A systematic review of laparoscopic port site hernias in gastrointestinal surgery

An 8-mm port site hernia after robotic-assisted ileocecal resection: a case report

BACKGROUND

Robotic-assisted surgery is steadily becoming more prominent. The majority of reports regarding port site hernias (PSHs) have involved laparoscopic procedures. Currently, it is common to suture the fascia at port sites that are 10 mm or larger; however, the closure of 5-mm port sites is not considered mandatory. The da Vinci® surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) utilizes a distinctive 8-mm port. We report a case of an early-onset PSH at an 8-mm port site after robotic-assisted ileocecal resection.

CASE PRESENTATION

A 74-year-old male patient with a body mass index of 19.7 kg/m2 was diagnosed with cecal cancer and underwent robotic-assisted ileocecal resection. A 3-cm midline incision was made at the umbilicus for insufflation. Under laparoscopic visualization, three ports (12 mm, 8 mm, and 8 mm) were inserted in the lower abdomen. An 8-mm port was inserted in the left subcostal region, and a 5-mm port was inserted in the left lateral abdomen. The procedure was performed without significant intraoperative complications. The fascia was closed only at the umbilicus and 12-mm port site; the fascia at the 8-mm port sites was not closed. The patient was initially discharged without complications; however, on postoperative day 11, the patient was urgently hospitalized again because of PSH incarceration. After manual reduction, the fascia was sutured closed under local anesthesia. The hernial defect was small and barely allowed the insertion of a little finger. There was no evidence of compression or significant damage to the fascia. On postoperative day 27, the patient was discharged after experiencing good recovery.

CONCLUSIONS

Robotic-assisted colectomy could contribute to the risk of PSHs because of its surgical characteristics. Although routine closure of the fascia at 8-mm port sites is not mandatory, it may be beneficial in certain cases.

Postoperative management and complications after abdominal surgery in children receiving peritoneal dialysis

BACKGROUND

Patients on peritoneal dialysis (PD) may develop PD-related complications that necessitate abdominal surgery. However, when to resume PD and how to prescribe PD fluid after surgery in pediatric patients are unknown.

METHODS

Patients on PD who underwent small-incision abdominal surgery between May 2006 and October 2021 were included in this retrospective observational study. The complications after surgery and characteristics of patients with PD fluid leakage were analyzed.

RESULTS

Thirty-four patients were included. They underwent 45 surgical procedures, including 23 inguinal hernia repairs, 17 PD catheter repositioning or omentectomy, and 5 others. The median time to resume PD was 1.0 (IQR, 1.0-3.0) days, and the median PD exchange volume at the initiation of PD after surgery was 25 (IQR, 20-30) ml/kg/cycle. PD-related peritonitis occurred in two patients after omentectomy and one after inguinal hernia repair. There was no PD fluid leakage or hernia recurrence among the 22 patients who had a hernia repair. Peritoneal leakage occurred in 3 of the 17 patients who had PD catheter repositioning or an omentectomy and was treated conservatively. No patients who resumed PD 3 days after small-incision abdominal surgery with less than half of PD volume had fluid leakage.

CONCLUSIONS

Our findings demonstrated that PD could be resumed within 48 h of inguinal hernia repair with no PD fluid leakage or hernia recurrence in pediatric patients. In addition, resuming PD 3 days after a laparoscopic procedure with less than half of the usual dialysate volume might reduce the risk of PD fluid leakage. A higher resolution version of the Graphical abstract is available as Supplementary information.

ECLAPTE: Effective Closure of LAParoTomy in Emergency-2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings

Laparotomy incisions provide easy and rapid access to the peritoneal cavity in case of emergency surgery. Incisional hernia (IH) is a late manifestation of the failure of abdominal wall closure and represents frequent complication of any abdominal incision: IHs can cause pain and discomfort to the patients but also clinical serious sequelae like bowel obstruction, incarceration, strangulation, and necessity of reoperation. Previous guidelines and indications in the literature consider elective settings and evidence about laparotomy closure in emergency settings is lacking. This paper aims to present the World Society of Emergency Surgery (WSES) project called ECLAPTE (Effective Closure of LAParoTomy in Emergency): the final manuscript includes guidelines on the closure of emergency laparotomy.

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.

Safety and Efficacy of Trocar Port-Site Closure Using a Biological Plug Closure in Laparoscopic Bariatric Surgery: a Prospective Study

PURPOSE

Port-site trocar closure is a challenging procedure in laparoscopic surgeries, especially in morbidly obese patients, and complications (herniation, bleeding, pain, and nerve trapping) have potentially severe consequences. This paper provides an overview of existing techniques of suturing and closure in intra-abdominal laparoscopic surgery, outlines the complications associated with port-site closure, and presents a novel technique designed to address those problems by using a sterile absorbable gelatin sponge with strong hemostatic properties (Cutanplast® Plug).

MATERIALS AND METHODS

In this prospective study, 83 successive obese patients undergoing laparoscopic bariatric surgery (sleeve gastrectomy, sleeve plication, gastric bypass), using a standardized skin incision for trocar insertion, had port-site closure using the Cutanplast plug procedure (n = 42) or conventional suturing techniques (n = 41).

RESULTS

The incidence of early complications was lower in the Cutanplast group; no patients had infections compared with 9.8% of Controls (p = 0.055) and no bleeding, ecchymosis, erythema, or redness occurred. Late complications during 2 years of follow-up were significantly lower in the Cutanplast group (0 vs. 7 hernias, p = 0.005). Most patients in the Cutanplast group required only 1-2 procedures (78.6% vs. 58.5%, p = 0.049), whereas 41.5% of controls required 3 procedures. In total, 82 trocars were used in the Cutanplast group versus 99 in controls. The single-step Cutanplast plug technique reduced operating times compared with two-step suturing techniques.

