Trocar site hernia

OBJECTIVE: To review the relationship between the pathogenesis and clinical manifestations of trocar site hernias seeking to confirm the definition of trocar site hernias by classification. DATA SOURCES: We searched this subject in English on MEDLINE by combining the words "trocar," "port," "hernia, and "laparoscopy."Data Extraction and STUDY SELECTION: We limited the main operations to cholecystectomy, colon and rectal surgery, fundoplication, and gastric surgery; finding 44 reports on these procedures. Of these, 19 were case reports, 18 were original articles (setting criteria; the incidence of the trocar site hernia was clarified, and involved >100 patients), and 7 technical notes on "how to do it" were collected. We obtained 19 additional reports using the references of those previously obtained. We, thus, reviewed 63 reports (24 case reports, 27 original articles, 7 technical notes, and 5 review articles). DATA SYNTHESIS: Trocar site hernia was classified into 3 types. The early-onset type that occurred immediately after the operation, with a small-bowel obstruction, especially the Richter hernia, frequently developing. The late-onset type that occurred several months after the operation, mostly with local abdominal bulging with no small-bowel obstruction developing. The special type that occurred indicated the protrusion of the intestine and/or omentum. Trocar site hernias with fascial defects of 10 mm or larger should be closed, including the peritoneum. Opinion varied if a 5-mm trocar site defect should be closed. CONCLUSION: It is useful to clearly classify trocar site hernias to improve management of laparoscopic procedures.     

Transabdominal preperitoneal repair of a port-site incisional hernia

A 47-year-old woman presented with an incisional hernia at the site of a 10-mm port placed in the left iliac fossa during laparoscopic oopherectomy performed 6 years previously. The hernia was repaired laparoscopically by a transabdominal preperitoneal approach using one 10-mm and two 5-mm ports. Adherent omentum was reduced from the sac and a wide flap of peritoneum extending 5 cm on all sides of the fascial defect was raised. The peritoneum was circumcised around the neck of the sac, leaving the sac undisturbed. A 12 x 12 cm polypropylene mesh was placed in the preperitoneal plane and secured in place with endoscopic spiral tackers. The peritoneal incision was approximated with a running 2-0 polyglactin suture. The patient had an uneventful recovery and was discharged after 48 hours. She resumed normal activity within 5 days and remains well one year later. A transabdominal preperitoneal repair seems a feasible alternative for repair of port-site incisional hernias that usually occur through a single and small fascial defect.     

Laparoscopic 5-mm trocar site herniation and literature review

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.     

Trokarhernien Eine seltene, potenziell gefährliche Komplikation nach laparoskopischen Eingriffen

With increasing numbers of laparoscopic procedures more postoperative trocar site hernias can be expected. This complication of minimally invasive surgery is rare but potentially dangerous. According to the literature, the overall incidence of trocar site hernias is expected to be around 1%. Among trocar site hernias, Richter's hernias are the most frequent, accounting for two-thirds of all small intestinal hernias. The following risk factors for the development of trocar site hernias have been identified: the trocar diameter, the trocar design, preexisting fascial defects, and some operation- and patient-related factors. Peritoneal and fascial closure should be done when blunt trocars of >10 mm have been employed. Based on the literature and our own experience, some preventive recommendations are given to further reduce the risk of hernia formation at trocar sites.     

Revision laparoscopy for incarcerated hernia at a 5-mm trocar site following pediatric laparoscopic surgery

We report the case of a 6-month-old female infant who developed post-operative bowel obstruction due to an incarcerated hernia through a 5-mm laparoscopic wound. The patient underwent laparoscopic Nissen fundoplication for gastroesophageal reflux. On day 6, she showed symptoms of ileus, and the diagnosis of a trocar wound hernia was made on day 13. The herniated intestine was reduced and the defective peritoneum and fascia were closed under relaparoscopic guidance, thus avoiding full-scale laparotomy. A trocar wound hernia causing early postoperative bowel obstruction is a rare complication, especially at 5-mm trocar puncture sites. Intraoperative dislodgment and reinsertion of working trocars may create fascial defects larger than the actual size of the trocar. All laparoscopic puncture wounds, even those <10 mm in size, should be closed at the fascial level in infants. Revision laparoscopy is considered preferable to manage trocar site complications in children.     

