Port site hernia in laparoscopic surgery: Mechanism, prevention and management

Return to theater following gynecologic surgeries: An institutional audit and review of the literature

OBJECTIVE

Return to theater (RTT) for reoperation following a primary surgery has significant implications for patients and the healthcare system. RTT following gynecologic surgeries is a critical clinical incident trigger for reporting and investigation of root cause analyses. Many of the causes of unexpected return to theater after surgery are avoidable and therefore provide essential learning opportunities to prevent future recurrence and to improve patient experience especially in those at risk of specific complications.

METHODS

The present study was a mixed method retrospective review of all unexpected reoperations following gynecologic surgeries over a 7-year period at Mid Yorkshire Teaching Hospitals NHS Trust and a review of the literature.

RESULTS

There were 24 RTTs following gynecologic surgeries during the period. The overall RTT rate was three per 1000. Hysterectomies accounted for 14 (58.3%) of the reoperations. Similarly, 11 (45.8%) of the reoperations were as a result of hemorrhagic complications. Other themes identified include port site hernia in three patients (12.5%), ureteric injury in two patients (8.3%), while three patients (12.5%) had no abnormality detected at reoperation.

CONCLUSION

Unexpected reoperation following gynecologic surgery is an uncommon complication at three per 1000 surgeries. Reactionary and secondary hemorrhages are the most common causes and hysterectomy irrespective of the approach remains the leading primary surgery. The causes are largely preventable.

Port Site Obstructed Hernia in a Morbidly Obese Patient: A Case Report

Indications for laparoscopic surgeries are increasing in the current era in view of the advantages they offer in terms of less perioperative morbidities, early mobilization, and better cosmesis. These benefits are perceived even more in obese women. However, there are special challenges in this population, associated with their body habitus, poor visibility, and perioperative anesthesia risks. Difficulty in port closure is one such problem encountered in these women causing inadequate rectus suturing and leading to port site hernia. We report a case of a 59-year-old morbidly obese lady who underwent a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection for carcinoma endometrium. The intraoperative course was uneventful. In the postoperative period, she developed acute obstruction due to port site herniation of the small bowel, which was not suspected till postoperative day five. This was due to an inaccurate assessment of her abdomen because of her body habitus. A CT scan was done in view of the non-resolving obstruction, which revealed herniation of a small bowel loop through the umbilical port. Immediate correction was resorted to under local anesthesia. Rectus sheath closure was done in the same sitting. The patient had a quick recovery after that and was discharged three days later. Rectus sheath closure should be done for all ports 10 mm or greater in diameter. There should be a low threshold to get cross-sectional imaging in postoperative obese women with non-resolving gastrointestinal symptoms.

Is fascial closure required for a 12-mm trocar? A comparative study on trocar site hernia with long-term follow up

BACKGROUND

Despite the infrequency of trocar site hernias (TSHs), fascial closure continues to be recommended for their prevention when using a ≥ 10-mm trocar.

AIM

To identify the necessity of fascial closure for a 12-mm nonbladed trocar incision in minimally invasive colorectal surgeries.

METHODS

Between July 2010 and December 2018, all patients who underwent minimally invasive colorectal surgery at the Minimally Invasive Surgery Unit of Siriraj Hospital were retrospectively reviewed. All patients underwent cross-sectional imaging for TSH assessment. Clinicopathological characteristics were recorded. Incidence rates of TSH and postoperative results were analyzed.

RESULTS

Of the 254 patients included, 70 (111 ports) were in the fascial closure (closed) group and 184 (279 ports) were in the nonfascial closure (open) group. The median follow up duration was 43 mo. During follow up, three patients in the open group developed TSHs, whereas none in the closed group developed the condition (1.1% vs 0%, P = 0.561). All TSHs occurred in the right lower abdomen. Patients whose drains were placed through the same incision had higher rates of TSHs compared with those without the drain. The open group had a significantly shorter operative time and lower blood loss than the closed group.

