VersaStepTM trocar hernia rate in unclosed fascial defects in bariatric patients

Effect of Fascial Closure versus Non-fascial Closure on Developing Trocar Site Hernias (TsH) in the Bariatric Population: A Systematic Review

BACKGROUND

Trocar site hernia (TsH) is an uncommon complication of bariatric surgery but potentially serious. People with obesity are more susceptible due to the difficulty in approximating fascial tissue. This study aims to investigate whether fascial closure (FC) or non-fascial closure (NFC) of trocar sites, in patients undergoing bariatric surgery, will affect the incidence of TsH.

METHODS

A systematic review was conducted from July to September of 2023 and registered on Prospero 2023 CRD42023403504. The study included articles of patients who underwent bariatric surgery describing the trocar site closure technique and incidence of TsH. The exclusion criteria involved procedures using a single port, natural orifice, open, or robotic techniques. Search engines included PubMed, Medline, Scopus, and ClinicalTrials. Data collection was conducted by authors independently and disagreements were resolved as per consensus.

RESULTS

Out of 1433 studies that were screened, 14 cohort studies consisting of 6143 participants met the eligibility criteria. Out of the 14 studies, three compared the development of TsH between the FC and NFC groups. Two of the three reported a significantly increased incidence of TsH in the NFC group (p = 0.02, p < 0.05), whereas the remaining article reported no significant difference in incidence between the two groups. The incidence of TsH in patients undergoing FC was found to be between 0 and 11.5% by five studies consisting of 1583 patients, whereas the incidence in patients undergoing NFC was found to be between 0 and 1.6% by another set of five studies comprising 2592 patients. The study's main limitations were data heterogeneity and lack of adequate comparative literature.

CONCLUSIONS

Comparative and non-comparative studies investigating the incidence of TsH between FC and NFC groups revealed contradictory results. Therefore, this systematic review showed non-conclusive results and further comparative studies must be conducted with more statistical evidence to formally declare an association.

American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass

BACKGROUND

Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB).

OBJECTIVE

This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU).

METHODS

PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee.

RESULTS

Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures.

CONCLUSIONS

This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.

Bladed and bladeless conical trocars do not differ in terms of caused fascial defect size in a Porcine Model

INTRODUCTION

Trocar insertion during laparoscopy may lead to complications such as bleeding, bowel puncture and fascial defects with subsequent trocar site hernias. It is under discussion whether there is a difference in the extent of the trauma and thus in the size of the fascia defect between blunt and sharp trocars. But the level of evidence is low. Hence, we performed a Porcine Model.

METHODS

A total of five euthanized female pigs were operated on. The average weight of the animals was 37.85 (Standard deviation SD 1.68) kg. All pigs were aged 90 ± 5 days. In alternating order five different conical 12-mm trocars (3 × bladeless, 2 × bladed) on each side 4 cm lateral of the mammary ridge were placed. One surgeon performed the insertions after conducting a pneumoperitoneum with 12 mmHg using a Verres' needle. The trocars were removed after 60 min. Subsequently, photo imaging took place. Using the GSA Image Analyser (v3.9.6) the respective abdominal wall defect size was measured.

RESULTS

The mean fascial defect size was 58.3 (SD 20.2) mm2. Bladed and bladeless trocars did not significant differ in terms of caused fascial defect size [bladed, 56.6 (SD 20) mm2 vs. bladeless, 59.5 (SD 20.6) mm2, p = 0.7]. Without significance the insertion of bladeless trocars led to the largest (Kii Fios™ First entry, APPLIEDMEDICAL©, 69.3 mm2) and smallest defect size (VersaOne™ (COVIDIEN©, 54.1 mm2).

CONCLUSION

Bladed and bladeless conical 12-mm trocars do not differ in terms of caused fascial defect size in the Porcine Model at hand. The occurrence of a trocar site hernia might be largely independent from trocar design.

Chronic abdominal pain after bariatric surgery: a narrative review

Objective: This paper reviews the prevalence, etiology, risk factors, diagnosis and prevention of chronic abdominal pain after bariatric surgery. Introduction: Chronic pain is a very common and complex problem that has serious consequences on individuals and society. It frequently presents as a result of a disease or an injury. Obesity and obesity-related comorbidities are a major health problem and are dramatically increasing year after year. Dieting and physical exercise show disappointing results in the treatment of obesity. Therefore, bariatric surgery is increasingly widely offered as a weight reducing strategy. In our pain clinic we see a lot of patients who suffer from chronic abdominal pain after bariatric surgery. This review aims to explore the link between chronic abdominal pain and bariatric surgery in this specific type of patients. Method: The review is based on searches in PubMed, Embase and Cochrane databases. Keywords are used in different combinations. We did a cross-reference of the articles included. Results: Chronic abdominal pain after bariatric surgery is very common. Around 30% of the bariatric patients experience persistent abdominal pain. An explanation for the abdominal pain is found in 2/3 of these patients. There is a wide variety of causes including behavioral and nutritional disorders, functional motility disorders, biliary disorders, marginal ulceration and internal hernia. Another, frequently overlooked, cause is abdominal wall pain. Unexplained abdominal pain after bariatric surgery is present in 1/3 of the patients with persistent abdominal pain. More studies are needed on the risk factors and prevention of unexplained abdominal pain in bariatric patients.

Trocar-site hernia following laparoscopic salpingo-oophorectomy in a middle-aged Japanese woman: an initial case report after 40 years of experience at a single center and a brief literature review

Background

In gynecology, the number of laparoscopic surgeries performed has increased annually because laparoscopic surgery presents a greater number of advantages from a cosmetic perspective and allows for a less invasive approach than laparotomy. Trocar site hernia (TSH) is a unique complication that causes severe small bowel obstruction and requires emergency surgery. Its use has mainly been reported with respect to gastrointestinal laparoscopy, such as for cholecystectomy. Contrastingly, there have been few reports on gynecologic laparoscopy because common laparoscopic surgeries, such as laparoscopic salpingo-oophorectomy, are considered low risk due to shorter operative times. In this study, we report on a case of a woman who developed a TSH 5 days postoperatively following a minimally invasive laparoscopic surgery that was completed in 34 min.

Case presentation

A 41-year-old woman who had undergone laparoscopic salpingo-oophorectomy 5 days previously presented with the following features of intestinal obstruction: persistent abdominal pain, vomiting, and inability to pass stool or flatus. A computed tomography scan of her abdomen demonstrated a collapsed small bowel loop that was protruding through the lateral 12-mm port. Emergency surgery confirmed the diagnosis of TSH. The herniated bowel loop was gently replaced onto the pelvic floor and the patient did not require bowel resection. After the surgical procedure, the fascial defect at the lateral port site was closed using 2-0 Vicryl sutures. On the tenth postoperative day, the patient was discharged with no symptom recurrence.