VersaStepTM trocar hernia rate in unclosed fascial defects in bariatric patients

Objective Use of the VersaStep^TM trocar system (US Surgical, Norwalk, CT) has the perceived advantage of minimal trocar-related hernias in patients undergoing Roux-en-Y gastric bypass surgery (RYGB). We performed a retrospective review of our last 747 consecutive operative procedures using these trocars. Methods and procedures The patient population was 747 consecutive patients who underwent laparoscopic RYGB at Duke University Health System Weight Loss Surgery Center from January 2002 through April 2005. A total of 3735 radially expanded trocar sites were used. VersaStep^TM trocars were used in all cases. The port configuration included one supraumbilical Hasson port, two 12-mm ports, and three 5-mm ports. The Hasson port was closed with a figure-of-eight number 1 Polysorb suture. All other trocar sites had no fascial closure. Intestinal anastomoses were created with a linear stapler in all of the laparoscopic cases, with hand suturing of the residual enterotomy. The fascial incisions were therefore not extended to accommodate an EEA stapler. The charts were reviewed for occurrence of subsequent trocar site hernias. Results There were no hernias at any of the VersaStep^TM trocar sites—an incidence of 0%. There were nine incisional hernias at the Hasson port site which later required surgical repair—an incidence of 1.20%. Conclusions There were no hernias detected at any of the 1494 12-mm or 2241 5-mm VersaStep^TM trocar sites, despite lack of suture closure. At the Hasson port site, there was a hernia incidence of 1.20%. In the bariatric RYGB population, routine suture closure of the fascia or muscle is not necessary when using radially expanding VersaStep^TM trocars.     

Preperitoneal Herniation Into a Laparoscopic Port Site Without a Fascial Defect

Background: Port site herniation is an uncommon event that usually occurs as a result of incomplete fascial closure. This allows the omentum or viscera to herniate through the incompletely closed defect. However, in laparoscopic surgery for morbid obesity, the omentum and viscera can herniate through the thick preperitoneal space even with a complete closure of the fascia. Case Report: A 19-year-old female with BMI 55 underwent uneventful long limb laparoscopic Roux-en-Y gastric bypass. On postoperative day 1 the patient had limited pain, was ambulating well, and was tolerating sips of liquids. A limited upper GI series performed on postoperative day 2 revealed no leak or obstruction. Several hours later the patient developed abdominal pain associated with nausea, which progressed to vomiting. CT of the abdomen suggested a port site herniation into the left subcostal port. The cause of the obstruction appeared to be herniation through the left subcostal port site. At laparotomy, a segment of bowel just distal to the anastomosis was found herniated through the port site. The Richter's hernia was reduced. Careful inspection of the fascia revealed a complete fascial closure, with the strangulated portion of the bowel incarcerated in the preperitoneal space. Following repair of the preperitoneal defect, her subsequent recovery was unremarkable. Conclusion: Laparoscopic surgery for morbid obesity presents the possibility for preperitoneal herniation. Closure, using a fascial closure device, under laparoscopic control, may offer a solution by closing both the fascia and peritoneum all at once.     

Application of a Trocar Wound Closure System Designed for Laparoscopic Procedures in Morbidly Obese Patients

Herniation into the trocar-site is a relatively common complication of laparoscopic surgery, and represents a serious cause of morbidity because of the potential to develop into a Richter's hernia. The risk of trocar-site herniation is greater in obese and bariatric patients, because of the larger preperitoneal space and elevated intra-abdominal pressure; thus, fascial closure alone is not adequate. Full-thickness trocarwound closure can prevent this complication. However, hand suturing and some port-closure devices can be difficult to use in this patient group. We report on the use of a specialized trocar wound closure system designed for use on obese and bariatric patients. In this report, we describe use of the system in the case of a 34-year-old Caucasian female who underwent a laparoscopic Roux-en-Y gastric bypass procedure.     

