Port-site Incisional Hernia Research Articles

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

ObjectivesThe 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. MethodsRobotically-assisted (RA) procedures performed for suspected gynecologic malignancy between 1/2006 and 12/2011 were retrospectively reviewed. Bladeless 12mm and 8mm 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. ResultsData from 842 procedures were included. Mean patient age was 55.6years. Mean Body Mass Index was 33.6kg/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 8mm trocar site. No port site hernias occurred. ConclusionPort site hernias and dehiscences are rare in RA gynecologic oncology procedures. When bladeless dilating trocars are used, routine closure of even up to a 12mm port site is unnecessary, even in cases requiring removal of the specimen through the trocar sites.

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

Objective: The incidence of port-site hernias and/or dehiscence using bladeless trocars is approximately 0.5% to 1%. Robotic surgery requires the use of additional port sites with increased manipulation of instruments, raising the concern for higher rates of port-site complications. We sought to characterize the incidence of port-site complications in patients who did not undergo routine fascial closure of robotic port sites.

Risk of Incisional Hernia after Minimally Invasive and Open Radical Prostatectomy

The number of radical prostatectomies has increased. Many urologists have shifted from the open surgical approach to minimally invasive techniques. It is not clear whether the risk of post-prostatectomy incisional hernia varies by surgical approach. In the linked Surveillance, Epidemiology and End Results (SEER)-Medicare data set we identified men 66 years old or older who were treated with minimally invasive or open radical prostatectomy for prostate cancer diagnosed from 2003 to 2007. The main study outcome was incisional hernia repair, as identified in Medicare claims after prostatectomy. We also examined the frequency of umbilical, inguinal and other hernia repairs. We identified 3,199 and 6,795 patients who underwent minimally invasive and open radical prostatectomy, respectively. The frequency of incisional hernia repair was 5.3% at a median 3.1-year followup in the minimally invasive group and 1.9% at a 4.4-year median followup in the open group, corresponding to an incidence rate of 16.1 and 4.5/1,000 person-years, respectively. Compared to the open technique, the minimally invasive procedure was associated with more than a threefold increased risk of incisional hernia repair when controlling for patient and disease characteristics (adjusted HR 3.39, 95% CI 2.63-4.38, p<0.0001). Minimally invasive radical prostatectomy was associated with an attenuated but increased risk of any hernia repair compared with open radical prostatectomy (adjusted HR 1.48, 95% CI 1.29-1.70, p<0.0001). Minimally invasive radical prostatectomy was associated with a significantly increased risk of incisional hernia compared with open radical prostatectomy. This is a potentially remediable complication of prostate cancer surgery that warrants increased vigilance with respect to surgical technique.

PORT SITE INCISIONAL HERNIA AFTER MINIMAL ACCESS SURGERY

Incisional hernia is a common sequel to open abdominal surgery, affecting 5–15% of patients. The introduction of laparoscopic surgery into clinical routine more than 20 years ago has dramatically changed the field of surgery. It is commonly held that the frequency of incisional hernia has been reduced since the introduction of minimal access surgery. The incidence of port site hernia ranges from 1% to 6%. The aim of this study is to identify most common causes of port site incisional hernia. This is a retrospective study of 2116 patients who underwent laparoscopic surgery between January 2006 and December 2010. The information obtained according to indication of surgery, onset of hernia, clinical risk factors for incisional hernia like age& sex, BMI, co-morbidity, and those related to surgical factors such as port site, port size, port site infection and abdominal access techniques. The data were retrieved for patients who developed port-site incisional hernia (PSIH). The incisional hernia rate for the entire series was 2.5%. Most port site hernias developed in the 10 mm port, in the umbilical and supra umbilical, midline and 0% for the off-midline. There was statistically significant difference in patient’s related risk factors regarding age, BMI and wound infection with development of port site hernias. Conclusion: In this series, the 10mm port in midline site is a significantly higher cause for incisional hernia than the off-midline and smallest port size. Open first access technique, obesity and port site infection also significantly increase the incidence of port site incisional hernia. Introductio

UP-02.061 Incidence of Port Site Hernia After Laparoscopic Surgery

Port site hernia may develop after laparoscopic surgery. In general, we can recognize 2 types of port site hernia. The first is early-onset port site hernia where hernial sac is not created yet. This type is often presented by bowel obstruction with or without bowel wall necrosis. The second is late-onset port site hernia with created hernial sac. This type is often presented by palpable mass in port site scar or pain in this area. We evaluated incidence of port site hernia in the retrospective descriptive study.