Conclusions

The TSH initially presented following laparoscopic salpingo-oophorectomy; however, the patient did not have common risk factors such as obesity, older age, wound infection, diabetes, and prolonged operative time. There was a possibility that the TSH was caused by excessive manipulation during the tissue removal through the lateral 12-mm port. Thereafter, the peritoneum around the lateral 12-mm port was closed to prevent the hernia, although a consensus around the approach to closure of the port site fascia had not yet been reached. This case demonstrated that significant attention should be paid to the possibility of patients developing TSH. This will ensure the prevention of severe problems through early detection and treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01528-6.

INCISIONAL HERNIA AFTER BARIATRIC SURGERY: ONLY THE PHYSICAL EXAMINATION IS ENOUGH?

BACKGROUND:

Incisional hernia is characterized by a bulging of the abdominal wall caused by the prolapse of intracavitary structures, such as a segment of the small intestine, through the trocar orifice. Ultrasonography and physical examination are used in the diagnosis of incisional hernia.

AIMS:

This study aimed to evaluate the difference between physical examination and abdominal ultrasonography at the diagnosis of incisional hernia in patients who underwent laparoscopic bariatric surgery.

METHODS:

A total of 123 patients who underwent Roux-en-Y gastric bypass type bariatric surgery performed by laparoscopy were analyzed for the presence or absence of hernia by physical and ultrasonography examination at each trocar incision site.

RESULTS:

In our results, a total of 7 hernias were detected by physical examination, while ultrasonography detected a total of 56 hernias in at least one of the incision sites. Lin's concordance analysis showed that the tests are not concordant. The association between body mass index and hernia detection (p=0.04 for physical examination and p=0.052 for ultrasonography) was observed. Ultrasonography detected more incisional hernias in 10-mm or larger trocars than in 5-mm trocars (p<0.0001, p<0.05). No differences were noted among the trocar types that were used.

CONCLUSIONS:

Abdominal ultrasonography showed to have a higher accuracy than physical examination, resulting in a substantial increase in incisional hernia detection at the trocar sites.

Incisional hernia after 2498 single-port access (SPA) gynecologic surgery over a 10-year period

The present study was conducted to report the perioperative outcomes of single-port access (SPA) laparoscopic gynecologic surgeries with focus on the incidence of postoperative incisional hernia from our cumulative data of 2498 patients. A retrospective review was performed on the women who had received SPA surgeries from 2008 to 2018. Patient characteristics and perioperative outcomes including the incidence of postoperative incisional hernia were analyzed. There were 2498 Korean patients who received SPA surgeries for various gynecologic diseases. The median age of the patients was 40.3 ± 9.2 years, and the mean body mass index (BMI) was 22.6 ± 3.2 kg/m². A total of 3 postoperative incisional hernia occurred during the study period. Two patients whose fascial layers were closed in running sutures developed hernias 6 and 8 months after their operations. One patient whose fascial layers were closed in interrupted sutures developed hernia 11 months after her operation. The incidence of postoperative incisional hernia following SPA surgery is low in Asian women whose BMI is relatively lower than other patient populations. Interrupted suture technique may reduce postoperative incisional hernia by providing a distinct visualization of fascial layers during closure. Detailed descriptions of our surgical techniques of closing the port incision are provided.

Does closure of fascia, type, and location of trocar influence occurrence of port site hernias? A literature review

BACKGROUND

Since the introduction of laparoscopic surgery, it has become more popular with many advantages over open surgery including faster recovery, shorter hospital stays, and decreased tissue trauma. Despite its benefits, laparoscopic surgery can result in its own unique complications, such as the formation of a trocar site hernia (TSH), which have been reported in approximately 0-1.0% of laparoscopic cases when using non-bladed trocars.

METHODS

A literature review was performed from June 1990 to June 2019. PubMed was searched using the keywords "laparoscopic surgery," "trocar site hernia," and "port site hernia." Only articles in English were identified but not limited to the USA.

RESULTS

The total number of patients in all articles was 18,533 with a mean follow-up period of 22.50 ± 1.76 months. The overall trocar site hernia rate was 0.104%. When comparing open vs. closed ports, there was no significant difference in the hernia incidence rate for 5-mm and 10-mm ports. When comparing bladed versus non-bladed trocars left open, there was a statistically significant difference with lower hernia incidence rates for non-bladed trocars over bladed trocars for 5-mm, 10-mm, and 12-mm ports. And when comparing trocar location from midline versus off-midline, there was a statistically significant higher TSH incidence in midline trocar locations.

CONCLUSION

Results suggest that TSH rate is lower when using non-bladed trocars for any size of trocar. When comparing whether fascial closure had an effect, the 5-mm and 10-mm ports had no difference in incidence rates and leaving the fascia open can reduce operative time, risk of needlestick injuries, and overall procedural cost. In addition, trocars at midline locations resulted in higher TSH incidence rates. Future research is still needed to assess for other factors that may influence hernia formation and how it can be minimized.

Trocar Site Hernias in Bariatric Surgery-an Underestimated Issue: a Qualitative Systematic Review and Meta-Analysis

The reported incidence of trocar site hernias in bariatric surgery ranges between 0.5 and 3%. The best available evidence derives from retrospective studies analysing prospective databases, thus including only patients who presented with symptoms or received surgical treatment due to trocar site hernias after a laparoscopic bariatric procedure. A systematic literature research was conducted up until September 2017. Search strategies included proper combinations of the MeSH terms 'laparoscopy' and 'bariatric surgery', 'trocar/port' and 'hernia'. Searches were not limited by publication type or language. The review was registered in PROSPERO (ID 85102) and performed according to the PRISMA guidelines. Sixty-eight publications were included. Pooled hernia incidence was 3.22 (range 0-39.3%). Thirteen trials reported systematic closure of the fascia; 12 trials reported no closure. Data availability did not allow for pooling to calculate relative risk. Higher BMI and specific hernia examination using imaging modalities were associated with a significantly higher incidence of trocar site hernias. Studies dedicated to detection of TsH reported a pooled incidence of 24.5%. Trocar site hernias are an underestimated complication of minimally invasive multiportal bariatric surgery. While high-quality trials are not available allowing for a precise calculation of the incidence, existing data are indicative of very high incidence rates. Risk factors for developing a trocar site hernia in bariatric surgery have not yet been systematically analysed. Prospective studies in this field are necessary.

Severe bowel incarceration in an eight-millimeter left-lateral trocar site after robot-assisted laparoscopic colposacropexy: A case report

Over the last twenty years, robotic surgery has become an increasingly important form of surgical intervention. However, it can have complications. Trocar site hernia (TSH), also known as port site hernia (PSH), is an uncommon complication, but in the case of bowel incarceration or strangulation it can cause significant morbidity. The lateral trocar sites usually do not need fascial closure, given their low susceptibility to hernia development. In this paper, we present a rare case of an incarcerated TSH from an 8 mm left lateral port after robotic colposacropexy. The patient was a 74-year-old woman with fourth-degree vaginal vault prolapse. She underwent robot-assisted colposacropexy and adnexectomy and was eventually discharged 3 days after surgery, with flatus. A few hours later, the woman developed generalized malaise and acute abdominal pain in the lower left quadrant, with no flatus or bowel movements. CT imaging revealed a small bowel dilatation with a transition point along the left lateral 8 mm trocar site. Laparotomy confirmed an incarcerated ischemic small bowel loop. This required a surgical 40 cm small bowel resection. Although uncommon, TSH is an important clinical entity to recognize after minimally invasive surgery. While it is known that a trocar site port of 10 mm or more does require fascial closure, it is not known whether the same is true of lateral 8 mm sites. Further studies are needed to reconsider the importance of lateral trocar site port fascial closure after robot-assisted surgery.

