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11/1/2018

Laparoscopic Port Site Hernias

Trocar site hernias occur in approximately 1% of laparoscopies. While rare, trocar site hernias are preventable.   Risk factors for trocar site hernia include increasing age, poor nutrition, infection, and BMI.  Higher rates are observed with pyramidal trocars when compared to conical or blunt.  Open entry (Hasson) technique is also associated with increased risk. Umbilical and midline trocar incisions have higher rates compared to lateral placement.  The strongest risk factor for development is use of port sites measuring > 10 mm.

Prevention of trocar site hernias is primarily through the use of smaller trocars. A hernia in a post sites ≤ 5mm is rare, most common with 10mm or larger incisions, and fascial closure should be performed with larger trocar incisions. Several techniques have been described for fascial closure of trocar sites.  Direct closure with a delayed absorbable suture is possible in thinner patients.  The fascia must be included in closure.  A 5/8 curved needle such as a UR5, can be used when visualization of the fascia is difficult.  A commercial fascial closure device may be used when visualization is especially difficult. 

Trocar site hernias are categorized as early- and late-onset.  Early-onset hernias typically present within 2 to 12 days of the surgery, usually with a painful bulge at the trocar site.  Early onset hernias do not contain peritoneum. Early onset hernias typically contain small bowel and cause obstruction, although in some instances only the anti-mesenteric border of the bowel wall protrudes (Richter’s hernia) and may become ischemic in the absence of obstruction. Bowel obstruction or Richter’s hernia with acute pain suggestive of ischemia are surgical emergencies and should be immediately repaired.  Computed tomography may be helpful in confirming the presence of small intestine, but is not necessary for diagnosis if clinical signs, symptoms, and history suggest a hernia.  If diagnosed early, reduction of the hernia contents and appropriate fascial closure is sufficient.  However, if the bowel has been incarcerated for a long period of time, a bowel resection may be necessary.  General surgery consultation is warranted if there is concern for bowel strangulation. Late-onset hernias are typically diagnosed between 0.7-27 months after the initial surgery.  They typically contain only peritoneum and present as a painless bulge at the prior trocar site. Repair is indicated if the bulge causes discomfort or interferes with daily activities. The use of suture or mesh for hernia repairs should be considered based on size of the hernia, underlying medical comorbidities, patient body mass index, and risk of recurrence.  

 

Further Reading:

Clark LH, Soliman PT, Odetto D, et al. Incidence of trocar site herniation following robotic gynecologic surgery. Gynecol Oncol. 2013 Nov;131(2):400-3. doi: 10.1016/j.ygyno.2013.08.021. Epub 2013 Aug 27.

Swank HA, Mulder IM, la Chapelle CF, et al. Systematic review of trocar‐site hernia. Br J Surg. 2012 Mar;99(3):315-23. doi: 10.1002/bjs.7836. Epub 2011 Dec 30.

Lambertz A, Stüben BO, Bock B, Eickhoff R, Kroh A, Klink CD, Neumann UP, Krones CJ. Port-site incisional hernia - A case series of 54 patients. Ann Med Surg (Lond). 2017 Jan 6;14:8-11. doi: 10.1016/j.amsu.2017.01.001. PMID: 28119777; PMCID: PMC5237772.

 

Initial approval September 2018, published November 2018; Reaffirmed March 2020. Reaffirmed December 2021; Minor Revision September 2023

 

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