Endoscopic extraperitoneal repair of a Grynfeltt hernia

There are three types of lumbar hernia: congenital, acquired, and incisional hernias. Acquired hernia can appear in two forms: the inferior (Petit) type and the superior type, first described by Grynfeltt in 1866. We report endoscopic extraperitoneal repair of a Grynfeltt hernia. A 46-year-old woman presented with a painful swelling in the left lumbar region that had caused her increasing discomfort. The diagnosis of Grynfeltt's hernia was made, and she underwent surgery. With the patient in a left-side decubitus position, access to the extraperitoneal space was gained by inserting a 10-mm inflatable balloon trocar just anteriorly to the midaxillary line between the 12th rib and the superior iliac crest through a muscle-splitting incision into the extraperitoneal space. After the balloon trocar had been removed a blunt-tip trocar was inserted. Using two 5-mm trocars, one above and another below the 10-mm port in the midaxillary line, the hernia could be reduced. A polypropylene mesh graft was introduced through the 10-mm trocar and tacked with spiral tackers. The patient could be discharged the next day after requiring only minimal analgesics. At this writing, 2 (1/2) years after the operation, there is no sign of recurrence. This Grynfeltt hernia could safely be treated using the extraperitoneal approach, which obviates opening and closing the peritoneum, thereby reducing operative time and possibly postoperative complications.     

Transballoon trocar insertion during preperitoneal hernia repair

Trocar insertion during laparoscopic preperitoneal hernia repair (TEP) can be troublesome because the space into which the trocars are inserted is smaller than that available for transabdominal approaches. Insertion of the trocars directly into the balloon used to dissect the preperitoneal space can facilitate this process. The insertion of a 5-mm trocar into the balloon does not usually result in balloon deflation, and a second trocar can be placed into the balloon as well. Removing the balloon, despite the trocars inside it, is straightforward, allowing the placement of a cannula at the balloon insertion site and initiation of the hernia repair.     

Prophylactic Closure of Trocar Orifices with an Intraperitoneal Mesh (Ventralex®) in Laparoscopic Bariatric Surgery

Laparoscopic surgery reduces, but not eliminates, the rate of incisional hernia. It is accepted that large trocar orifices should be sutured, in order to prevent future herniation. In morbidly obese patients, the closure of the anterior fascia is a very difficult job, and it does not prevent from preperitoneal herniation. Ventralex composite mesh is a very easy-to-place device, which closes satisfactorily both the peritoneal opening and the subcutaneous trocar pathway. We recommend its use for large diameter orifices and Hasson orifices in bariatric patients.     

Totally extrafasdal endoscopie preperitoneal hernia repair: a merger of anatomy and surgery. The exact description to endoscopkally dissect the spermatic fascia

Summary  Stoppa introduced giant preperitoneal mesh repair after parietalisation of the cord in inguinal hernias. Based on this principle, a preperitoneal mesh is inserted during the laparoscopic transabdominal preperitoneal (TAPP) repair. Central to the Stoppa operation is identification of the bloodless plane between peritoneum and urogenital fascia. Dissection of this plane has not been described for the TAPP hernia repair. We present a reproducible, anatomicallybased method of finding and dissecting the urogenital fascia in the TAPP. Methods: After routine peritoneal incision, the urogenital fascia is identified late-rally in the Bogros space, where it is loosely adherent to the peritoneum. Here, developing the cleavage plane between the fascia and peritoneum is easy. The dissection is extended medially into the space of Retzius. Once the medial and lateral planes have been dissected, reducing the hernia sac is uncomplicated and bloodless. Because the urogenital fascia continues around the cord structures as the spermatic sheath, there is no danger of damaging these and it is easy to parietalise the vas deferens and testicular vessels. The mesh is then inserted true to the original dictates of Stoppa. Discussion: The precise preperitoneal dissection plane has not been elucidated for laparoscopy. The fascial anatomy in the groin is a complex arrangement between peritoneum, urogenital fascia and transversalis fascia. Dissection between the correct fascial layers allows rapid identification of the exact anatomy in an avascular plane. This ensures true parietalisation of the cord structures in an ordered and anatomically correct fashion.     

Trocar site hernia after laparoscopic cholecystectomy

AIM: The aim of this study was to elucidate the influence of pre and perioperative factors on the development of trocar site hernia after a laparoscopic cholecystectomy procedure. PATIENTS AND METHODS: A total of 776 patients who underwent a laparoscopic cholecystectomy procedure in our Department of General Surgery between 1999 and 2004 were assigned as the study group. The control group included patients without trocar site hernias after a cholecystectomy. The effect of five variables, including gender, age, body mass index (BMI), operation duration, and the type of cholecystitis on the development of a trocar site hernia after a laparoscopic cholecystectomy was assessed by univariable and multivariable models. RESULTS: In the univariate analysis, female gender (P = 0.021), older age (P < 0.001), higher BMI at the time of surgery (P < 0.001), and an increased duration of surgery (P < 0.001) have been found to increase the likelihood of a trocar site hernia formation. However, in the multivariable model, the gender was not a significant variable to influence the development of this complication. CONCLUSIONS: The development of a postoperative trocar site hernia may be prevented by the closure of 10-mm trocar sites in patients who are older than 60 years, obese, and who have a longer duration of operation.     