Long-term follow-up after single-incision laparoscopic surgery

BACKGROUND

Single-incision laparoscopic surgery (SILS) is growing in popularity. The increased diameter of the umbilical incision might raise questions about the possibility of a greater risk of postoperative incisional hernia in comparison to conventional laparoscopy. This study aims to disclose the frequency of incisional hernia after SILS in long-term follow-up as well as to reveal the factors predisposing patients to this feared complication.

METHODS

The patient collective consists of cholecystectomy and appendectomy patients, who were operated on using SILS technique. Follow-up was achieved through letter correspondence, telephone interview, and clinical examination. Effects of demographic variables and operative parameters including age, sex, BMI, ASA score, duration of surgery, pre-existing hernia as well as postoperative incidence of incisional hernia were investigated using univariate and multivariate analyses.

RESULTS

A total of 286 cases with complete follow-up were included in the analyses. Mean follow-up duration was 58.4 months. 192 patients (67.1%) underwent cholecystectomy; 94 (32.9%) had an appendectomy. The study collective consisted of 218 women (76.2%) and 68 men (23.8%). Mean age at the date of the operation was 38.5 (median 36, range 13-74). In 5 cases (1.7%), the surgical approach was converted into conventional laparoscopy. Intraoperative complication rate was 0.3% and postoperative complication rate was 5.9%. 7 patients (2.4%) developed an incisional hernia. Obese patients had an incisional hernia incidence of 10.9%. 3 out of 19 patients (15.8%) with a pre-existing umbilical hernia developed an incisional hernia during follow-up. Obesity and pre-existing umbilical hernia proved to have a significant association with incisional hernia incidence in univariate and multivariate analyses. Sex, age, procedure (appendectomy vs cholecystectomy), presence of acute inflammation, and duration of surgery did not show a statistically significant association with incisional hernia.

CONCLUSION

Detection of incisional hernia necessitates a long follow-up duration. Obesity and pre-existing umbilical hernia are associated with a higher incidence of this complication. Following a careful patient selection, SILS offers a safe approach for cholecystectomy and appendectomy procedures.

Trocar site hernia following laparoscopic cholecystectomy: a 10-year single center experience

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard of treatment for patients with symptomatic cholelithiasis. Compared to open cholecystectomy, LC is associated with significantly lower postoperative complications. Trocar site hernia (TSH) is an uncommon, but potentially dangerous, complication of LC. The aim of this study was to evaluate the incidence of TSH following LC.

METHODS

The records of all patients who underwent elective LC between January 2004 and December 2013 were retrospectively reviewed. The open technique with a vertical incision infraumbilically was used to establish pneumoperitoneum. Two or three other skin incisions were made and trocars were inserted. In all cases, only the fascia at the site of infra-umbilical incision was closed. Following hospital discharge, all patients were regularly re-examined 1, 4 and 52 weeks postoperatively and were contacted by phone during November-December 2015. Based on the findings from clinical and telephone follow-ups, the incidence of TSH was recorded. Using univariate/multivariate analysis, we investigated several variables to identify risk factors for TSH development.

RESULTS

During the study period, 1172 patients were eligible and included in the final analysis. Seven patients (0.6%) presented TSH at 1-year follow-up. At the end of the study and with a mean follow-up of 65.86 ± 25.19 months, 11 patients (0.94%) presented TSH. Interestingly, all TSHs were developed at the infra-umbilical site. Multivariate analysis identified obesity as an independent risk factor for TSH.

CONCLUSION

The incidence of TSH following LC is considerably low. Obesity is an independent risk factor for TSH development, while closure of fascial incision of 10 mm below the xiphoid is not justified.

Incidence of Port-Site Hernias: A Survey and Literature Review

BACKGROUND

The impact of laparoscopy on the prevalence of incisional hernias remains unclear. The aim of this study is to determine (1) surgeon perceptions of port-site hernias (PSHs), (2) the true incidence of PSH.

MATERIALS AND METHODS

A survey on PSH was given to determine the surgeon-reported rate of PSH. A literature review was performed for studies with a primary outcome of PSH. Studies were evaluated using checklists, and scores were used to compare risk of bias. Risk of bias was graphed against PSH incidence.

RESULTS

From 38 surgeons surveyed, the surgeon perceived rate of PSH was a median (range) of 0.5% (0% to 5%) for ports ≤5 mm, 5% (0.1% to 20%) for ports extended, and 5% (0.1% to 40%) for ports ≥10 mm. Thirty studies showed a PSH rate from 0% to 39.3%. Higher quality studies reported higher rates of PSH.

CONCLUSIONS

Surgeons underestimate the incidence of PSH, but high-quality literature suggests that it may be nearly 40%.

Retrospective single-surgeon study of outcomes after laparoendoscopic single-site cholecystectomy and sigmoidectomy

PURPOSE

Laparoendoscopic single-site (LESS) surgery is performed through a single port but requires a larger incision than conventional laparoscopy, which theoretically increases the risk of laparoscopic port hernia. Our primary objective is to determine the trocar site hernia rate among our patients.

METHODS

This retrospective study is based on the analysis of demographic, intraoperative, and postoperative data of 219 patients who underwent cholecystectomy or sigmoidectomy by LESS surgery between December 1st, 2009 and November 30th, 2012.

RESULTS

Cholecystectomy and sigmoidectomy LESS surgery were performed on 190 and 29 patients, respectively. Three patients developed a trocar site hernia within a median follow-up time of 34.7 months. Eleven patients were obese, 20 had a history of abdominal surgery, and 20 had a preoperative umbilical hernia but none of them developed a trocar site hernia, neither did the 11 subsequently pregnant women. Significant association was found between preoperative umbilical hernia and early complications including incisional cellulitis and hematoma.

CONCLUSIONS

A rate of 1.4% of trocar site hernia was observed in our study population. This rate is similar to the one reported after conventional laparoscopy. Peri-umbilical incision, longer than that with conventional laparoscopy, allowed better preexisting hernia handling, made anatomical closing easier among obese patients, and facilitated specimen extraction thus limiting traumatic operations.

Subcutaneous placement of lap band port without fascial fixation provides safe and durable access

BACKGROUND

Laparoscopic adjustable gastric band access port has been routinely sutured to the anterior fascia of the abdominal wall using nonabsorbable sutures. We present our technique demonstrating that nonfascial fixation with using a mesh allows for a safe and durable placement of the port in the superficial subcutaneous tissue.