The vermiform appendix presenting in a laparoscopic port site hernia

Laparoscopic port site hernias (PSHs) are uncommon but present a potential source of morbidity due to incarceration of the hernial contents which is usually omental fat or small bowel. We report only the third case of the vermiform appendix presenting in a symptomatic PSH; we discuss the appropriate management of this condition as well as ways in which the incidence of PSHs may be reduced.

Single-port access prosthetic repair for primary and incisional ventral hernia: toward less parietal trauma

Although still under development, single-port access (SPA) approach may be of interest in patients prone to port-side incisional hernia, ensuring absence of increased fascial incision. This forms the basis for evaluating SPA for prosthetic ventral hernia repair. We report a new SPA technique of ventral hernia repair using working-channel endoscope, standard laparoscopic instruments, and 10-mm port. Prospective experience with SPA prosthetic repair of primary and incisional ventral hernia in 52 patients for 55 ventral hernias is presented. Median (range) patient age was 46 years (26-85 years), and BMI was 28 kg/m2 (20-38 kg/m2). Mean fascial defect was 16.2 cm2 for primary hernia (n=23) and 48.3 cm2 for incisional hernia (n=32). Intraperitoneal composite mesh repair was achieved through single 10-mm flank port using working-channel endoscope. Meshes were fixed using absorbable tackers and transfascial stitches. SPA repair of primary and incisional ventral hernia was completed in all cases without conversion to standard laparoscopy. Median (range) operative time was 54 min (39-95 min). Mesh size ranged from 118 to 500 cm2. No intra- or postoperative complications were recorded, except two seromas. Median (range) hospital stay was 1 day (1-5 days). One patient presented prolonged postoperative pain on mesh fixation that resolved after 3 months. No recurrence or port-site incisional hernias have been recorded at median (range) follow-up of 16 months (3-28 months). SPA prosthetic repair of primary and incisional ventral hernia is easily feasible according to natural exposition by pneumoperitoneum and gravity. In the present series, SPA ventral hernia repair appears to be safe for experienced SPA surgeons. It may decrease parietal trauma and scarring in patients prone to incisional hernia. SPA repair may be associated with a decrease in rate of port-site incisional hernia compared with multiport laparoscopy, but this has to be verified by randomized trial with standard laparoscopic approach on long-term follow-up.

M1665 Radial Dilating Trocar System is Associated With a Low Incidence of Port Site Hernias Among Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass Surgery

M1665 Radial Dilating Trocar System is Associated With a Low Incidence of Port Site Hernias Among Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass Surgery

Hernia After Pediatric Urological Laparoscopy

The incidence of port site hernia following adult laparoscopy is 0.1% to 3.0%. There are no known published reports concerning hernia incidence or related factors after pediatric urological laparoscopic interventions. We present our experience with port site incisional hernias following pediatric urological laparoscopy. We reviewed all pediatric urological laparoscopic procedures performed at Children's Medical Center Dallas from 2000 to 2008. A total of 261 cases were identified with followup available in 218 (83.5%). In 187 cases there were sufficient data to evaluate outcomes for each port site separately, and compare the size, location and fascial closure status to hernia development. Median patient age was 6.1 years (range 0.4 to 18.8). A total of 218 patients had a median followup of 5.7 months (range 0.2 to 83.4). Seven hernias (3.2%) were diagnosed at a median of 1.2 months (range 0.1 to 15.1) postoperatively. Patients with hernia were younger than those without hernia, at 1.1 years (range 0.5 to 3.9) vs 6.2 years (0.4 to 18.8, p = 0.04). We analyzed 571 port sites in 187 cases. In 385 ports (67.4%) the fascia was closed. Hernia developed in 4 of 385 ports (1.0%) that were closed and in 3 of 186 (1.6%) that were not closed. No significant relationship was observed between hernia development and port size or location. The incidence of port site hernia after pediatric urological laparoscopy was 3.2%, similar to the reported incidence in adults. While development of hernia after pediatric urological laparoscopy is rare, it is more likely to occur in infants. Due to the low incidence of this complication, it is difficult to draw conclusions regarding contributing factors.