CONCLUSION

Routine performance of fascial closure when using a 12-mm nonbladed trocar may not be needed. However, further prospective studies with cross-sectional imaging follow-up and larger sample size are needed to confirm this finding.

Evaluation of Closure Technique on Incidence of Incisional Hernia Following Single Port Laparoscopy in Gynecologic Oncology Surgery

STUDY OBJECTIVE

To evaluate incidence and risk factors for incisional hernia in women undergoing single-port laparoscopy (SPL) for gynecologic oncology indications with a standardized fascia closure (SC) technique versus historical controls (HC).

DESIGN

Retrospective cohort study.

SETTING

Single academic institution.

PATIENTS

Women who underwent SPL from 6/1/2017-12/31/2019 for gynecologic oncology indications with SC were compared to HC who underwent SPL from 1/1/2009-12/31/2015.

INTERVENTIONS

Data was collected for patient demographics, postoperative outcomes, and incisional hernia development. Univariate analysis and multivariable regression models were built for predictors of incisional hernia.

MEASUREMENTS AND MAIN RESULTS

Of 1,163 patients, 242 (20.8%) patients had SC and 921 (79.2%) patients had HC. SC cohort had lower rates of diabetes versus HC (10.3% vs. 15.3%; p = .049) but no differences in hypertension (36.8% vs. 43.0% p = .081) and obesity (42.6% vs. 36.9%, p = .11). 1,123 (96.6%) patients did not undergo conversion to multi-port laparoscopy or laparotomy, of whom 7.2% (n=81) of patients developed an incisional hernia; there was no difference in incisional hernia development for SC with SPL (n= 237) versus HC with SPL (n= 886) (9.7% vs. 6.5%, p = .095). On multivariable analysis, increased BMI (OR 1.06; 95% CI 1.03-1.09, p < .001) and diabetes (OR 2.41; CI 1.34-4.32, p = .003) were associated with incisional hernia, but age (OR 1.00; CI .98-1.02, p = .92), length of surgery (OR 1.00; CI 1.00-1.01, p = .62), and hypertension (OR .89; CI .52-1.53, p = .68) were not. Patients with prior abdominal surgeries (OR 1.92; CI 1.14-3.26, p = .015) and hand-assist surgery (OR 3.17; CI 1.48-6.80, p = .003) were significantly associated with incisional hernia.

CONCLUSION

Implementation of a SC protocol did not decrease rate of incisional hernia versus HC during SPL. Risk of incisional hernia must be considered for SPL planning in patients with complex medical comorbidities and prior abdominal surgery.

Laparoscopic Port-Site Hernia: An Underrecognized Iatrogenic Complication of Laparoscopic Surgery

Importance

Port-site hernia is an iatrogenic complication with a documented incidence between 0.65% and 2.8%. However, the true incidence could be higher because of delayed onset, asymptomatic nature, and loss to follow-up. Port-site hernia could be further complicated by incarceration or strangulation leading to small bowel obstruction requiring emergent surgical intervention, thus imposing significant financial and emotional burden to patients.

Objective

This article aims to provide a summary of the available literature concerning port-site hernia and explore preventive strategies for future clinical practice.

Evidence Acquisition

This review was formulated through electronic literature searches in Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. The reference lists of the included studies were hand searched to identify other relevant articles to capture all available literature in this narrative review.

Results

Following screening for eligibility based on relevance to the topic under consideration, 28 studies were identified. This included 5 original articles, 1 case series, and 22 review articles, including 4 systematic reviews. Included studies were critically appraised in formulating this review.

Conclusions

Port-site hernia is an underrecognized yet preventable complication with careful consideration of predisposing technical and host factors, thorough attention to surgical technique, or use of a fascial closure device.

Relevance

With the widespread and increasing use of laparoscopic methods to treat surgical pathologies, knowledge of this complication is imperative to encourage prevention strategies and facilitate early recognition and management should it occur.

A simple and reliable procedure for laparoscopic port-site closure

PURPOSE

One of the complications in laparoscopic surgery is port-site hernia. It is a rare but potentially dangerous complication. Especially when using ports with a size 10 mm or more, it is required to securely close the port site. However, this procedure is often difficult especially for obese patients.