METHODS

Retrospective chart review included 102 consecutive patients who had Lap band surgery performed by single surgeon (EA) from June 2011 until April 2013. The port was sutured to a piece of polypropylene mesh and tunneled in the subcutaneous tissue away from the incision. Patients' demographics were analyzed as well as the following parameters: OR time for port placement, follow-up, port complications requiring revision, difficult access facilitated by fluoroscopy imaging, port infection, and skin erosion.

RESULTS

The study included 102 consecutive patients (23 males and 79 females), mean age was 49 years old, mean weight was 284.7 lb, mean height was 66.2 in., and mean body mass index (BMI) was 46.3 kg/m(2). The average operative time for port placement was 4 min, mean follow-up was 12 months, port complications occurred in 2 % of the patients while fluoroscopy for difficult port access was required in 3 %. No cases of port infections or skin erosions occurred.

CONCLUSIONS

Superficial subcutaneous placement of Lap Band Port using mesh fixation without anchoring the port to the fascia provides safe and durable access. Deep incisions to secure the port directly to the fascia might not be necessary.

Evaluating the Effect of Drain Site on Abdominal Pain after Laparoscopic Gastric Bypass Surgery for Morbid Obesity: A Randomized Controlled Trial

Background: Most morbidly obese patients complain of abdominal pain after laparoscopic gastric bypass (LGBP) surgery. In this study, the relationship between the prevalence and severity of pain and the drain site was assessed. Methods: Fifty morbidly obese patients undergoing LGBP surgery were selected, and a drain was randomly inserted postoperatively to the left 5 mm port in 25 cases and to the right in the other 25. All patients filled out a questionnaire, including a visual analog scale for the quality and quantity of pain, exacerbating and alleviating factors and its relation to patient's positioning, in the first 24 hours, first week, and first month after the operation. Result: In both groups, all patients had abdominal pain 24 hours after the operation. However, in the right-sided drain group, most patients (52%) experienced mild pain, whereas most patients (56%) in the left-sided drain group had severe pain (p=0.028). At weeks 1 and 4, there was no significant difference between the two groups in terms of severity of pain (p=0.068 and 0.875, respectively, for both times). After the first 24 hours and first week, the mean pain score was significantly lower in the right-sited drain group compared to the left-sited drain group (p=0.012 and 0.006). Conclusion: Early abdominal pain after LGBP surgery is significantly reduced in the right-sided drain group.

Common postoperative findings unique to laparoscopic surgery

The interpretation of images obtained in patients who have recently undergone abdominal or pelvic surgery is challenging, in part because procedures that were previously performed with open surgical techniques are increasingly being performed with minimally invasive (laparoscopic) techniques. Thus, it is important to be familiar with the normal approach used for laparoscopic surgeries. The authors describe the indications for various laparoscopic surgical procedures (eg, cholecystectomy, appendectomy, hernia repair) as well as normal postoperative findings. For example, port site hernias are more commonly encountered in patients with trocar sites greater than 10 mm and occur at classic entry sites (eg, the periumbilical region). Similarly, preperitoneal air can be encountered postoperatively, often secondary to trocar dislodgement during difficult entry or positioning. In addition, intraperitoneal placement of mesh during commonly performed ventral or incisional hernia repairs typically leads to postoperative seroma formation. Familiarity with normal findings after commonly performed laparoscopic surgical procedures in the abdomen and pelvis allows accurate diagnosis of common complications and avoidance of diagnostic pitfalls.

Potential risk of port-site adhesions in patients after laparoscopic myomectomy using radially expanding trocars

OBJECTIVE

To investigate the incidence of port-site adhesions following use of radially expanding trocars (RETs) at laparoscopic myomectomy by observation via second-look laparoscopy (SLL).

METHODS

In a retrospective study, data from patients who underwent SLL after laparoscopic myomectomy between January 2007 and June 2012 at Juntendo University Hospital, Tokyo, were assessed for the incidence of port-site adhesions forming below RET incisional scars when fascial and peritoneal defects had not been closed.

RESULTS

During the study period, 554 patients underwent SLL, and 2176 incisional scars were examined. Adhesions were detected in 15 patients (2.8%); thus, the incidence of port-site adhesions under scars was 0.7% (15/2176). Among these 15 patients, the wounds with adhesions were located as follows: 6 (1.1%) under the umbilical scar, 5 (0.9%) under the right lower abdominal scar, 2 (0.4%) under the left upper abdominal scar, and 2 (0.4%) under the left lower abdominal scar. According to multiple regression analysis, the duration of laparoscopic myomectomy was positively associated with port-site adhesions (odds ratio, 1.79; 95% confidence interval, 1.09-2.94; P=0.02).

CONCLUSION

The present data suggest that the incidence of port-site hernias and adhesions under RET incisional scars is low despite the non-closure of fascial and peritoneal defects.

Wound complications following laparoscopic surgery in a nigerian hospital

Background:

Different complications may occur at laparoscopic port sites. The incidence of these varies with the size of the ports and the types of procedure performed through them.

Objectives:

The aim was to observe the rate and types of complications attending laparoscopic port wounds and to identify risk factors for their occurrence.

Patients and Methods:

This is a prospective descriptive study of all patients who had laparoscopic operations in one general surgery unit of a University Teaching Hospital in Nigeria between January 2009 and December 2012.

Results:

A total of 236 (155 female and 81 male) patients were included. The laparoscopic procedures include 63 cholecystectomies, 49 appendectomies, 62 diagnostic, biopsy and staging procedures, 22 adhesiolyses, six colonic surgeries, eight hernia repairs and 22 others. Port site complications occurred in 18 (2.8%) ports on 16 (6.8%) patients including port site infections in 12 (5.1%) and hypertrophic scars in 4 (1.7%) patients, while one patient each had port site bleeding and port site metastasis. Nine of 11 infections were superficial, while eight involved the umbilical port wound.

Conclusion:

Port site complications are few following laparoscopic surgeries in our setting. We advocate increased adoption of laparoscopic surgeries in Nigeria to reduce wound complications that commonly follow conventional open surgeries.

Trocar site hernias from using bladeless trocars: should fascial closure be performed?

Laparoscopic surgery is the modality of choice in the surgical treatment of colorectal malignancies. The reported incidence of trocar site hernias is 0.65–2.80% with conventional cutting-tip trocars, and this risk increases with the diameter of the trocar. Newer bladeless, blunt-tipped trocars effectively mitigate this risk, and routine fascial closure has been generally deemed unnecessary. We present two cases of trocar site hernias despite the use of bladeless trocars in laparoscopic colorectal surgery, challenging the conventional wisdom of leaving such fascial defects open.

Functional abdominal pain syndrome in morbidly obese patients following laparoscopic gastric bypass surgery

Background:

Roux-en-Y gastric bypass surgery (RYGBP) is one of the most common bariatric surgeries, which is being performed using various techniques like gastrojejunostomy by hand swen, linear or circular stapler. Abdominal pain is a common complaint following laparoscopic gastric bypass procedure (LGBP), which has different aetiologies, such as overeating, adhesion, internal herniation, bile reflux and many more. In this study LGBP was performed in an ante-colic ante-gastric pattern in a double loop manner and the prevalence and distribution of pain in morbidly obese patients undergoing LGBP was assessed.