CONCLUSION

Closure of port-site trocar incisions using Cutanplast plug is fast, efficient, with potential to reduce operating times and decrease bleeding and herniation from port-site trocars insertion, particularly in obese patients.

Drain-site hernia after laparoscopic rectal resection: A case report and review of literature

BACKGROUND

Drain-site hernia (DSH) has an extremely low morbidity and has rarely been reported. Small bowel obstruction is a frequent concurrent condition in most cases of DSH, which commonly occurs at the ≥ 10 mm drain-site. Here we report a rare case of DSH at the lateral 5 mm port site one month postoperatively without visceral incarceration. Simultaneously, a brief review of the literature was conducted focusing on the risk factors, diagnosis, and prevention strategies for DSH.

CASE SUMMARY

A 76-year-old male patient was admitted to our institution with intermittent abdominal pain and a local abdominal mass which occurred one month after laparoscopic radical resection of rectal cancer one year ago. A computed tomography scan showed an abdominal wall hernia at the 5 mm former drain-site in the left lower quadrant, and that the content consisted of the large omentum. An elective herniorrhaphy was performed by closing the fascial defect and reinforcing the abdominal wall with a synthetic mesh simultaneously. The postoperative period was uneventful. The patient was discharged seven days after the operation without surgery-related complications at the 1-mo follow-up visit.

CONCLUSION

Emphasis should be placed on DSH despite the decreased use of intra-abdominal drainage. It is recommended that placement of a surgical drainage tube at the ≥ 10 mm trocar site should be avoided. Moreover, it is advisable to have a comprehensive understanding of the risk factors for DSH and complete closure of the fascial defect at the drainage site for high-risk patients.

Prevention of incisional hernia after single-port sleeve gastrectomy (PRISM): a prospective non-randomized controlled study

BACKGROUND

SPSG carries a risk of incisional hernia, particularly in patients with high body mass index. Prophylactic mesh placement with either permanent or absorbable mesh could decrease the occurrence of incisional hernia, with uncertainty on other postoperative parietal complications.

METHODS

This is a non-randomized monocentric single-blinded prospective study. High-risk patients (body mass index ≥ 45 kg/m²) underwent either 3 strategies of parietal closure (suture with or without permanent or absorbable mesh) during SPSG. The primary outcome was the occurrence of radiologically defined incisional hernia during the first postoperative year. Secondary outcomes included surgical site infection rates and postoperative pain.

RESULTS

Between November 2018 and November 2019, 255 patients were included (85 in each group). All patients reached one-year postoperative follow-up. Significantly more incisional hernias were observed in the no mesh group in comparison with permanent and absorbable mesh groups, respectively (20% vs. 7.1% vs. 5.1%, P = 0.005). No difference was observed in mesh groups. No difference was observed regarding other parietal complications. One patient in the absorbable mesh group presented a superficial surgical site infection and required surgical drainage without mesh removal and one patient in the permanent mesh group presented a parietal hematoma and required surgical drainage with mesh removal. Twenty-six (92.8%) asymptomatic patients presented incisional hernia discovered on the one-year CT-scan.

CONCLUSIONS

Prophylactic mesh placement during SPSG decreases the occurrence of postoperative incisional hernia. Routine permanent mesh placement could be proposed in high-risk patients.

Economizing on a 12 mm port incision site: modification of robotic bowel stapling technique in Da Vinci X/Xi left colonic resections-the modified Norfolk and Norwich robotic stapling technique

The modified Norfolk and Norwich technique allows to replace a 12 mm port incision site by an 8 mm one, therefore reducing potential postoperative complications linked to 12 mm incisions by robotically stapling through the routinely placed suprapubic Alexis port.

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.

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.

Does size matter? Opioid use after laparoscopy for apical pelvic organ prolapse using an 8mm versus 10-12mm accessory port

STUDY OBJECTIVE

To determine if a change in lateral accessory port (LAP) size from 10-12mm to 8mm among women undergoing laparoscopic native tissue pelvic organ prolapse (POP) surgery was effective at reducing opioid use after surgery.

DESIGN

Prospective cohort of women taking part in a POP surgical registry.

SETTING

Tertiary academic hospital in Calgary, Canada.

PATIENTS

Women undergoing laparoscopic uterosacral ligament apical suspensions for stage ≥2 POP with either uterine preservation or concomitant hysterectomy. 92 women were included during a 15-month study period from June 2020 to September 2021.

INTERVENTIONS

Laparoscopic apical suspension using either a 10-12mm or 8mm LAP, with the change occurring at the mid-point of the study period. Fascial defects from 10-12mm ports were closed with a fascial closure device. Perioperative care and technique were otherwise unchanged.

MEASUREMENTS AND MAIN RESULTS

Post-operative opioid use was measured by mean morphine equivalent daily dose (MEDD), accounting for all oral and intravenous opioids used in the first 24-hours post-surgery. 50 cases (54.3%) used a 10-12mm LAP, 42 cases (45.7%) used an 8mm LAP. Mean MEDD after surgery with a 10-12mm LAP was significantly higher than with an 8mm LAP (35.3 (95% CI 24.9-45.6) vs. 13.6 (95% CI 8.0-19.2), p<0.001). Proportion of women who did not require opioids post-operatively was higher in the 8mm group (45.2%, n=19) than the 10-12mm group (18.0%, n=9) (cOR 3.76, 95% CI 1.47-9.66). Similarly, the proportion of women who did not fill an opioid prescription after discharge was higher in the 8mm group (35.7%, n=15) than the 10-12mm group (16.0%, n=8) (cOR 2.92, 95% CI 1.09-7.81). These results remained statistically significant after adjustment for age, body mass index, race/ethnicity, length of procedure, and concomitant procedures performed.