Prevention of trocar site incisional hernia following laparoscopic ventral hernia repair.

BACKGROUND AND OBJECTIVES: Trocar-site incisional hernia following laparoscopic ventral hernia repair is reported to have a relatively high incidence. The main reasons are trocar diameter and design, pre-existing fascial defects, and some operation- and patient-related factors. The aim of this article to show a new technique of ventral hernia repair that could prevent trocar site incisional hernia. METHODS: After establishing the pneumoperitoneum, three 5-mm ports are inserted in positions according to the site and size of the hernia. The procedure begins by dissection of the adhesions of bowel loops or omentum (if any) from the hernia to clear a good margin for mesh coverage. Then a single 10-mm to 15-mm port (mesh insertion port) is inserted in the center of the ventral hernia depending on the size of the mesh. The mesh is fixed in position with a 5-mm tacker. The peritoneum and underlying superficial fascia are carefully closed before closing the skin. RESULTS: A total of 35 patients were recruited for this method. The mean hospital stay was 1.5 days, the mean age was 50.35 years and the mean operative time was 40 minutes. In all patients, 10x15-cm ePTFE was used. No single incidence of trocar-site incisional hernia occurred during a mean follow-up of 2 years. Three (8.57%) patients developed complications and no mortality was reported. CONCLUSION: The mesh introduction through the port, which is situated at the center of the hernia defect is a simple, cost-effective technique and will prevent trocar-site incisional hernia.     

Laparoscopic port sites do not require fascial closure when nonbladed trocars are used

The development of nonbladed obturators with integrated stability sleeves allows for creation of a muscle-splitting dilated laparoscopic port site with minimal abdominal wall defects after removal of trocar sleeves. Our objective was to determine the safety of using nonbladed obturators and not closing laparoscopic fascial port sites. Seventy patients underwent various laparoscopic procedures including the following: seven laparoscopic Roux en Y gastric bypasses, 21 laparoscopic cholecystectomies, 23 laparoscopic hernia repairs, 10 laparoscopic Nissen fundoplications, two laparoscopic appendectomies, two laparoscopic liver biopsies, one laparoscopic common bile duct exploration, one laparoscopic jejunal resection, one laparoscopic low anterior resection, one laparoscopic splenectomy, and one bedside diagnostic laparoscopy. A total of 180 laparoscopic port sites did not undergo fascial closure involving 110 10- to 12-mm ports. One hundred eighty nonbladed trocars were inserted without complication during laparoscopic surgery. In all cases the nonbladed obturator did not cause bleeding or injure viscera. Upon removal of large laparoscopic ports, the fascial defect was less than 6 to 8 mm, and the muscles of the abdominal wall covered the port site defect. The anterior fascial defect did not line up with the posterior fascial defect after removal of CO2 insufflation. No patients have developed ventral incisional hernias in the postoperative period (median follow-up of 11 months). We conclude that the use of nonbladed laparoscopic trocars is a safe technique with the ability to visualize dissection through the abdominal wall layers to create the smallest port dissection without bleeding or cutting muscle fibers. The ability to split the abdominal wall musculature allows the surgeon to forego closure of the small fascial defect.     

Omental herniation through a 3-mm umbilical trocar site: unmasking a hidden umbilical hernia.

BACKGROUND: The incidence of umbilical hernia following laparoscopic surgery varies from 0.02-3.6%. The incidence of pre-existing fascial defects, however, may be as high as 18% in patients undergoing abdominal laparoscopic surgery. Previous recommendations have been made to close any fascial defect greater than or equal to 10 mm. Reported here is a case of herniation through a 3-mm trocar site incision and the discovery of a pre-existing fascial defect. CASE REPORT: A 32-year-old female underwent an uncomplicated laparoscopic tubal ligation using a 3-mm umbilical port. Prior to umbilical trocar removal at the completion of the case, the carbon dioxide was evacuated from the abdomen and the sleeve was withdrawn under direct vision. Neither the fascial nor skin incisions were sutured. On postoperative day two, the patient returned with omentum herniating from the 3-mm site. At surgery, a 1.5-cm pre-existing fascial defect was discovered adjacent to the trocar site. The hernia sac tracked laterally to the base of the umbilicus, and the omentum had slid into the sac and out the skin opening. CONCLUSION: As this report illustrates, herniation associated with laparoscopic trocar sites can occur with incisions as small as 3 mm. The presence of pre-existing fascial defects can cause increased morbidity in any laparoscopic surgery, and as illustrated in this report, may predispose the patient to site herniation. The detection and management of these defects is crucial in preventing postlaparoscopic complications.     

