Port site metastasis after robotic-assisted laparoscopic hysterectomy for uterine cervical cancer: A case report and literature review

ObjectiveThe incidence of port site metastasis after robotic-assisted laparoscopic surgery for cervical cancer is not well known. According to recent studies of gynecological malignancies, the reported incidence is low and comparable to the results of conventional laparoscopic surgery. Here, we report the case of a patient who suffered port site metastasis after robotic-assisted laparoscopic hysterectomy for stage IB1 uterine cervical cancer.Case reportThe current case is, as we know, only the third episode of port site metastasis after robotic-assisted laparoscopic surgery for cervical cancer documented in the medical literature. Following diagnosis of the port site metastasis, the patient was treated with concurrent chemoradiotherapy (CRT) and experienced a remarkable early response. We reviewed the patient's medical chart and imaging studies, and searched the Medline database to evaluate the incidence, prognosis and treatment outcomes of such cases of port site metastasis in uterine cervical cancer patients.ConclusionCRT resulted in a rapid decrease in tumor size and relief of abdominal pain in our patient. CRT might be considered as a salvage or palliative modality in patients with port site metastasis and/or locoregional recurrence.     

Port site metastasis of ovarian carcinoma remote from laparoscopic surgery for benign disease

BACKGROUND: The use of laparoscopic surgical procedures has continued to expand due to the many advantages that this surgical approach offers. However, as we continue to realize the benefits and expand the scope of laparoscopic procedures, new complications may occur. CASE: This is the case of a 77-year-old gravida 2 para 2 who underwent exploratory laparotomy and surgical staging with optimal cytoreduction for Stage IIIC papillary serous ovarian carcinoma in February 1998. Her past surgical history was significant for total abdominal hysterectomy and left salpingo-oophorectomy in 1955 for symptomatic leiomyomata and for a laparoscopic cholecystectomy in July 1997. After initial platinum-based chemotherapy, she presented with an enlarging nodule at the right upper quadrant laparoscopic port site. Fine needle aspiration confirmed recurrent papillary serous ovarian carcinoma. After a discussion of her options, she elected to undergo surgical resection with postoperative salvage chemotherapy. CONCLUSION: Port site recurrences have been previously reported in patients who underwent initial surgical evaluation for ovarian carcinoma utilizing the laparoscopic approach. However, it is unusual for recurrent cancer to appear in port sites or operative incisions not related to the initial cancer surgery. This report serves to caution the gynecologic oncologist that the first evidence of recurrence may be at a laparoscopic port site from prior benign gynecologic or nongynecologic surgery.     

Laparoscopic port-site recurrence following surgery for a stage IB squamous cell carcinoma of the cervix with negative lymph nodes

BACKGROUND: Port-site metastases are commonly reported after laparoscopic surgery for ovarian cancer, but have also been reported in patients with cervical or endometrial cancer with positive lymph nodes. Recently, a case of port-site recurrence after laparoscopic surgery for a patient with node-negative early-stage adenocarcinoma of the cervix was reported. We report the first case of port-site metastasis in a patient with stage IB squamous cell carcinoma of the cervix with negative lymph nodes. CASE: A 31-year-old woman had a laparoscopy for pelvic pain. Under anesthesia, she was noted to have a grossly abnormal-looking cervix and a biopsy revealed squamous cell carcinoma. She was referred to a gynecological oncologist and underwent radical hysterectomy and pelvic lymph node dissection through a transverse lower abdominal incision 6 weeks later. Nineteen months postoperatively, she presented with a soft tissue mass in a suprapubic laparoscopic trocar site. CONCLUSION: It is postulated that cells dislodged at the time of cervical manipulation and biopsy may have passed through the fallopian tubes and implanted in the laparoscopic port site due to the "chimney effect" caused by the pneumoperitoneum.     

Port-site Metastasis after Laparoscopic Extraperitoneal Paraaortic Lymphadenectomy for Stage IIb Squamous Cell Carcinoma of the Cervix

We report a case of port-site metastasis near the optic trocar site after extraperitoneal laparoscopic lymphadenectomy for cervical carcinoma. A 42-year-old woman with International Federation of Gynecology and Obstetrics clinical stage IIb squamous cell carcinoma of the cervix was evaluated with laparoscopic extraperitoneal paraaortic lymphadenectomy for staging. The aortic nodes were positive. The patient was treated with chemotherapy and radiotherapy. Then brachytherapy was performed. The patient was treated with 6 cycles of weekly topotecan. At month 12, a 4-cm left retroperitoneal mass was detected and excised. Pathologic examination showed an invasive squamous cell carcinoma with tumor-positive margins. Laparoscopic surgery for cancer may result in iatrogenic metastases at the port sites. But all of the port-site recurrence can not be explained by current factors leading to tumor metastases.     