CONCLUSION

Compared to 10-12mm port, use of an 8mm LAP during laparoscopic native-tissue apical POP surgery is associated with decreased opioid use in the first 24 hours after surgery.

[A rare case of gerniation and incarceration of the gallbladder]

The authors report a rare case of herniation and incarceration of the gallbladder at the site of abdominal drainage tube deployment in a patient undergoing treatment for aortic valve disease. An incarcerated postoperative ventral hernia was confirmed by contrast-enhanced CT of the abdomen. Emergency surgery was not indicated due to spontaneous reduction, short duration of incarceration and no peritoneal signs. This case reminds us the possibility of ventral hernias, containing the gallbladder, at the site of abdominal drainage tube deployment. According to the literature, untimely diagnosis of this event can result fatal consequences.

Incarcerated 5-mm Port Site Hernia: A Systematic Literature Review and Case Report

Background

Port site hernias are a recognized complication of laparoscopic surgery and carry a high risk of strangulation because of the small size of the defect involved. Most hernias occur in trocar sites that are larger than 10 mm. This has resulted in the accepted practice that fascial defects larger than 10 mm are closed, incorporating the peritoneum and fascia, whereas defects less than 10 mm are not closed.

Results

We report a port site hernia at a 5-mm port site in a 90-year-old woman after ventral rectoplexy. A systematic review of literature found 27 cases of 5-mm port site herniation: 10 cases in general surgery and 17 cases in gynecological surgery.

Conclusion

The possibility of herniation through 5-mm port sites should be known to avoid a delay in recognition, diagnosis, and treatment.

The "Flip-Flap" Technique for Laparoscopic Port-Site Closure-Description of a Novel, Cost-Effective Technique with Review of Literature

Overview  Laparoscopic approach has changed the face of surgical care offered to patients. Almost all surgical procedures across specialties are now undertaken by the laparoscopic approach. Closure of port sites to prevent trocar-site hernias (TSHs) forms an integral part of the laparoscopic procedure. TSH is an area of preventable surgical morbidity. We hereby report our technique that is easily applicable, simple, safe, and highly cost-effective. It requires no additional instruments or retractors, is easy to learn, and has a very favorable safety profile.

Materials and Methods  This prospective case series enrolled a total of 454 port-site closures in 255 patients undergoing different laparoscopic procedures over a period of 2 years. The intraperitoneal tissue forceps were used in the reverse direction to lift the fascia up and a right-angled retractor was used to retract back the skin and subcutaneous tissue. The port-site closure is done under vision and no adverse events were reported.

Results  This technique was used in 454 port sites in 255 patients. No intraoperative incidents were noted. There is no requirement of any specialized instruments or retractors. No additional tissue trauma or dissection is required. There is no extension of operative time. The technique is simple to learn and easy to teach. No bowel injuries or TSHs were reported during a follow-up of 26 months.

Conclusion  The described technique is easy, simple, cost-effective, and has a good safety profile.

Postoperative complications of colorectal cancer

Colorectal cancer is the third most common cancer, and surgery is the most common treatment. Several surgical options are available, but each is associated with a range of potential complications. The timely and efficient identification of these complications is vital for effective clinical management of these patients in order to minimise their morbidity and mortality. This review aims to describe the range of commonly performed surgical treatments for colorectal surgery. In addition, frequent post-surgical complications are explored with investigative options explained and illustrated.

Five-millimeter Trocar Site Hernia with a Parastomal Hernia Sac: A Case Report

Here, we report our experience with a 5-mm trocar site hernia (TSH) near a stoma. This is the first report describing the relationship between TSH and extraperitoneal colostomy. A 72-year-old man underwent laparoscopic abdominoperineal resection with extraperitoneal sigmoid colostomy and partial hepatectomy for rectal cancer accompanied by synchronous liver metastasis (pT3N1aM1a Stage IVA Union for International Cancer Control [UICC] 8th edition). The surgical procedures were completely performed without morbidity. After 1 year, he presented to our hospital with sudden nausea. Computed tomography (CT) revealed small bowel obstruction due to a 5-mm TSH, 1 cm from the stoma. The patient underwent laparoscopic hernia repair. The incidence of a 5-mm TSH is low. However, an abdominal wall vulnerability caused by the extensive exfoliation of the retroperitoneum due to the construction of the colostomy was observed, and the extraperitoneal colostomy influenced the onset of the 5-mm TSH. When the port and hernia sites are located in close proximity to each other, even a 5-mm trocar site may increase the incidence of TSH.

Low long-term incidence of incisional hernia after cholecystectomy: A systematic review with meta-analysis

BACKGROUND

Various surgical approaches are available for cholecystectomy, but their long-term outcomes, such as incidence of incisional hernia, are largely unknown. Our aim was to investigate the long-term incidence of incisional hernia after cholecystectomy for different surgical approaches.

METHODS

This systematic review and meta-analysis was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A protocol was registered on PROSPERO (CRD42020178906). Three databases were searched for original studies on long-term complications of cholecystectomy with n > 40 and follow-up ≥6 months for incisional hernia. Risk of bias within the studies was assessed using the Newcastle-Ottawa Scale and the Cochrane "risk of bias" tool. Meta-analysis of the incidence of incisional hernia after 6 and 12 months was conducted when possible.

RESULTS

We included 89 studies. Of these, 77 reported on multiport or single-incision laparoscopic cholecystectomy. Twelve studies reported on open cholecystectomy and 4 studies on robotic cholecystectomy. Weighted mean incidence proportion of incisional hernia after multi-port laparoscopic cholecystectomy was 0.3% (95% confidence interval 0-0.6) after 6 months and 0.2% after 12 months (95% confidence interval 0.1-0.3). Weighted mean incidence of incisional hernia 12 months postoperatively was 1.5% (95% confidence interval 0.4-2.6) after open cholecystectomy and 4.5% (95% confidence interval 0.4-8.6) after single-incision laparoscopic cholecystectomy. No meta-analysis could be conducted for robotic cholecystectomy, but incidences ranged from 0% to 16.7%.

