The String Puppet Technique: A Useful Tool for Transumbilical Surgery

Introduction: Transumbilical single-port surgery (TSPS) has emerged to outdare minimally invasive surgery by trying to obtain better aesthetic results, further reduction of morbidity, and further enhanced postoperative recovery. Nonetheless, TSPS entails many challenges. One of them is the limited triangulation of the surgical instruments, which does not contribute to proper organ retraction during surgery. This makes dissection uncomfortable and difficult for the surgeon, and tissue retraction has to be accomplished by using fixation or sling sutures instead of another trocar. The learning curve of TSPS is harsh, because experience is needed to learn to manage the external crowding and collision of instruments, select the most adequate surgical instrument set to be used, and also wisely choose the best patient candidates for this type of procedure.1 The string puppet technique described in this article and displayed in the video (run time 1 minute, 51 seconds) is a useful TSPS maneuver that helps achieve optimal organ retraction. An internal grasper is used to hold organs or tissues inside the abdominal cavity but can be moved, directed, and controlled externally through leashes, just like a puppeteer manipulates a puppet. Materials and Methods: A straight needle with a 2.0 nylon suture is introduced through the skin in the epigastric region. The needle is then externalized through a 12-mm umbilical trocar using a 10-mm scope with a 6-mm working channel. The needle is removed from the suture and the loose end of the suture is held or fixed externally to avoid sliding inside the abdominal cavity. The procedure is repeated on the right flank. Once the two loose ends of the sutures are outside of the abdomen, they are both tied up to a stainless steel alligator clamp. The grasper is placed at the tip of the laparoscope with its jaws open and descends into the abdominal cavity through the operating channel. Once inside, the grasper can be directed and secured to the target area with the aid of a Thomas forceps. The alligator clamp allows for strong organ retraction but also easy repositioning. In this video, the infundibulum is held by the grasper and external traction is provided by means of both sutures. Movement and position of the organ or tissue can be adjusted and corrected during the surgery to accommodate to the surgeon's needs. Once no longer necessary, the grasper can be withdrawn along with both sutures through the umbilical port. Results and Conclusions: One of the major difficulties of TSPS is to achieve proper organ retraction. The string puppet technique is a useful maneuver to overcome this problem and can be used in any area of the abdomen. It is easy to perform, unexpensive, and does not require any sophisticated instruments. No competing financial interests exist. Runtime of video: 1 mins 51 secs