Objectives:

The aim of this study was to analyze the distribution and frequency of post LGBP pain in morbidly obese patients.

Patients and Methods:

This study was performed on 190 morbidly obese patients referred to Hazrat Rasoul Hospital in Tehran. After LGBP, pain was measured in the following intervals: 24 hours, one week and one month after the operation. Before the operation onset, 2 mg Keflin and 5000 IU subcutaneous heparin were administered as prophylaxis. LGBP was performed using five ports including: one 11 mm port was placed 15-20 cm far from the xiphoid, one 12-mm port in mid-clavicular line at the level of camera port, one 5-mm port in subcostal area in ante-axillary region in the left, another 5-mm port in the right mid-clavicular area and a 5-mm port in sub-xyphoid. All operations were done by the same team. Staple was used for all anastomoses and hand sewn technique to close the staple insertion site. The mesenteric defect was left open and no effort was made to repair it.

Results:

The results of this study showed that 99.94 % of the patients had complains of pain in the first 24 hours of post operation, about 60% after one week and 29.5 % still had pain after one month. In addition, left upper quadrant (LUQ) was found to be the most prevalent site for the pain in 53.7% of the patients in the first 24 hours, 59.6% after one week and 16.8% after one month (except for obscure pain) with a significance of < 0.05.

Conclusions:

In this study, the authors analyzed the location and disturbance level of pain after LGBP, which could serve as a cornerstone for further researches. The authors suggest that long-term follow-up (for more than a year after operation) should be considered in future studies and also the relationship between the drainage site and pain should be investigated.

Incidence of port site hernias and/or dehiscence in robotic-assisted procedures in gynecologic oncology patients

OBJECTIVES

The incidence of port site hernia and/or dehiscence using bladeless trocars is 0-1.2%. Robotic surgery uses additional port sites and increases manipulation of instruments, raising the concern for more complications. We sought to characterize the incidence of port site complications following robotic surgery when fascia was not routinely closed.

METHODS

Robotically-assisted (RA) procedures performed for suspected gynecologic malignancy between 1/2006 and 12/2011 were retrospectively reviewed. Bladeless 12 mm and 8mm robotic trocars were used. Fascial closure was not routinely performed except after specimen removal through the port site. The decision to close the fascia remained at the discretion of the surgeon.

RESULTS

Data from 842 procedures were included. Mean patient age was 55.6 years. Mean Body Mass Index was 33.6 kg/m(2). RA-total laparoscopic hysterectomy (TLH)± unilateral or bilateral salpingo-oophorectomy (BSO)± lymphadenectomy (LND) accounted for 91.6% of procedures. Final pathology confirmed malignancy in 58.6% of cases, primarily endometrial cancer. In 35 cases, the specimen was removed through the port site; fascia was closed in 54.3% of them and no port site hernias or dehiscences occurred. Only one patient underwent a RA-TLH/BSO/LND for endometrial adenocarcinoma and had a port site dehiscence of the 8mm trocar site. No port site hernias occurred.

CONCLUSION

Port site hernias and dehiscences are rare in RA gynecologic oncology procedures. When bladeless dilating trocars are used, routine closure of even up to a 12 mm port site is unnecessary, even in cases requiring removal of the specimen through the trocar sites.

Analysis of laparoscopic port site complications: A descriptive study

CONTEXT:

The rate of port site complications following conventional laparoscopic surgery is about 21 per 100,000 cases. It has shown a proportional rise with increase in the size of the port site incision and trocar. Although rare, complications that occur at the port site include infection, bleeding, and port site hernia.

AIMS:

To determine the morbidity associated with ports at the site of their insertion in laparoscopic surgery and to identify risk factors for complications.

SETTINGS AND DESIGN:

Prospective descriptive study.

MATERIALS AND METHODS:

In the present descriptive study, a total of 570 patients who underwent laparoscopic surgeries for various ailments between August 2009 and July 2011 at our institute were observed for port site complications prospectively and the complications were reviewed.

STATISTICAL ANALYSIS USED:

Descriptive statistical analysis was carried out in the present study. The statistical software, namely, SPSS 15.0 was used for the analysis of the data.

RESULTS:

Of the 570 patients undergoing laparoscopic surgery, 17 (3%) had developed complications specifically related to the port site during a minimum follow-up of three months; port site infection (PSI) was the most frequent (n = 10, 1.8%), followed by port site bleeding (n = 4, 0.7%), omentum-related complications (n = 2; 0.35%), and port site metastasis (n = 1, 0.175%).

CONCLUSIONS:

Laparoscopic surgeries are associated with minimal port site complications. Complications are related to the increased number of ports. Umbilical port involvement is the commonest. Most complications are manageable with minimal morbidity, and can be further minimized with meticulous surgical technique during entry and exit.

The incidence of trocar-site hernia in minimally invasive bariatric surgery: a comparison of multi versus single-port laparoscopy

INTRODUCTION

Single-port laparoscopy (SPL) employs a 1.5- to 2.5-cm incision at the umbilicus for the placement of a single working port. We hypothesized that the longer incision created by SPL compared with multiport laparoscopy may increase the incidence of trocar-site hernias. We examined our experience with SPL in bariatric operations.

METHODS

There were 734 laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding procedures performed at our institution between 2001 and 2011. Fifty-eight patients were lost to follow-up or had a short duration of follow-up (<1 month). Of the remaining 676 cases, 163 were performed via SPL. All laparoscopic wounds created by trocar size greater than 12 mm were closed with absorbable suture.

RESULTS

Patient demographics of the SPL group and the multiport group were similar in terms of age, gender, and comorbidities. The average body mass index (BMI) of the SPL group was lower than the multiport group (43.5 ± 5.3 vs. 45.8 ± 7.7, p < 0.01). The mean follow-up for the SPL group was 11 months versus 24 months for the multiport group. There were three trocar-site hernias out of 513 cases in the multiport compared to one hernia out of 163 cases in the SPL group (0.6 vs. 0.6 %, p = 0.967). All trocar-site hernias occurred at the 15-mm port site. The median time to hernia occurrence for the multiport group was 13 months (range, 1-18). In the SPL group, the hernia occurred at 8 months. On multivariate analysis, age, BMI, SPL, procedure type, and the postoperative weight loss were not associated with the development of trocar-site hernias.

CONCLUSIONS

SPL did not increase the rate of trocar-site hernia in this series. A low rate of trocar-site hernia can be achieved with the use of SPL in bariatric surgery.

Incidence and prevention of ventral incisional hernia

OBJECTIVE

Ventral incisional hernia is a common complication of abdominal surgery. The incidence ranges from 2% to 20% and varies greatly from one series to another. The goal of this study was to determine the incidence, risk factors, and preventive measures for ventral incisional hernia.

MATERIALS AND METHODS

An analysis of the surgical literature was performed using the search engines EMBASE, Cochrane Library, and PubMed with the keywords: abdominal hernia, wound dehiscence, incisional hernia, incidence, trocar site hernia, and hernia prevention.