CONCLUSION

We found low 1-year incidences of incisional hernia after multiport laparoscopic and open cholecystectomy, whereas risks of incisional hernia were considerably higher after single-incision laparoscopic and robotic cholecystectomy.

MDCT imaging in Spigelian hernia, clinical, and surgical implications

OBJECTIVE

Spigelian hernia is an uncommon congenital or acquired defect in the transversus abdominis aponeurosis with non-specific symptoms posing a diagnostic challenge. There is a paucity of radiology literature on imaging findings of Spigelian hernia. The objective of this study is to explore the role of MDCT in evaluating Spigelian hernia along with clinical and surgical implications.

MATERIALS AND METHODS

In this IRB approved, HIPAA compliant retrospective observational analysis MDCT imaging findings of 43 Spigelian hernias were evaluated by two fellowship-trained radiologists. Imaging features evaluated were: presence of Spigelian hernia, laterality, relation to "hernia belt" (between 0 and 6 cm cranial to an imaginary axial line between both anterior superior iliac spines), the hernia neck and sac sizes, hernia content, and other coexistent hernias (umbilical, incisional, inguinal). Patient's demographics (age, gender, BMI, conditions with increased intra-abdominal pressure) were also recorded for any correlation.

RESULTS

60% (26/43) of Spigelian hernias were located below the hernia belt while 33% (14/43) within the hernia belt and 7% (3/43) above the hernia belt. The most common subtype of Spigelian hernia encountered was interparietal (84%). The mean hernia neck diameter was 3.4 cm, mean hernia sac volume was 329 cc. Hernia content included: fat (43/43) bowel (23/43), fluid (3/43). 3 patients had no clinical history provided, the remaining 37 patients' clinical presentation was asymptomatic in 73% (27/37), acute abdominal pain in 5% (2/37) and chronic abdominal pain in 22% (8/37). None of the hernia were incarcerated and none of the patients underwent emergent surgery. No significant correlation was noted between Spigelian hernia and causes of increased intra-abdominal pressure. 90% of our patients had other abdominal hernias. 30.9 was the mean BMI (20.8-69.1).

CONCLUSION

Most of the Spigelian hernia occurred below the traditionally described hernia belt and the majority are of interparietal subtype that can be best diagnosed with MDCT in contrast to physical examination.

Guideline No. 412: Laparoscopic Entry for Gynaecological Surgery

OBJECTIVE

To evaluate the benefits and risks of laparoscopic surgery and provide clinical direction on entry techniques, technologies, and their associated complications in gynaecological surgery.

TARGET POPULATION

All patients, including pregnant women and women with obesity, undergoing laparoscopic surgery for various gynaecological indications.

OPTIONS

The laparoscopic entry techniques and technologies reviewed in formulating this guideline included the closed (Veress needle-pneumoperitoneum-trocar) technique, direct trocar insertion, open (Hasson) technique, visual entry systems, and disposable shielded and radially expanding trocars.

OUTCOMES

Implementation of this guideline should optimize decision-making in the selection of entry technique for laparoscopic surgery.

EVIDENCE

We searched English-language articles from September 2005 to December 2019 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library using the following MeSH search terms alone or in combination: laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Canadian Task Force on Preventive Health Care approach (Appendix A).

INTENDED AUDIENCE

Surgeons performing laparoscopic gynaecological surgery.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Incidence and risk factors for trocar-site incisional hernia detected by clinical and ultrasound examination: a prospective observational study

Background

Trocar site incisional hernia (TSIH) is the most frequent complication associated with laparoscopic surgery. Few studies currently describe its incidence or risk factors. The aim of this report is to determine the real incidence of TSIH and to identify risk factors.

Methods

A cross-sectional prospective study was performed including consecutive patients who underwent a laparoscopic procedure during a 4 months period. All the patients were assessed both clinically (TSIHc) and by an ultrasonographic examination (TSIHu). The main variable studied was the incidence of TSIH. A multivariate analysis was performed to identify risk factors.

Results

76 patients were included. 27.6% of patients were clinically diagnosed as having TSIH (TSIHc) but only 23.7% of those cases were radiologically confirmed (TSIHu). In the logistic regression analysis, age > 70 years (OR 3.462 CI 1.14–10.515, p = 0.028) and body mass index (BMI) ≥ 30 kg/m² (OR 3.313 CI 1.037–10.588, p = 0.043) were identified as risk factors for TSIH. The size of the trocar also showed statistically significant differences (p < 0.001). Mean follow-up time was 34 months.

Conclusions

TSIH is under-diagnosed due to the lack of related symptomatology and the inadequacy of the postoperative follow-up period. We detected discrepancies between the clinical and ultrasonographic examinations. TSIHu should be considered as the gold standard for the diagnosis of TSIH. Risk factors such as age, BMI and size of the trocar were confirmed. Patients should be followed-up for a minimum of 2 years.

Trial registration The study has been retrospectively registered in Clinicaltrials.gov on June 4, 2020 under registration number: NCT04410744

Special type trocar-site hernia with evisceration of the appendix following laparoscopic repair of a perforated duodenal ulcer

Trocar-site hernia is an uncommon complication of laparoscopic surgery and can be classified as early-onset, late-onset or special type. Special type hernias usually occur in the early postoperative period and result in evisceration of intra-abdominal contents through all layers of the abdominal wall without an overlying hernia sac. We present a case of special type herniation of the appendix through a 5-mm trocar site in the right iliac fossa following laparoscopic repair of a perforated duodenal ulcer. In this case, herniation occurred after removal of a drain inserted through the trocar site intraoperatively and was treated with emergent open appendicectomy. A number of patient and technical factors may be associated with an increased risk of trocar-site herniation including increasing age, elevated body mass index, increasing trocar size, longer procedure duration and absence of fascial closure. These factors must be borne in mind when planning trocar placement and number to reduce the risk of herniation.