METHODS

We herein devised a new closure method by using a device developed for port site. These techniques are methods that can close the port site by a combination of putting in and out of thread and port rotation without removing a port. The port-site closure with these techniques was done for 53 port sites of 41 patients.

RESULTS

The port site was closed horizontally or vertically, depending on the shape of the port site for two patients. Modified Z-suture was done for other 37 patients. To date, we have not noted any complications from this new method, including port-site hernia.

CONCLUSION

With our technique, we could save operation time and reduce stress of us especially for obese patients. We would like to increase the number of patients and verify the safety and usefulness in further study.

Umbilical Port Site Hernia and Diastasis Recti

Purpose

The port site hernia (PSH) is a specific type of incisional hernia related to the trocar sites of laparoscopic surgery. Diastasis recti of the abdominis muscle (DR) is the separation of the rectus muscle by a certain distance. The present study aims to present our experience with umbilical PSH and concomitant DR and to raise awareness of DR as one of the risk factors of umbilical PSH.

Methods

Eighteen patients with umbilical PSH after laparoscopic abdominal surgery, was retrospectively reviewed. Preoperative CT was analyzed to measure the Inter-recti distance (IRD) for all patients. Other factors, such as trocar size, wound infection, obesity (BMI), port extension, suture materials, and pre-existing co-morbidities, were recorded and analyzed.

Results

Extension of the port incision was associated with umbilical PSH. Ten out of eighteen umbilical PSH patients (56%) had DR before they had first laparoscopic surgery. Nine (50%) patients showed sarcopenia. Moreover, four out of five recurrences had DR. More than two recurrences were all associated with DR.

Conclusion

Port extension and sarcopenia were risk factors of umbilical PSH. Also, DR might be a possible risk factor of umbilical PSH occurrence and recurrence. Surgeons should be aware of the presence of DR before the planning of the laparoscopic surgery by diagnostic imaging. If DR is associated with umbilical PSH, we need to consider the correction of both pathologies at the same time.

Long-term outcome of laparoscopic sleeve gastrectomy from a single center in mainland China

BACKGROUND/OBJECTIVE

Laparoscopic sleeve gastrectomy (LSG) is at present the most popular bariatric procedure due to its significant weight loss, remission of co-morbidities, and acceptable morbidity. But, there are not many studies showing its long term efficacy and safety in Chinese patients. The aim of this study is to give five results of LSG in terms of weight loss, co-morbidity (Type 2 diabetes mellitus) resolution and possible complications from a single center in mainland China.

MATERIAL AND METHODS

This is a retrospective study of 218 obese patients who underwent LSG by a single surgeon from June 2011 to June 2016. Patients were subjected to standardized perioperative evaluation and education program. Patients were followed up after 1, 3, 6, 12, 18, and 24 months and yearly thereafter. Long term outcomes in terms of weight loss in kg, % of total weight loss (%TWL), % excess weight loss (%EWL), % resolution of type 2 diabetes mellitus (T2DM) and % complication rate are studied.

RESULTS

The %TWL was 33.8 ± 5.9, 28.8 ± 8.9, 26.6 ± 6.9, 18.0 ± 7.6, 15.0 ± 7.1 and %EWL was 62.8 ± 16.9 (n-96), 49.5 ± 18.5 (n-43), 39.8 ± 13.1 (n-15), 32.2 ± 2.1 (n-13), 19.5 ± 8.7 (n-2) at 1, 2, 3, 4 and 5 years, respectively. T2DM remission rate was 72.9% at one year. There were no major complications like leak, stricture, staple line bleeding, port site herniation and gastro-esophageal reflux disease (GERD). There was no mortality. Most common early complication was port site dehiscence (10%), managed conservatively; none requiring readmission. No reoperation was done for weight regain.

CONCLUSION

LSG is a safe and effective procedure with good five year results. Weight regain remains a concern two years post surgery. Standardization of LSG is important to reduce major complications.