RESULTS

The overall incidence of incisional hernia after laparotomy was 9.9%. The incidence was significantly higher for midline incisions compared with transverse incisions (11% vs. 4.7%; P=0.006). In contrast, the incidence of ventral hernia was only 0.7% after laparoscopy. A compilation of all the studies comparing laparotomy to laparoscopy showed a significantly higher incidence of incisional hernia after laparotomy (P=0.001). Independent risk factors for incisional hernia included age and infectious complications. Only two meta-analyses were able to show a significant decrease in risk-related to the use of non absorbable or slowly absorbable suture material. No difference in incisional hernia risk was shown with different suture techniques (11.1% for running suture, 9.8% for interrupted sutures: NS).

CONCLUSION

A review of the literature shows that only the choice of incisional approach (transverse incision or laparotomy vs. midline laparotomy) allows a significant decrease in the incidence of ventral incisional hernia.

Incidence and prevention of ventral incisional hernia

OBJECTIVE

Ventral incisional hernia is a common complication of abdominal surgery. The incidence ranges from 2% to 20% and varies greatly from one series to another. The goal of this study was to determine the incidence, risk factors, and preventive measures for ventral incisional hernia.

MATERIALS AND METHODS

An analysis of the surgical literature was performed using the search engines EMBASE, Cochrane Library, and PubMed with the keywords: abdominal hernia, wound dehiscence, incisional hernia, incidence, trocar site hernia, and hernia prevention.

RESULTS

The overall incidence of incisional hernia after laparotomy was 9.9%. The incidence was significantly higher for midline incisions compared with transverse incisions (11% vs. 4.7%; P=0.006). In contrast, the incidence of ventral hernia was only 0.7% after laparoscopy. A compilation of all the studies comparing laparotomy to laparoscopy showed a significantly higher incidence of incisional hernia after laparotomy (P=0.001). Independent risk factors for incisional hernia included age and infectious complications. Only two meta-analyses were able to show a significant decrease in risk-related to the use of non absorbable or slowly absorbable suture material. No difference in incisional hernia risk was shown with different suture techniques (11.1% for running suture, 9.8% for interrupted sutures: NS).

CONCLUSION

A review of the literature shows that only the choice of incisional approach (transverse incision or laparotomy vs. midline laparotomy) allows a significant decrease in the incidence of ventral incisional hernia.

Incarcerated hernia in 11-mm nonbladed trocar site following laparoscopic appendectomy

This report emphasizes the importance of performing meticulous closure on all trocar sites 10-mm and greater.

Background:

Nonbladed trocars are considered less traumatic to the abdominal wall due to the lack of fascial incision. It has been suggested that closure of the abdominal fascia may be unnecessary when such nonbladed trocars are used.

Case Report:

We report on 2 patients who were diagnosed with trocar-site hernias 2 days after laparoscopic appendectomy performed using 11-mm nonbladed trocars.

Conclusion:

Although rare, trocar-site hernias after laparoscopic surgery with nonbladed trocars remain a cause of postoperative morbidity and require prompt intervention. Therefore, this report underscores the significance of performing meticulous closure of all trocar sites that are ≥10mm.

Incidence and risk factors for trocar site hernia following laparoscopic cholecystectomy: a long-term follow-up study

BACKGROUND

The aim of this retrospective study was to assess the incidence of trocar site hernias (TSH) following laparoscopic cholecystectomy (LC) through a long-term follow-up and to elucidate the significance of several technical and patient-related factors.

METHODS

A total of 313 patients submitted to LC between 2000 and 2004 were included in our study. The pneumoperitoneum was always performed by means of Hasson's technique at the umbilical site and the operative trocars were positioned using either the American technique or the French technique. Closure of the fascial defect was performed only at the umbilical site. The effects of several variables, including age, gender, size of gallstones, co-existing umbilical hernia, complexity of operation, diabetes, obesity, malnutrition, smoking, and heavy manual work on the development of TSH were assessed by univariate and multivariate models.

RESULTS

Thirteen cases of TSH (4.1 %) were detected over a mean follow-up period of 89.8 months (range: 60-128). Of these, 11 (84.6 %) developed at the umbilicus and 2 at the 10 mm subxiphoid site (15.4 %). At univariate and multivariate analysis, gallstones ≥ 2 cm (p = 0.030; OR = 9.95, p = 0.01) and obesity (p = 0.002; OR = 22.93, p < 0.01) were found to increase the likelihood of TSH development.

CONCLUSIONS

After long-term follow-up, the incidence of TSH following LC was higher than expected. The insertion of large trocars at the umbilical site plays a key role in the development of TSH. Other conditions such as obesity and large gallstones can be additional risk factors since the umbilical defect must often be widened in these cases.

Incidence of port-site hernias after robot-assisted radical prostatectomy with the fascial closure of only the midline 12-mm port site

BACKGROUND AND PURPOSE

Port-site hernias are rare complications that occur in approximately 1% of all laparoscopic surgeries. With the use of bladeless, blunt-tipped entry trocars, some surgeons have argued that not all port sites need fascial closure. Several cases of port-site hernia, however, have been reported recently with the use of bladeless trocars. This study evaluated the incidence of port-site hernias after robot-assisted radical prostatectomy (RARP) as we routinely closed the fascia of only the midline 12-mm port site.

PATIENTS AND METHODS

From 2006 to 2009, 498 patients with localized prostate cancer underwent RARP. Bladeless dilating trocars were used in all of our patients. Routinely, six ports were used: two 12 mm, three 8 mm, and one 5 mm. Fascial closure was performed only for the midline supraumbilical 12-mm port site.

RESULTS

In 498 cases of RARP, there were two port-site hernias (0.4%, 2/498). Both cases occurred at the midline supraumbilical 12-mm camera port site. No hernia developed at nonmidline port sites, including the lateral 12-mm port site.

CONCLUSION

Trocar site hernias after RARP are rare. When bladeless dilating trocars are used, routine closure of fascia of non-midline 12-mm or smaller port sites is not necessary. Splitting the muscle and fascia without cutting likely renders routine closure of fascia unnecessary for nonmidline ports that are ≤ 12 mm.

Systematic review of trocar-site hernia

BACKGROUND

Broad implementation of laparoscopic surgery has made trocar-related complications clinically important. Trocar-site hernia (TSH) is an uncommon, but potentially serious, complication that occasionally requires emergency surgery. This systematic review was conducted to establish the prevalence and risk factors for TSH.

METHODS

The review was conducted according to the PRISMA guidelines. MEDLINE, Embase, Web of Science and the Cochrane Library were searched to 7 June 2010 for studies on TSH.

RESULTS

Twenty-two articles were included. One study was a randomized clinical trial, five were prospective cohort studies and 16 were retrospective cohort studies. The prevalence of TSH is low, with a median pooled estimate of 0·5 (range 0-5·2) per cent. No meta-analysis on risk factors could be performed. Pyramidal trocars, 12-mm trocars and a long duration of surgery were identified as the most important technical risk factors for TSH. Older age and a higher body mass index were observed to be patient-related risk factors.