Laparoscopic repair of lateral sided trocar site hernias

Objectives

Repair of trocar site hernia (TSH) has been mentioned in a limited number of studies. Trocar site hernias are mostly located in the umbilical region with a small size. Laparoscopic repair could be a choice due to the appearance of large defects and requirement of mesh repair for lateral sided TSH. We aimed to share our experience with laparoscopic repair of lateral sided trocar site hernia (LRTSH) with a long term follow up.

Material and Methods

Twenty-three patients who underwent LRTSH between March 2013 and July 2015 were included in our study. Four edges of the mesh were fixed with pre-tied 2/0 polypropylene suture for 9 patients initially (Group 1). Unexpected complication of chronic pain in 3 patients led us to revise our method and we avoided to position the mesh with transabdominal sutures for the rest of the patients (Group 2).

Results

Nineteen (82.6%) female and 4 (17.4%) male patients, with a mean age of 50.9 years underwent laparoscopic repair. Following the revision and avoiding transabdominal sutures to position the mesh, no complaint of chronic pain was observed, and the difference was statistically significant between the groups (p<0.05).

Conclusion

Previous laparoscopic surgery indicates the lack of obstacle in laparoscopic repair of TSH, and LRTSH can be considered as first option in treatment. Shorter mean operative time in obese patients and lack of recurrence in our series support this view. Using transabdominal sutures should be avoided to prevent chronic pain in LRTSH.

Feasibility of Single-Incision Plus One Port Laparoscopic Low Anterior Resection for Rectal Cancer

PURPOSE

Single-incision laparoscopic surgery is a recently developed minimally invasive surgical technique. We aimed to compare the feasibility and safety of single-incision plus one port laparoscopic low anterior resection (S+1-LAR) with those of multi-port laparoscopic low anterior resection (M-LAR) for mid-to-low rectal cancer.

METHODS

We retrospectively reviewed patient characteristics and surgical outcomes by assessing data collected from the medical records of patients who underwent elective laparoscopic low anterior resection for mid-to-low rectal cancer at the Gangneung Asan Hospital.

RESULTS

From April 2015 to April 2019, 52 patients underwent S+1-LAR (n=28) or M-LAR (n=24) for mid-to-low rectal cancer at Gangneung Asan Hospital. There were no significant between-group differences in clinical characteristics. The mean postoperative 1-day pain score was significantly lower in the S+1-LAR group. Surgical outcomes and postoperative complications did not differ significantly between the two groups.

CONCLUSION

S+1-LAR is a feasible and safe technique and is comparable with M-LAR in terms of surgical outcomes of patients with mid-to-low rectal cancer.

Trocar umbilical hernia repair by open suture repair and open suture-mesh repair in an ambulatory setting in comparison to recurrent and primary umbilical hernia repair

Reports on the ambulatory open repair of umbilical trocal hernias are missing. Patients with trocar, primary and recurrent umbilical hernia open suture and open suture–mesh repair with prospective follow-up were retrospectively evaluated. Patients received perioperative antibiotic prophylaxis, preemptive analgesia and modified anesthesia. In total, 171 patients with umbilical hernia (51 years, female 14%; male 86%) were treated with open suture (n = 29; 17%) and suture–mesh (n = 142; 83%) repair. In total, 10% of patients were treated for trocar hernia (late onset), 5% for recurrent hernia and 85% for a primary umbilical hernia. In total, 29% of trocar hernia repairs had minor complications associated with obesity (40%) and comorbidity (80%). Age, suture and suture–mesh repair were not associated with complications. According to guidelines for umbilical hernia repair open flat mesh may be useful in the treatment of trocar hernia.

Imaging Postoperative Abdominal Hernias: A Review with a Clinical Perspective

Postoperative internal hernia is a challenging but critical diagnosis in postoperative patients presenting with acute abdomen. Postoperative internal hernias are increasingly being recognized after Roux-en-Y gastric bypass (RYGB) and bariatric surgeries. These internal hernias have a high risk of closed-loop obstruction and bowel ischemia; therefore, prompt recognition is necessary. Computed tomography (CT) is the imaging modality of choice in cases of postoperative acute abdomen. Understanding the types of postoperative internal hernia and their common imaging features on CT is crucial for the abdominal radiologist. Postoperative external hernias are usually a result of defect or weakness of the abdominal wall created because of the surgery. CT helps in the detection, delineation, diagnosis of complications, and surgical planning of an external hernia. In this article, the anatomy, pathophysiology, and CT features of common postoperative hernias are discussed. Afterreading this review, the readers should be able to (1) enumerate the common postoperative internal and external abdominal hernias, (2) explain the pathophysiology and surgical anatomy of Roux-en-Y gastric bypass-related hernia, (3) identify the common imaging features of postoperative hernia, and (4) diagnose the complications of postoperative hernias.

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.

