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.