Disseminated carcinomatosis after laparoscopic surgery for presumably benign ruptured ovarian teratoma

The authors reported the intraperitoneal carcinomatosis after laparoscopic surgery for presumably benign ruptured ovarian teratoma in a 28-year-old woman. A 28-year-old female patient exhibited intraperitoneal carcinomatosis after a laparoscopic surgery for ruptured mature teratoma of the ovary with occult malignant transformation. The complication was found two months after initial laparoscopic surgery. Laparoscopic surgery was smooth including oophorectomy, and removing all spilled specimens within the abdominal cavity. At the end of the laparoscopic surgery, cleaning the abdominal cavity and irritating the port site were also performed. Cytology of the abdominal cavity and all removed specimens did not show evidence of malignancy. She followed up regularly and uneventfully except for persistently abdominal fullness and erythematous change of umbilical portal site. Evidence demonstrated intestinal obstruction associated with ascites after a detailed evaluation. Although the patient received supportive treatment the symptom exacerbated. Therefore, the patient was treated with exploratory laparotomy. Pathology proved with intraperitoneal carcinomatosis caused by squamous cell carcinoma. All tumor evaluations including tumor markers, a thorough physical examination, imaging studies and evaluations of the nuclear medicine were negative except of intraperitoneal carcinoma, origin to be determined. The patient is dead 14 months' post-treatment by exploratory laparotomy. Although it was not clear that the laparoscopic approach or the disease itself worsened indeed the prognosis because the disease was already disseminated before the laparoscopy, we still emphasized the possible limitation of laparoscopic surgery if diagnosis at original surgery is impaired, of if excision is incomplete and the delay between the laparoscopic procedure and the carcinomatosis.     

Port-site recurrence after laparoscopic surgery for endometrial carcinoma

Background: Women with endometrial carcinoma are being treated with laparoscopic surgery, but the risk of port-site recurrences remains undefined.Case: A 58-year-old woman underwent laparoscopically assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and laparoscopic lymphadenectomy for endometrial cancer. Final surgical stage was IA, with grade 2 histology. Twenty-one months later, she developed a 5-cm recurrent tumor mass at a lateral laparoscopic port site. The mass was resected, and a restaging laparotomy performed, without evidence of other metastases. Radiation therapy was administered to the involved anterior abdominal wall. Two and one half years later, there is no evidence of recurrence.Conclusion: An isolated laparoscopic port-site recurrence might be attributable to the initial laparoscopic management of an otherwise good-prognosis endometrial carcinoma.     

Five-Millimeter Trocar Site Small Bowel Eviscerations after Gynecologic Laparoscopic Surgery

Trocar site hernia is a known complication after laparoscopic surgery, especially at 10-mm and larger port sites. Only a few cases of herniation through 5-mm port sites are reported in the literature. We describe 2 cases of bowel herniation and bowel obstruction through 5-mm port sites. The patients were 63 and 74 years old; both had endometrial cancer and underwent an uncomplicated hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy with peritoneal drains left at the lateral 5-mm port sites. Each patient presented symptoms of small bowel obstruction after which the drains were removed and were found to have evisceration through a laterally placed 5-mm port site. The bowel was reduced locally, and a segmental bowel resection was needed in 1 case. Bowel herniation can occur through the fascial defect after placement of a 5-mm port, especially if drains have been placed at the port site.     

腹腔镜子宫肌瘤剔除术后Trocar口部位腹壁平滑肌瘤一例

腹腔镜Trocar口部位腹壁平滑肌瘤十分罕见,国内外报道仅为个案,其发病原因可能与盆腔手术医源性种植有关。报道1例首都医科大学附属北京妇产医院（我院）妇科微创中心收治的腹壁平滑肌瘤患者,该患者2010年因子宫肌瘤于我院行腹腔镜子宫肌瘤剔除术。2015年自觉左下腹原手术瘢痕处肿块,2018年自觉肿块进行性增大。2021年入院行开腹手术治疗,术中发现原左侧腹腔镜Trocar口腹壁脂肪层内4.0 cm×4.0 cm肌瘤结节,病理及免疫组织化学检查提示腹壁平滑肌瘤,考虑是由既往腹腔镜肌瘤剔除术引起的医源性寄生。医源性寄生平滑肌瘤的预防十分关键,但目前无法完全避免医源性寄生平滑肌瘤的发生,需进一步深入研究。     

Laparoscopic port site implantation with ovarian cancer

We report the cases of 3 patients in whom tumor implantation developed at the port site at which ovarian cancer was removed laparoscopically. The 3 patients, who were aged 30, 32, and 40 years, all had an ovary that did not appear cancerous removed by laparoscopy through a port site. All 3 patients underwent re-exploration within 3 weeks and were found to have tumoral spread and port site implantation of tumor. When ovarian cancer is removed laparoscopically, the potential exists for intra-abdominal tumoral spread. When surgical staging is undertaken after laparoscopic removal of ovarian cancer, the port site should be excised in a full-thickness fashion.     