Incidence of acute postoperative robotic port-site hernias: results from a high-volume multispecialty center

Fascial closure at 8-mm robotic port sites continues to be controversial. As the use of the robotic platform increases across multiple abdominal specialties, there are more case reports describing reoperation and small bowel resection for acute port-site hernias. A retrospective review of all robotic abdominal surgeries performed from 2012 to 2019 at NYU Langone Medical Center was conducted. Patients who had a reoperation in our facility within 30 days were identified, and medical records reviewed for indications for reoperation and findings. The study included 11,566 patients, of which 82 patients (0.71%) underwent a reoperation related to the index robotic surgery within 30 days. Fifteen of 11,566 patients (0.13%) had acute port-site hernias, and 3 of these 15 patients required small bowel resection. Eleven of 15 acute port-site hernias (73%) were at 8-mm robotic port site, 2 of which required a small bowel resection. More than a third of the patients had a hernia at an 8-mm port site where a surgical drain had been placed. Considering that each robotic case, regardless of specialty, has three ports at a minimum, the true incidence of acute postoperative robotic port-site hernia is 0.032% (11/34,698), with the incidence of concomitant small bowel resection being 0.006% (2/34,698). The incidence of acute port-site hernias from 8-mm robotic ports is exceedingly low across specialties. Our results do not support routine fascial closure at 8-mm robotic port sites due to an extremely low incidence. However, drain sites require special consideration.

Trocar-site incisional hernia after laparoscopic colorectal surgery: a significant problem? Incidence and risk factors from a single-center cohort

BACKGROUND

Trocar-site incisional hernia (TSIH) after laparoscopic surgery has been scarcely studied. TSIH incidence and risk factors have never been properly studied for laparoscopic colorectal surgery.

METHODS

A retrospective analytic study in a tertiary hospital was performed including patients who underwent elective laparoscopic colorectal surgery between 2014 and 2016. Clinical and radiological TSIH were analyzed.

RESULTS

272 patients with a mean age of 70.7 years were included. 205 (75.4%) underwent surgery for a malignant disease. The most common procedure was right colectomy (108 patients, 39.7%). After a mean follow-up of 30.8 months 64 (23.5%) patients developed a TSIH. However, only 7 out of 64 (10.9%) patients with a TSIH underwent incisional hernia repair. That means that 2.6% of all the patients underwent TSIH repair. 44 (68.8%) patients had TSIH in the umbilical Hasson trocar. In the multivariate analysis, the existence of an umbilical Hasson trocar orifice was the only statistically significant risk factor for TSIH development.

CONCLUSIONS

Incidence of TSIH was high, although few patients underwent incisional hernia repair. Most TSIH were observed in the umbilical Hasson trocar, which was the only risk factor for TSIH development in the multivariate analysis. Efforts should be addressed to avoid TSIH in the umbilical Hasson trocar.

Trocar-site hernia after gynecological laparoscopic surgery: a 20-year, single-center experience

Background:

Trocar-site hernia (TSH) is a serious complication after laparoscopic procedures. Although it is a rare entity, it can have life-threatening consequences. This study aimed to retrospectively analyze the potential associated factors for TSH following gynecologic laparoscopy and summarize prevention strategies based on our experience.

Methods:

We searched for gynecological laparoscopic surgeries in the medical records system of Peking Union Medical College Hospital (PUMCH) from August 1998 to July 2018 and further sifted through the results for cases involving TSH. All included patients were divided into different groups according to patient characteristics, and the rate of TSH was compared among groups. Moreover, the detailed information of all patients with TSH was recorded and analyzed. Statistical analyses were performed with GraphPad Prism 6.

Results:

The approximate total rate of post-operative TSH among gynecologic laparoscopy procedures performed at PUMCH in the last 20 years was 0.016% (9/55,244). The rate of TSH was significant higher in elder patients (≥60 years old; 3/2686, 0.112%) than in younger patients (<60 years old, 6/52,558; 0.011%, P = 0.008). Moreover, the approximate rate of TSH was significantly higher after single-incision laparoscopic surgery (SILS, 2/534, 0.357%) than conventional laparoscopic surgery (7/54,710, 0.013%, P = 0.003). The average age of patients with TSH was 53.4 years (range, 35.0–79.0 years). Two of the nine patients had late-onset TSH following SILS; the other seven had early-onset TSH following conventional laparoscopy. Five TSH cases occurred at right lateral port sites, and the remaining three occurred at the umbilical port site. All patients underwent repair surgery, and one required small bowel resection.

Conclusion:

Older age and SILS are potential associated factors for TSH development, while reducing excessive manipulation and improving suturing skills, especially at the umbilical trocar site following SILS and the right lateral trocar site, can avoid herniation.

Laparoscopic Gastrectomy Using Instruments with a Minimal Diameter for Early Gastric Cancer: A Feasible Alternative to Conventional Laparoscopic Gastrectomy for Experienced Surgeons

Background: The application of laparoscopic surgery using instruments that are 3 mm or less in diameter for patients with early gastric cancer (EGC) has not yet been established. We aimed to evaluate the feasibility and safety of laparoscopic gastrectomy using instruments with minimal diameter. Methods: We retrospectively analyzed 41 patients who underwent laparoscopic subtotal gastrectomy with D1-positive lymph node dissection for EGC. Among them, 17 patients underwent laparoscopic gastrectomy using instruments with a minimal diameter (experimental group), while 24 patients underwent conventional laparoscopic gastrectomy (control group). In the experimental group, we used two 3-mm trocars, one 5-mm trocar, and the GelPOINT^® Advanced Access Platform. We compared operative outcomes between the two groups and assessed the learning curve of laparoscopic gastrectomy using instruments with minimal diameter. Results: The operative outcomes were similar between the two groups. The preoperative-to-postoperative day 2 ratio of neutrophil count in the experimental group was significantly lower than in the control group (2.07 versus 2.65; P = .038). Morbidity was not observed in the experimental group and 3 patients experienced complications in the control group, although it was not significantly different (P = .252). The operation time according to the accumulation of cases was stable without any significant change in the experimental group. Conclusions: Laparoscopic gastrectomy using instruments with minimal diameter is technically feasible and safe for EGC and could also be a good alternative to conventional laparoscopic gastrectomy to minimize the impact of surgical invasiveness when performed by experienced surgeons.