Trocar site herniation of the small bowel after laparoscopic bilateral adnexectomy despite fascial closure: a case report

In this paper we report a case of an incarcerated hernia occurring through the peritoneal and muscular defect caused by a previous trocar insertion. The patient developed the hernia eight days after bilateral laparoscopic adnexectomy and presented small bowel obstruction signs. This hernia occurred despite correct closure of the internal oblique fascia. The patient was re-operated and exploratory laparoscopy confirmed the diagnosis. The hernia was reduced via a small extension of the previous incision, and the defect was repaired by separated stitches. This case shows that a trocar site hernia can appear despite correct closure of the fascia, which is poorly described except for obese patients. It suggests the need for careful closure of the abdominal wall including the peritoneum after a laparoscopic procedure. Trocar site hernia has to be considered in cases of post laparoscopic small bowel obstruction. We reviewed the literature and found no randomized control study concerning this problem: only reviews, retrospective studies, case reports and technical notes. These papers are discussed and compared with our case.     

Trocar Site Herniation of the Small Bowel After Laparoscopic Bilateral Adnexectomy Despite Fascial Closure: a Case Report

In this paper we report a case of an incarcerated hernia occurring through the peritoneal and muscular defect caused by a previous trocar insertion. The patient developed the hernia eight days after bilateral laparoscopic adnexectomy and presented small bowel obstruction signs. This hernia occurred despite correct closure of the internal oblique fascia. The patient was re-operated and exploratory laparoscopy confirmed the diagnosis. The hernia was reduced via a small extension of the previous incision, and the defect was repaired by separated stitches. This case shows that a trocar site hernia can appear despite correct closure of the fascia, which is poorly described except for obese patients. It suggests the need for careful closure of the abdominal wall including the peritoneum after a laparoscopic procedure. Trocar site hernia has to be considered in cases of post laparoscopic small bowel obstruction.

We reviewed the literature and found no randomized control study concerning this problem: only reviews, retrospective studies, case reports and technical notes. These papers are discussed and compared with our case.     

Radially expanding laparoscopic trocar ports significantly reduce postoperative pain in all age groups

Background  

Trocar entry points have been identified as a significant source of pain after laparoscopic surgery. This is particularly true of the larger 12-mm ports that require deep fascial closure to avoid port-site herniation. We investigated whether using radially expanding trocars not requiring fascial closure compared to conventional cutting trocars for the 12-mm port in transabdominal preperitoneal (TAPP) hernia repairs had any effect on postoperative analgesic requirements and return to work or normal activity.     

Port-site closure: a new problem, an old device.

OBJECTIVE: Trocar-site incisional hernias and their complications are reported in 1% to 6% of patients. Such hernias are attributed to the difficulty of applying standard suturing techniques to wound closure. We report our experience with a simple device, the Deschamps ligature needle. METHODS: The Deschamps needle has a handle and a tip (sharp or blunt), with an opening to pass suture. The blunt tip is very effective for closing trocar sites. Disposable needles are obviously sharp, but can bend on the needle holder and break in a deep small incision. The Deschamps needle is a rigid, noncutting instrument that can be forced through fascia and peritoneum (around the surgeon's fingertip) avoiding loss of pneumoperitoneum. A full-thickness closure is accomplished. We perform closure under direct vision through the scope. Tactile sense is provided by the surgeon's finger. The last trocar site is closed in the same manner without the scope. RESULTS: We have used the Deschamps needle since 1992 in all (1400) laparoscopic procedures. We close 10-mm and 5-mm trocar sites and have not observed wound dehiscence or hernias at these sites. CONCLUSION: The Deschamps needle is effective in preventing incisional hernias and wound dehiscence. It is cost-effective. Disposable, single-use devices vary in price from $30 to $75 each. The Deschamps needle is sold in Italy at approximately $35 each. Considering that it may have been in the trays of most operating rooms for years (as in our case), and the number of procedures performed, we conclude that the real cost of this instrument is almost negligible.