Ovarian remnant syndrome at the port site

Ovarian remnant syndrome is a rare gynecologic complication, mostly induced by difficult salpingo-oophorectomy with the residual ovarian tissue on the pelvic side wall. This is a report of a rare case of ovarian remnant syndrome at a port site after laparoscopic oophorectomy and a review of the related literature. A 22-year-old virgin had a laparoscopic oophorectomy for an endometrioma 5 years earlier. Postoperatively, she visited gynecologic clinics for a frequent painful sensation at the left port site. After sonographic examination and under the impression of a recurrent endometrioma, laparotomy and cyst excision were performed. Surprisingly, ectopic ovary was diagnosed by the pathologist. Review of the literature revealed ovarian remnant implantation at a port site as a very rare type of ovarian remnant syndrome. During laparoscopic oophorectomy in a woman without sexual exposure who is not a good candidate for culdotomy, the removal of the excised ovary through the port site is sometimes difficult and residual ovarian tissue implantation may occur. There are many methods to reduce the risk of port-site seeding, which we must keep in mind and execute to prevent such a complication.     

Métastase orificielle sur site de trocart après lymphadénectomie rétropéritonéale pour un adénocarcinome endométrial

Port-site metastasis is a rare but serious complication of laparoscopic surgery. The etiologies are poorly identified and multiple. We report the case of port-site metastasis after laparoscopic retroperitoneal lymphadenectomy for endometrial adenocarcinoma. In the literature, three cases of port-site metastasis after laparoscopic retroperitoneal lymphadenectomy are reported: two cases concerning cervical cancer and one case concerning a kidney cancer. To our knowledge, this is the only case about port site metastasis after laparoscopic retroperitoneal lymphadenectomy for endometrial adenocarcinoma.     

Port-site metastasis following laparoscopic lymphadenectomy for adenosquamous carcinoma of the cervix.

Although incisional metastases following surgery for cervical cancer are extremely rare, port-site disease following minimal-access surgery is becoming increasingly reported. We report a case of a metastasis which occurred at a port site following laparoscopic removal of lymph nodes affected by cervical adenosquamous carcinoma. This report adds to the literature suggesting that cutaneous tumor deposition may be enhanced by this method of surgery.     

Metastatic cancer spread at the laparoscopic puncture site. Report of a case in a patient with carcinoma of the ovary. Case report

The aim of this study is to draw attention to the possibility of the occurrence of a metastatic spread at the laparoscopic entrance site in patients suffering from a carcinoma of the ovary. This event has rarely been mentioned in medical literature before. A case is presented here in which a localized tumoral lesion appeared after a laparoscopic staging study in the abdominal wall, exactly at the site used for the introduction of the accessory laparoscopic trocar in a patient suffering from a carcinoma of the ovary.     

Port site recurrences following laparoscopically managed early stage endometrial cancer

Faught W, Fung Kee Fung M. Port site recurrences following laparoscopically managed early stage endometrial cancer. Int J Gynecol Cancer 1999; 9: 256–258.
Laparoscopic management of endometrial cancer, although gaining in acceptance, has been associated with recurrent disease at trocar insertion sites in advanced disease. We report on a patient with a port site recurrence in early stage endometrial cancer.
An 84-year-old patient with cancer of the endometrium underwent a laparoscopic surgical staging, vaginal hysterectomy, and adjunct radiation treatment. The final surgical pathology was grade 3, stage IC endometrioid adenocarcinoma. Seven months post-treatment, she presented with bilateral port site recurrences in the lower abdominal wall.
Trocar port site recurrence in gynecologic cancer patients may be enhanced by laparoscopic management and are not limited only to patients with advanced disease.     

Umbilical Richter's hernia after minimally invasive laparoscopy. A case report

A case of Richter's hernia in the umbilical trocar site following laparoscopic radiofrequency thermal ablation of uterine myomas is presented. A 10-mm trocar was inserted through the umbilical site and the radiofrequency needle was introduced percutaneously into the uterine fibroid. Trocar was extracted under direct visual control after carbonic gas deflation. The fascial layer of umbilical port was not sutured. The umbilical Richter's hernia presented 13 days later required bowel resection. This case stresses the importance of suturing the fascial defects of 5-mm larger ports also in diagnostic and in minimally invasive laparoscopic procedures.     

Early Incisional Hernia Following Laparoscopic Surgery

Summary: Incisional hernia following laparoscopic surgery is seldom reported unless further complication arises and the presentation is usually late. A case of early incisional hernia following a laparoscopic ovarian cystectomy was reported. The hernia occurred through a 10/11 mm trocar port 3 days after the operation. Awareness of this clinical problem, its relationship to the site of abdominal entry, possible enlargement of the fascial defect during operation and hence the need of meticulous closure of the fascia when a large trocar is used will avoid such occurrence.     