The Lister AirSeal® port closure technique - Initial patient outcomes

INTRODUCTION

The 12-mm AirSeal® port is widely used in robotically assisted laparoscopic prostatectomy due to its ability to maintain stable pneumoperitoneal pressures and smoke evacuation. However, it creates a potential risk of port site hernia. We have traditionally used EndoClose™ to perform full thickness closure of this port, but noted that patients experienced increased pain related to this procedure, which sometimes persisted for several months. Using the Da Vinci Si we performed peritoneal closure with 2-0 vicryl by switching the fourth arm to the right master controller. The external oblique sheath was closed outside with 1 Ethibond.

MATERIALS AND METHODS

We performed this closure in 20 consecutive patients (group 1). Postoperative day 1, 2 and post-discharge telephone consultation pain scores (1-10) were recorded and compared with the previous 20 consecutive patients who had the EndoClose closure (group 2).

RESULTS

We recorded an instructional video to enable reproduction of the new technique. The mean length of stay was 1.5 days for patients in group 1 and 1.9 days for those in group 2 (P = 0.04). There was no difference in operating time or average day 1 pain scores. Post-discharge follow-up call revealed 1 of 20 patients who had AirSeal port site pain in group 1 and 5 of 17 in group 2 (P = 0.04). Pain scores also tended to be higher for group 2.

CONCLUSIONS

Our preliminary analysis of this novel technique to close the AirSeal port in two separate layers improves postoperative pain related to this port site.

Trocar site closure with a novel anchor-based (neoClose®) system versus standard suture closure: a prospective randomized controlled trial

BACKGROUND

Patients with obesity have a higher risk of trocar site hernia. The objective of the present study was to compare a standard suture passer versus the neoClose^® device for port site fascial closure in patients with obesity undergoing laparoscopic bariatric surgery.

METHODS

This is a randomized, controlled trial with two parallel arms. Thirty five patients with BMI ≥ 35 kg/m² and undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass were randomized to each group. Port site fascial closure for trocars ≥ 10 mm was performed with the neoClose^® device in the study group and the standard suture passer in the control group. Primary outcomes were time required to complete closure and intensity of postoperative pain at the fascial closure sites. Secondary outcomes were intraabdominal needle depth and incidence of trocar site hernia.

RESULTS

The use of the neoClose^® device resulted in shorter closure times (20.2 vs 30.0 s, p = 0.0002), less pain (0.3 vs 0.9, p = 0.002) at port closure sites, and decreased needle depth (3.3 cm vs 5.2 cm, p < 0.0001) compared to the standard suture passer. There was no trocar site hernia at the one-year follow-up in either group.

CONCLUSIONS

Use of the neoClose^® device resulted in faster fascial closure times, decreased intraoperative needle depth, and decreased postoperative abdominal pain at 1 week as compared to the standard suture passer. These data need to be confirmed on larger cohorts of patients with longer follow-up.

Richter's hernia in a 5-mm trocar site

We present an unusual case of a trocar site incision hernia at a 5-mm trocar port occurring approximately 2 weeks post-operatively after a laparoscopic cholecystectomy. The patient, in her mid-60s, reported diffuse abdominal pain, constipation, nausea and vomiting. An abdominal X-ray demonstrated dilated small bowel loops with gas-fluid levels. Abdominal computed tomography revealed the small bowel herniation through the 5-mm port site. Laparotomy confirmed a Richter’s hernia of the small bowel in the fascia defect. This case highlights the necessity to examine and investigate any complaint post-operatively and deliberate its possible significance. Furthermore, it demonstrates that, even during a normal recovery period for a patient without any underlying disease or risk factors, a rare complication could still develop in a delayed fashion multiple days post-operatively from a laparoscopic procedure. High clinical suspicion is essential in order to avoid further deterioration of the patient condition and optimal treatment.

Clinical outcomes and inflammatory response to single-incision laparoscopic (SIL) colorectal surgery: a single-blinded randomized controlled pilot study

AIM

Single-incision laparoscopic (SIL) surgery is expanding, but its benefits, efficacy and safety compared with conventional laparoscopic (CL) surgery remain unclear. This pilot study examined clinical outcomes and biochemical markers of inflammation for colorectal resections by SIL and CL in a randomized controlled pilot trial.

METHOD

Fifty patients undergoing elective colorectal resection were randomized to either SIL or CL. Primary outcomes were operating time and length of stay (LoS); secondary outcomes included combined length of scars, pain scores, complications, Quality of Life EQ5D-VAS and the inflammatory markers interleukin-6 (IL-6), IL-8 and C-reactive protein (CRP) at baseline, 2, 6, 24 and 72 h.

RESULTS

There was no difference in age, gender, body mass index, indications and site of surgery, American Society of Anesthesiologists grade or incidence of previous surgery between the groups. Except for one conversion from SIL to open surgery, surgery was completed as intended. No difference between SIL and CL was found for operating time [median 130 (72-220) vs 130 (90-317) min, respectively, P = 0.528], LoS [median 4 (3-8) vs 4 (2-19)days, P = 0.888] and time to first flatus [2 (1-4) vs 2 (1-5) days, P = 0.374]. The combined length of scars was significantly shorter for SIL [4 (2-18) vs 7 (5-8) cm, P < 0.001]; in each group, four postoperative complications occurred (16%). Postoperative pain scores were similar [mean 7.67 (interquartile range 4) vs 7.25 (interquartile range 3.75), P = 0.835] to day 3. EQ5D-VAS was no different for both groups at discharge [72.5 (40-90) vs 70 (30-100), P = 0.673] but slightly higher for CL at 3 months [79 (45-100) vs 90 (50-100), P = 0.033].The IL-6, IL-8 and CRP levels between both groups showed similar peaks and no significant differences.