Port-Site Hernia Following Laparoscopic Cholecystectomy

Port-site hernia is a rare but potentially serious complication of laparoscopic cholecystectomy. This study aimed to review the current literature, assess the incidence and causes of port-site hernias, and identify methods to reduce the risk. A systematic search of the literature published in English from 1995 to 2010 was conducted using PubMed to identify all reports of port-site, trocar-site, or incisional hernia following laparoscopic cholecystectomy. Studies in over 100 patients were identified before the application of defined exclusion criteria. The incidence of port-site hernia was calculated and compared with historical data. Predisposing factors were reviewed. Seven studies met the search criteria, with 99 port-site hernias in 5984 patients. The overall incidence of port-site hernia was 1.7% (range, 0.3% to 5.4). The most important factors were older age, higher body mass index, preexisting hernia, trocar design, trocar diameter, increased duration of surgery, and extension of the port site for gallbladder extraction. The incidence of port-site hernia is low but likely to be underestimated and has not declined over time. Awareness of the predisposing factors and modification of techniques may help to reduce the risk.

Outcomes of sleeve gastrectomy for morbid obesity: A safe and effective procedure?

Background Sleeve gastrectomy is being performed with increasing frequency in Australia for the treatment of morbid obesity. The aims of this study were to show that sleeve gastrectomy can be performed safely with a low rate of complications and effective short to medium term weight loss. Methods A retrospective review of prospectively collected data from a single surgeon series between 2006 and 2009. Results A total of 185 patients were treated with laparoscopic sleeve gastrectomy (LSG) over a three-year period. The percentage excess weight loss (%EWL) was 47.2% at one year, 60.7% at two years and 66% at three years. There were no leaks; two staple line bleeds requiring reoperation via laparoscopy, one port site infection and one port site incisional hernia. There were no deaths. The average operating time was 111 min and the average hospital length of stay was 2.35 days. Conclusion Laparoscopic sleeve gastrectomy can be performed safely and with excellent weight loss. More long term follow up is required.

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.

"Semi-open" blunt primary access to the abdominal cavity during laparoscopic surgery: a new technique.

Despite major technologic advances in laparoscopic surgery, the creation of the pneumoperitoneum remains a critical step and is associated with a recognized incidence of complications. The aim of this study was to evaluate the safety and feasibility of a new "semi-open" blunt technique for primary cannulation of the abdominal cavity in patients undergoing laparoscopic surgery. Between October 2000 and November 2001, 300 patients underwent laparoscopic surgery under the care of one surgeon. Surgery was elective in 158 patients and urgent/emergent in 142 patients. The semi-open blunt technique for primary cannulation of the peritoneal cavity was applied in 241 (80%) of the patients and was periumbilical in most cases. A closed blunt technique was applied in 48 (16%) of the patients, and the Veress needle was used in 11 (4%) of the patients. The semi-open blunt technique for primary cannulation of the abdominal cavity successfully achieved access in all patients in whom it was attempted. Minor live injuries occurred in two patients (one with the semi-open method and one with the Veress needle). No port site incisional hernias were encountered during a median follow-up of 6 months. The semi-open blunt technique of primary cannulation of the peritoneal cavity achieves rapid, safe, and successful access to the abdomen for laparoscopy. It is associated with minimal periportal gas leakage and port dislodgement and is an alternative method for primary cannulation.