CONCLUSION

TSH is an uncommon complication of laparoscopic surgery. The most important technical risk factors are the design and size of the trocars. The scientific evidence for recommendations to avoid TSH is sparse.

Randomized prospective trial on the occurrence of laparoscopic trocar site hernias

INTRODUCTION

Laparoscopy has become the gold standard in an increasing number of procedures. We analyze the incidence of trocar site hernias (TSH) and determine whether closure of the external fascia prevents onset of TSH and possible complications.

METHODS

We performed a simple-blind randomized trial with two groups, one in which all the orifices were closed by suturing the external fascia of the abdominal wall (group A), and another in which the orifices were left open, closing only the skin (group B). Monitoring for TSH lasted 2 years from the intervention. The trial has been registered at www.clinicaltrials.gov with the clinicaltrials.gov identifier number: NCT01240434.

RESULTS

A total of 195 patients were randomized. Thirty-three were removed from the study after conversion to open surgery, early open reoperation, or loss to follow-up. The remaining 162 patients comprised the study population, 80 in group A and 82 in group B. We found no differences between the groups regarding basic demographic data, kind of surgery, or topographic distribution of the trocars. Five TSH were diagnosed-four in group A and one in group B (P=.176)-and there was no relation between TSH and trocar size (11 or 12 mm) or location. We found 10 wound infections, 7 in group A and 3 in group B (P=.154).

CONCLUSION

Our study suggests that the onset of TSH does not depend on trocar size or location. There is no evidence that suture of the fascial defect prevents the onset of TSH. In addition, we found a trend toward a higher incidence of wound infection among patients in whom the fascia had been sutured.

The risk of umbilical hernia and other complications with laparoendoscopic single-site surgery

STUDY OBJECTIVE

To estimate the risk of umbilical hernia and other latent complications in women who underwent laparoendoscopic single-site surgery (LESS) for a gynecologic indication.

DESIGN

Retrospective, nonrandomized clinical study (Canadian Task Force classification II-2).

SETTING

Four tertiary care academic medical centers.

PATIENTS

Women undergoing LESS for a benign or malignant gynecologic indication from 2009 to 2011.

INTERVENTIONS

A total of 211 women underwent LESS via a single 1.5- to 2.0-cm umbilical incision. All surgeries were performed by advanced gynecologic laparoscopists. Incisions were repaired with a running, delayed absorbable suture. Subject demographics and clinical variables were collected and surgical outcomes analyzed.

MEASUREMENTS AND MAIN RESULTS

Median age and body mass index were 45 years and 30 kg/m(2), respectively. Approximately half of study subjects underwent a hysterectomy with or without salpingo-oophorectomy, and 15% had a diagnosis of cancer. Overall, 0.9% of women were diagnosed with a preoperative umbilical hernia, and 2.4% of women experienced a major perioperative complication. After a median postoperative follow-up time of 16 months, 2.4% had development of an umbilical hernia. However, 4/5 of these women had significant risk factors for fascial weakening independent of LESS, including requirement for a second abdominal surgery in 1 subject and a cancer diagnosis with postoperative chemotherapy administration in 2 subjects. When these subjects deemed "high risk" for incisional disruption were excluded from the analysis, the umbilical hernia rate was 0.5% (1/207). On univariable analysis, obesity was the only factor associated with complications (p = .04).

CONCLUSION

When performed by advanced laparoscopic surgeons, laparoendoscopic single-site gynecologic surgery is associated with a low risk of major adverse events. Additionally, the overall umbilical hernia rate was 2.4% and was lower (0.5%) in subjects without significant comorbidities.

Laparoscopic 5-mm trocar site herniation and literature review

This report concludes that there is no evidence to recommend routine closure of 5-mm trocar incisions; the choice should be left to the discretion of the individual surgeon.

Objective:

To evaluate the evidence for fascial closure of 5-mm laparoscopic trocar sites.

Methods:

We conducted electronic database searches of PubMed and the Cochrane Library for articles published between November 2008 and December 2010. We used the keywords trocar hernia, trocar-site hernia, laparoscopic hernia, trocar port-site hernia, laparoscopic port-site hernia. Prospective and retrospective case series, randomized trials, literature reviews, and randomized animal studies of trocar hernias on abdominal wall defects from gynecologic, urologic, and general surgery literature were reviewed. The Cochrane Database was reviewed for pertinent studies. Metaanalysis was not possible due to the significant heterogeneity between studies and lack of randomized trials large enough to assess the incidence of this rare complication.

Results:

Trocar-site hernias are a rare but known complication of laparoscopic surgery. Trocar size ≥10mm is associated with an increased rate of hernia development. Currently, the accepted gynecologic surgical practice is closure of fascial incisions ≥10mm, while incisions <10mm do not require closure. However, large prospective and retrospective case series reports from general surgery and urology literature support nonclosure of blunt or radially dilating trocars in paramedian sites. Expert opinion and small case reports suggest that in cases of prolonged manipulation of 5-mm trocar sites the surgeon should consider fascial closure, because extension of the initial incision may have occurred.

Conclusion:

There is no evidence to recommend routine closure of 5-mm trocar incisions; the choice should continue to be left to the discretion of the individual surgeon.

Port-site hernia following laparoscopic cholecystectomy

The incidence of port-site hernia is variable, but evidence suggests that awareness of risk factors and modification of technique can minimize risk.

Background:

Port-site hernia is a rare but potentially serious complication of laparoscopic cholecystectomy. This study aimed to review the current literature, assess the incidence and causes of port-site hernias, and identify methods to reduce the risk.

Methods:

A systematic search of the literature published in English from 1995 to 2010 was conducted using PubMed to identify all reports of port-site, trocar-site, or incisional hernia following laparoscopic cholecystectomy. Studies in over 100 patients were identified before the application of defined exclusion criteria. The incidence of port-site hernia was calculated and compared with historical data. Predisposing factors were reviewed.

Results:

Seven studies met the search criteria, with 99 port-site hernias in 5984 patients. The overall incidence of port-site hernia was 1.7% (range, 0.3% to 5.4). The most important factors were older age, higher body mass index, preexisting hernia, trocar design, trocar diameter, increased duration of surgery, and extension of the port site for gallbladder extraction.

Conclusion:

The incidence of port-site hernia is low but likely to be underestimated and has not declined over time. Awareness of the predisposing factors and modification of techniques may help to reduce the risk.

Low risk of trocar site hernia repair 12 years after primary laparoscopic surgery

BACKGROUND

The risk of trocar site hernia (TSH) may be 0-22%, but no large scaled data with long-term follow-up are available. The purpose of this study was to estimate the long-term risk of TSH repair.

METHODS

All patients in Denmark who underwent a laparoscopic procedure in 1997 were identified using the Danish National Patient Register and followed during a 12-year period. Hospital records for patients with an incisional or umbilical hernia repair were tracked and manually analyzed for possible relationship between reoperation and the initial laparoscopy.