CONCLUSION

SIL colorectal surgery by experienced laparoscopic surgeons appears to be safe and equivalent to CL, with no discernible difference in its effect on the physiological response to surgical trauma.

Efficacy and reliability of the use of a needle grasper to prevent trocar site hernia

Introduction

Port site herniation is one of the serious complications of laparoscopic surgery, which decreases its benefits. Closure of a fascia defect at the port site is an important problem of laparoscopic surgery, especially in obese patients.

Aim

To evaluate needle grasper fascia closure.

Material and methods

We closed the port site fascia using a percutaneous organ-holding device (needle grasper) in laparoscopic cholecystectomy patients. This study included 334 patients who underwent laparoscopic cholecystectomy between January 2015 and January 2017 in our hospital. Patients were divided into 2 fascia closure groups: group 1 with a standard simple suturing technique and group 2 with a needle grasper to close the port site. Patient demographics, operative details, and postoperative outcomes were collected and evaluated.

Results

There were 243 female and 91 male (total 334) patients with the mean age of 49.18 ±13.15 years. Only 1 patient in the BMI > 30 kg/m² group of patients had port site hernia development with the needle grasper technique at the end of the 8-month follow-up period. The port site hernia incidence was higher in group 1 than group 2 (p < 0.001), but there was no significant difference in terms of operation duration between the two groups (p < 0.001, p = 0.709, respectively). In patients with a BMI > 30 kg/m², both operation duration and port site hernia incidence were higher in simple suture closure than in the needle grasper technique (p < 0.001, p = 0.016, p = 0.005).

Conclusions

The needle grasper technique is easy, simple, safe, fast, and effective for fascia closure of port sites. This method can also be applied in obese patients easily, safely and in a short time.

Port insertion for minimally invasive surgery: a report of practices in the Irish Republic

BACKGROUND

With rapidly evolving surgical technologies, minimally invasive surgery (MIS) has become the mainstay approach for many surgeons worldwide. As laparoscopic surgery was introduced in Ireland over two decades ago, we may be encountering a higher prevalence of related complications.

AIMS

This study aimed to gather data pertaining to risk factors for port-site herniation in MIS.

METHODS

A 14-point anonymous questionnaire was distributed electronically between January and May 2017 to consultant and trainee laparoscopists in the Republic of Ireland. This survey related to laparoscopic volume and surgical approaches to laparoscopic port-sites.

RESULTS

There were 172 eligible responses nationally. Approaches to peritoneal access included Hasson, veress (blind puncture) and SILS were 66.3, 32.6 and 1.2%, respectively. Senior surgeons and specialists in Obstetrics and Gynaecology (OBGYN) reported significantly higher utilisations of closed peritoneal access (p < 0.05). Of the participants, 119 (69.2%) reported using a bladeless trocar over a bladed type. Fascial closure was utilised in 94.2% of ≥ 10 mm and 2.3% of 5-mm ports using absorbable suture in 76.7%, non-absorbable suture in 14.5% and port closure devices in 8.7%. Perceptions of risk factors for PSH were not congruent with significant variations in responses between levels of expertise.

CONCLUSIONS

This study demonstrates significant variations in laparoscopic port-site practices amongst surgeons nationally. The new era of practitioners may benefit from evidence-based technical workshops and guidelines to increase awareness and reduce potential complications.

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.

Laparoscopic ventral hernia repair using only 5-mm ports

BACKGROUND

The technique of laparoscopic ventral hernia repair has been evolving since it was first described over 20 years ago. We report a new technique where polyester mesh was back loaded through a 5-mm port site, coming into contact with the skin. This avoids the need for any 10-12-mm ports.

METHODS

A prospective database of laparoscopic ventral hernia repairs was examined. A single surgeon performed 344 laparoscopic ventral hernia repairs using this technique over 60 months. Follow-up was conducted by both clinical and independent phone review.

SURGICAL TECHNIQUE

Laparoscopic access was achieved via a 5-mm optical port, adding two, or occasionally three, 5-mm extra ports. Hernia contents were reduced and the extra-peritoneal fat excised; 5-mm tooth graspers were placed through the lateral port and then in a retrograde fashion through the uppermost port. The port was removed, and the mesh pulled back into the abdominal cavity and positioned with a minimum of 3-cm overlap. The mesh was fixed using absorbable tacks and sutures.

RESULTS

Most patients had primary umbilical hernias. There was one case of mesh infection due to enteric organisms. This occurred in a patient undergoing repair of a stoma site hernia, resulting from a Hartmann's procedure for perforated diverticulitis. There was no other evidence of acute or chronic mesh infection despite cutaneous contact with the mesh. In this series, there was an overall hernia recurrence rate of 2.4%.

CONCLUSION

Laparoscopic ventral hernia repair using only 5-mm ports is a safe, effective technique with no extra risk of infection.

Quality criteria in bariatric surgery: Consensus review and recommendations of the Spanish Association of Surgeons and the Spanish Society of Bariatric Surgery

Bariatric surgery has proven to be highly effective in controlling obesity and metabolic syndrome; the results of this surgery are not only expressed in terms of weight loss, but also in terms of resolution of comorbidities, improved quality of life and complications. The different parameters used to measure these outcomes require uniformity and reference patterns. Therefore, it is essential to identify those indicators and quality criteria that are helpful in defining the «best practice» principles in bariatric surgery. In this regard, the Section of Obesity of the Spanish Association of Surgeons, in collaboration with the Spanish Society for Bariatric Surgery (SECO), present as an objective to identify the key points that define «quality» in this type of surgery. We describe the main indicators based on the published literature as well as the criteria for referral of the main comorbidities according to the evidence found and grades of recommendation.