Establishing a laparoscopic gastric bypass program

ObjectiveTo evaluate the outcomes for laparoscopic Roux-en-Y gastric bypass in a newly developed bariatric surgery program. Methods:A prospective analysis of the initial 100 patients who underwent laparoscopic Roux-en-Y gastric bypass at a community based teaching hospital between December 2000 and October 2001 was performed. Study endpoints included operative time, early (less than 7 days) and late complication rates, hospital length of stay (LOS), time to initiation of oral diet, and percentage of excess body weight loss. ResultsThere were 91 women and 9 men with a mean age of 39 years (range 21 to 57). Mean preoperative weight was 126.4 kg (range 92.3 kg to 214 kg), with a mean preoperative body mass index of 47.4 (range 37.3 to 75.7). Ninety (90%) patients had at least one significant medical comorbidity (median = 6 per patient). Mean operative time was 2.4 hours (range 1.0 to 6.5; 3.0 hours for the first 50 patients and 1.8 hours for the last 50 patients). Three patients required conversion to open gastric bypass, all due to equipment failure (two harmonic scalpel failures and one linear stapler malfunction). Seven patients had early complications, 3 with anastomotic hemorrhage requiring transfusion, 3 with intestinal leaks requiring reoperation, and 1 with transected nasogastric tube. Eleven patients had late complications: 5 patients with small bowel obstruction, all due to herniation through the transverse colon mesentery (these occurred early in the series, prompting a change in technique, with no subsequent occurrences), 3 with gastrojejunostomy strictures requiring endoscopic dilation, 2 superficial wound infections, and 1 port-site incisional hernia. No complications occurred in the last 40 patients. No deaths occurred. Median hospital stay was 2 days (range 1 to 37); 3 days in the first 50 cases and 1 day in the last 50 cases. The median number of days to the start of an oral diet was 1 day. Average excess body weight loss was 34% (median follow-up 4 months). Conclusions:Laparoscopic Roux-en-Y gastric bypass is a technically challenging procedure that can be safely integrated into a bariatric treatment program with good results. Improved outcomes, shorter operative times, and fewer complications are associated with increased surgical experience.

Incisional hernia following laparoscopic surgery: Two unusual cases and literature review

Laparoscopic procedures are becoming an increasing part of general surgery. Patients are now being exposed to a new spectrum of complications. We report two unusual port site incisional hernias. A review of the literature has identified only 30 previously reported cases, a surprisingly small total given the number of laparoscopic procedures performed annually in all specialities. These 30 cases all occurred through 10/11 mm port sites. They appeared early in the post-laparoscopic period; of 23 known, six were noted at the conclusion of the procedure and 11 appeared within 2 weeks. A high index of suspicion is required as small bowel involvement is common (12 of 18 patients where content was noted) though a palpable mass was present in only four patients. The cause of small bowel obstruction in the early post-laparoscopic period can be diagnosed and possibly treated with a laparoscopic technique.

Rate of Conversion and Postoperative Complications of Laparoscopic Cholecystectomy in District Level Hospital of Bangladesh

Laparoscopic cholecystectomy (LC) has become the gold standard for the surgical treatment of gallbladder disease, but conversion to open cholecystectomy and postoperative complications are still inevitable in certain cases. Knowledge of the rate and underlying reasons for conversion and postoperative complications could help surgeons during preoperative assessment and improve the informed consent of patients. We decide to review the rate and causes of conversion and postoperative complications of our LC series. This study included 760 consecutive laparoscopic cholecystectomies from July 2006 to June 2011 at Faridpur Central Hospital and Faridpur Medical College Hospital. All patients had surgery performed by same surgeon. Conversion to open cholecystectomy required in 19 (2.5%) patients. The most common reasons for conversion were severe adhesions at calot's triangle (6, 0.83%) and acutely inflamed gallbladder (5, 0.66%). The incidence of postoperative complications was 1.58%. The most common complication was wound infection, which was seen in 5 (0.66%) patients followed by biliary leakage in 3 (0.40%) patients. Delayed complications seen in our series is port site incisional hernia (2, 0.26%). LC is the preferred method even in difficult cases. Our study emphasizes that although the rate of conversion to open surgery and complication rate are low in experienced hands, the surgeons should keep a low threshold for conversion to open surgery and it should not be taken as a step in the interest of the patient rather than be looked upon as an insult to the surgeon. Key words: Laparoscopic cholecystectomy (LC); Open cholecystectomy; Conversion; Complications; Calot's triangle DOI: http://dx.doi.org/10.3329/fmcj.v6i2.9204 FMCJ 2011; 6(2): 74-77