RESULTS

We included 7,626 patients. During follow-up, we identified 95 patients with TSH repair with a cumulative risk of 1.3% being lowest after minor gynecological procedures and appendectomy and highest after fundoplication, cholecystectomy, and oophorectomy. The TSH was mainly at the umbilicus site (n = 63, 66%), and 15 (16%) of the TSH repairs were performed as an emergency procedure.

CONCLUSIONS

The long-term risk of TSH repair is low, but the risk of an emergency operation for TSH is relatively high, which suggests that all patients with a TSH should be offered elective repair.

Abdominal pain after gastric bypass: suspects and solutions

BACKGROUND

Gastric bypass remains the mainstay of surgical therapy for obesity. Abdominal pain after gastric bypass is common and accounts for up to half of all postoperative complaints and emergency room visits. This article reviews the most important causes of abdominal pain specific to gastric bypass and discusses management considerations.

METHODS

The current surgical literature was reviewed using PubMed, with a focus on abdominal pain after gastric bypass and the known pathologies that underlie its pathogenesis.

RESULTS

The etiologies of abdominal pain after gastric bypass are diverse. A thorough understanding of their pathogenesis impacts favorably on clinical outcomes.

CONCLUSIONS

The differential diagnosis for abdominal pain after gastric bypass is large and includes benign and life-threatening entities. Its diverse causes require a broad evaluation that should be directed by history and clinical presentation. In the absence of a clear diagnosis, the threshold for surgical exploration in patients with abdominal pain after gastric bypass should be low.

Trocar site hernia after laparoscopic colectomy: a case report and literature review

Background. Trocar Site Hernia (TSH) is defined as an incisional hernia which occurs after minimally invasive surgery on the trocar incision site.In 2004 Tonouchi classified trocar site hernias into 3 types: Early onset type; Late onset type; Special type. Case Report. We report the case of a 76-year old woman that underwent an emergency explorative laparotomy on the 10th p.o. day after a laparoscopic left hemicolectomy. Surgery showed a small bowel herniation through the 12 mm trocar incision site; the intestinal loop appeared necrotic and had to be resected, and the hernia orifice was repaired. We carried out a review of literature about this topic. Discussion. The clinical onset of a trocar site hernia is usually early, occurring within the 30th post operative day and it is caused by the omentum or small bowel entrapment into the trocar orifice. The clinical presentation is insidious, with progression to an acute abdomen, and an emergency surgical approach is often required. Conclusions. TSH is a severe complication of operative laparoscopy especially with large-bore trocar ports. The incidence of TSH resulting from our review ranges from 0.007% to 22% with an average of 1.85%. Prevention of TSH appears to be more effective when trocar insertion through the abdominal wall is tangential, the closure of both the fascia and the peritoneum is performed if the incision is greater than 7 mm, the suture of extra umbilical port site is performed under laparoscopic vision.

A systematic review of laparoscopic port site hernias in gastrointestinal surgery

INTRODUCTION

Port site hernia is an important yet under-recognised complication of laparoscopic surgery, which carries a high risk of strangulation due to the small size of the defect involved. The purpose of this study was to examine the incidence, classification, and pathogenesis of this complication, and to evaluate strategies to prevent and treat it.

METHODS

Medline was searched using the words "port site hernia", "laparoscopic port hernia" "laparoscopic complications" and "trocar site hernias". The search was limited to articles on cholecystectomy, colorectal, bariatric or anti-reflux surgery published in English. A total of 42 articles were analysed and of these 35 were deemed eligible for review. Inclusion criteria were laparoscopic gastrointestinal surgery in English only with reported incidence of port site herniation. Studies were excluded if insufficient data was provided. Eligible studies were also cross-referenced.

RESULTS

Analysis of 11,699 patients undergoing laparoscopic gastrointestinal procedures demonstrated an incidence of port site hernias of 0.74% with a mean follow-up of 23.9 months. The lowest incidence of port site herniation was for bariatric surgery with 0.57% in 2644 patients with a mean follow-up of 67.4 months while the highest incidence was for laparoscopic colorectal surgery with an incidence of 1.47% in 477 patients with a mean follow-up of 71.5 months.

CONCLUSION

All fascial defects larger than or equal to 10mm should be closed with peritoneum, while smaller defects may require closure in certain circumstances to prevent herniation. Laparoscopic port site herniation is a completely preventable cause of morbidity that requires a second surgical procedure to repair.

[Trocar site incisional hernia in laparoscopic surgery]

Trocar site incisional hernias (TSIH) are the most common complications in laparoscopic surgery. We have carried out a review of the literature with the aim of establishing their incidence, the reasons for them happening, and their prevention. After a search in the MEDLINE PubMed and PubMed CENTRAL data bases from 1991 to 2009, combining the words: "hernia", "laparoscopy" and "trocar", we obtained 545 articles, of which we analysed 60 of them. The incidence of TSIH varies between 0.18% and 2.8%. The diameter of the trocar, obesity and age play a fundamental role when proceeding to close the fascia, a closure which is the most important factor to prevent these incisional hernias appearing. The appearance of new laparoscopic material and the increasing more common closure of defects of the fascia means that new and more extensive prospective studies should be performed.

Trocar site hernia after laparoscopic surgery: a qualitative systematic review

PURPOSE

There is a risk of developing a trocar site hernia (TSH) after laparoscopic surgery, but data is sparse and based mostly on retrospective studies with a short and poorly defined follow-up period. Surgical approaches and patient-related co-morbidity have also been suggested as risk factors for development of TSH. The aim of the present review was to perform a qualitative systematic analysis to estimate the incidence of TSH and to discuss the surgical and patient-related risk factors for development of TSH.

METHODS

The literature search was until 19 May 2010. Studies with TSH, defined as either operation for TSH or a hernia found during clinical follow-up, were included. We included randomised controlled trials, prospective non-controlled studies including >200 patients, and retrospective studies including >200 patients. The review was completed according to the PRISMA guidelines.

RESULTS

We included 19 studies in adults and 3 studies in paediatric patients (<18 years), and a total of 30,568 adults and 1,098 children were analysed. The overall incidence of TSH was 0-5.2%. TSH occurred most often (96%) in trocar sites of a minimum of 10 mm, located mostly in the umbilicus region (82%). Data supported a higher incidence of TSH when the trocar site fascia was not sutured, and in pre-school children undergoing a laparoscopic procedure.

CONCLUSIONS

Current data suggests a relatively low incidence of TSH but that all trocar incisions of a minimum of 10 mm should be closed. In pre-school children undergoing laparoscopic surgery, all port sites should be closed.

Postoperative bowel herniation in a 5-mm nonbladed trocar site

The possibility of a strangulated hernia involving a 5-mm port site warrants consideration under the appropriate clinical scenario.

Background:

Incisional hernias are a rare complication of laparoscopic surgery, with a reported incidence of <1%.

Case Report:

We describe a case of bowel herniation and strangulation involving a 5-mm trocar site.

Conclusion:

Although there is growing literature supporting fascial closure of abdominal port sizes ≥10mm, there is sparse data to suggest closure of 5-mm port sites. Our case illustrates that in appropriate clinical scenarios, the possibility of a strangulated hernia involving a 5-mm port site warrants consideration.