Port Site Closure Methods and Hernia Prevention

Abstract

Laparoscopic port site hernias have been frequently reported (incidence of 0.02%–5% with an average of 1%) since the first case was documented in 1968 by Fear et al. Larger port size and increasing numbers of ports required to perform more complex laparoscopic procedures are likely to increase the incidence of port site hernias (PSH). PSH tend to develop more frequently at umbilical and midline port sites due to the thinness of the umbilical skin and weaknesses in the linea alba. The presence of an undetected umbilical hernia when the port site is near the umbilicus can also increase the incidence of a PSH in that location if both the port site and the preexisting umbilical hernia are not closed with a formal herniorrhaphy. About one-quarter of PSH are umbilical. Overlapping muscle and fascial layers explains the reduced incidence of PSH at lateral port locations. Closure of the fascial defect does not completely prevent the development of PSH, although the incidence is higher if a fascial closure is not attempted. PSH have been reported through port sites of all sizes (including 5 mm). However, more than 90% of PSH occur through trocar sites 10 mm or larger. Patients usually present within 2 weeks of surgery, although some cases have been reported years after the initial surgery. The development of unremitting pain, fever, or other gastrointestinal complaint after laparoscopic surgery requires immediate investigation. The contents of these hernias are usually small bowel or omentum or, on rare occasions, large bowel. The spectrum of symptoms range from no symptoms to pain due to omental infarction or small bowel obstruction. Richter’s hernia is very common among PSHs due to the small size of the fascial defect. The insidious nature of Richter’s hernia can lead to significant morbidity. PSH should be suspected in all patients with bowel obstruction up to 1 year after laparoscopic surgery. A computed tomography (CT) scan can be helpful in making the diagnosis. Comorbid conditions that can increase the incidence of PSH include diabetes mellitus, wound infection, and obesity. Laparotomy or repeat laparoscopic surgery is required to repair the PSH. Adhesiolysis and bowel resection are also necessary in up to 10% of the patients. The associated morbidity of these iatrogenic hernias underscores the importance of preventing the condition. Every attempt should be made to keep the incidence less than the expected 1% by closing the fascia and the peritoneum. Trocars used for laparoscopic surgery usually range between 5 and 15 mm. Port sites (PS) 10 mm or greater should be closed if at all possible. Current consensus is not uniform about the management of PS less than 10 mm. In this chapter, we detail the indications, various methods, and techniques to ensure proper port site closure to minimize the occurrence of PSH.