Class III - contaminated (acute, non-purulent versus purulent distinction matters at the margin, but perforated appendicitis with gross purulent fluid is contaminated at minimum, and frank pus with perforation is often classed as dirty/infected).

What that means for the umbilical skin:

• Primary skin closure over a contaminated port site raises the risk of superficial SSI, which in a 12 mm umbilical site can progress to a fascial problem. Common practice is to leave the subcutaneous tissue and skin open to heal by secondary intention, or to place a loose wick/loop, or to approximate loosely - institutional and surgeon preference varies and the evidence is not unanimous.
• The fascia is still closed regardless of the skin decision. Contamination is a reason to change how the skin is managed, not to leave a fascial defect.

The CSFA's role: the skin-closure decision belongs to the surgeon. Your obligation is to state the classification out loud ("this is contaminated - do you want the skin closed or left open?"), get an explicit answer, and document what was done and by whom. Silently closing the skin and saying nothing is the error.

Also flag: irrigation volume and any topical antibiotic use, drain placement, and whether the specimen went for culture - all affect the postoperative wound plan.

Document (surgeon's record, with your documentation consistent with it):

• Wound classification (Class III/contaminated) and the source of contamination.
• Port site locations and sizes; which fascia were closed; suture material and technique; who closed them.
• The skin closure decision and rationale (e.g., "umbilical skin left open to heal by secondary intention given purulent contamination").
• Drains, if any, type and output at close.
• Dressings applied and any packing.
• Final counts correct, including the suture needles used for fascial closure.
• Specimens and cultures sent.

Hand off verbally to the receiving nurse/team: the umbilical wound is open (or loosely closed), what dressing is on it, when it should next be checked, signs to report (increasing pain, spreading erythema, purulent drainage, fever), and that the patient should be told in plain language what to expect from a wound healing by secondary intention.

Reasoning principle: a contaminated wound that is managed well intraoperatively can still fail postoperatively if the next team does not know what was left open and why.