Port-site recurrence following laparoscopic surgery in cervical cancer

Abstract. Tjalma WAA, Winter-Roach BA, Rowlands P, de Barros Lopes A. Port-site recurrence following laparoscopic surgery in cervical cancer.
Port-site metastasis (PSM) after laparoscopic lymphadenectomy in cervical cancer is a new phenomenon. This situation creates potential therapeutic difficulties, especially in node-negative and early stages of disease. We report a case of port-site metastases following laparoscopic removal of para-aortic lymph nodes in a 74-year-old women with stage IIIb squamous cancer of the cervix, together with an update of all the previous published cases in the literature. None of the removed lymph nodes showed evidence of metastatic carcinoma. The patient received radiation therapy and a complete response was accomplished. Fifteen months after the operation, the patient presented with a suspicious lesion around the umbilical port-site. The lesion was excised and histology confirmed metastatic disease. The patient was further treated with cisplatin. However, she died of her disease after 24 months. The development of a port-site recurrence after laparoscopic surgery in cervical cancer could jeopardize use of this approach. Therefore, all patients undergoing laparoscopic surgery for malignancies should have careful follow-up with special attention to the port sites.     

Laparoscopic port-site metastases in patients with gynecological malignancies

OBJECTIVE: The purpose of this study is to review all reported cases of laparoscopic port-site metastases in patients with gynecological malignancies. Potential etiologies as well as options for prevention are discussed. METHODS: We searched the Medline database for English-language articles presenting raw data on laparoscopic port-site metastases in patients with gynecological malignancies. RESULTS: We found 31 articles describing port-site metastases in 58 patients. Forty patients had low malignant potential (seven patients) or invasive ovarian carcinoma (33 patients). The median age of these patients was 50 years (range: 22-79), and 83% had advanced (stage III or IV) disease. Seventy-one percent of the patients (24 of 34) had ascites, and 97% (29 of 30) had carcinomatosis. Seventy-five percent of the laparoscopic procedures in this group were performed for diagnosis. Median time to diagnosis of port-site metastases was 17 days (range: 4-730). Seventy-one percent of port-site recurrences (15 of 21) were isolated to a tissue-manipulating port. Twelve patients had port-site metastases after laparoscopy for cervical cancer. The median age was 44 years (range: 31-74). Eighty percent of cases were squamous cell carcinoma. In 75% of the patients, laparoscopy was performed for therapeutic purposes. The median time to diagnosis of port-site metastases was 5 months (range: 1.5-19). Four patients had port-site metastases after laparoscopy for uterine cancer. The median age was 63 years (range: 56-72). The median time to diagnosis of metastases was 13.5 months (range: 6-21). Half of the recurrences were in the tissue-manipulating port. Port-site metastases after laparoscopy were reported for one patient each with a diagnosis of fallopian tube carcinoma and vaginal carcinoma. CONCLUSIONS: Laparoscopic port-site metastases are a potential complication of laparoscopy in patients with gynecological malignancies, even in patients with early-stage disease.     

Small bowel obstruction at a Filshie clip applicator port site

Laparoscopic Filshie clip sterilisation remains a common method of permanent female contraception. Worldwide, approximately 190 million couples use tubal occlusion (United Nations world population monitoring. United Nations, 2002). Trocar site incisional hernia has been reported as a complication of laparoscopic surgery where a 10-mm port was employed (Tonouchi et al. Arch Surg 139(11):1248–1256, 2004). It is common practice to repair port sites of 10 mm or more to prevent herniation. Port sites of 5 mm are not routinely repaired by most surgeons because it is thought that such iatrogenic fascial defects are not large enough to predispose to hernia (Reardon et al. J Laparoendosc Adv Surg Tech A 9(6):523–525, 1999). We report a rare case of early Filshie clip applicator port site intestinal obstruction following laparoscopic sterilisation. The mechanism of hernia formation and a preventive strategy are discussed.     

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

Objectives

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

Methods

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

Results

Data from 842 procedures were included. Mean patient age was 55.6 years. Mean Body Mass Index was 33.6 kg/m². RA-total laparoscopic hysterectomy (TLH) ± unilateral or bilateral salpingo-oophorectomy (BSO) ± lymphadenectomy (LND) accounted for 91.6% of procedures. Final pathology confirmed malignancy in 58.6% of cases, primarily endometrial cancer. In 35 cases, the specimen was removed through the port site; fascia was closed in 54.3% of them and no port site hernias or dehiscences occurred. Only one patient underwent a RA-TLH/BSO/LND for endometrial adenocarcinoma and had a port site dehiscence of the 8 mm trocar site. No port site hernias occurred.

Conclusion

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