Port Site Hernia Research Articles

175 Rare Complications and Management of Port Site Hernias (PSH) Following Robotic-Assisted Radical Prostatectomy (RARP)

Abstract Robot-assisted surgery has become increasingly prevalent in surgical practice and is very commonly performed in urological cancers especially of the prostate gland. Robotic surgical techniques are safe and reproducible; however, they have their associated complications. Risk factors such as the nature of cancer, learning curve of the surgery, experience of the surgeon and patient characteristics have been implicated for potential complications. Complications can range from bleeding, infection, bowel injury, ureteric and nerve damage. Port site hernias (PSH) are an infrequent complication with a reported incidence varying from 0.2–4.8%. Although uncommon, they can result in high morbidity due to bowel incarceration and strangulation. We report two cases of PSH from our large district general hospital, both at the supraumbilical port site after robotic assisted radical prostatectomy (RARP). The first case presented with complete evisceration and strangulation of a segment of small bowel and the second with bowel incarceration and small bowel obstruction. Our cases highlight potentially rare but severe complications of RARP that should be promptly recognised and urgently treated to prevent significant patient morbidity and mortality.

10-mm versus 5-mm umbilical port in laparoscopic cholecystectomy: A comparative study in a medical college in Eastern India

Background: Laparoscopic cholecystectomy (LC) the most common laparoscopic surgery performed worldwide. The surgical technique of LC has undergone many modifications; in respect to reduction of port sizes or number of ports. Conventionally, 10-mm 30° laparoscope is being used but, 5-mm 30° laparoscopes through 5-mm umbilical port (modified LC) are also being utilized by many surgeons worldwide. Aims and Objectives: The aims of this study were to compare the outcome of conventional LC with modified LC, in terms of feasibility, safety, and efficacy. Materials and Methods: This prospective randomized study was carried out in the Department of Surgery, ESIC-PGIMSR, Joka during June 2017–December 2018. One hundred and fifty patients of diagnosed symptomatic gall stone disease were randomly allocated into two study groups. Group-I contained 75 patients, who underwent LC by conventional method whereas, and 75 patients in Group-II underwent LC by modified method. Follow-up was done at 6 weeks, 6 months, and 1 year after surgery. Data were analyzed by appropriate statistical tests. Results: The mean operating time and mean pain score over umbilical wound were found to be statistically significant. However, no significant differences were obtained in terms of average hospital stay, post-surgical complications such as post-site bleeding, cystic artery bleeding, biliary spillage, and wound infection. Only one patient in the 10-mm umbilical port group, having body mass index of 31 developed umbilical port-site hernia. Regarding wound cosmesis, no significant difference was obtained. Conclusion: Performing LC with a 5-mm 30° laparoscope through 5-mm umbilical port is a safe and feasible option for laparoscopic surgeons.

Some Consideration about Port Site Hernia after Laparoscopic Surgery.

Introduction: Port site hernias continue to be a major problem in laparoscopic surgery. The causes of this type of hernia are numerous. The main ones are operative wound infection, obesity, male gender, diabetes, BPH, etc. However, in addition to these factors it seems that in the etiology of post laparoscopic port - site hernias are at least two other factors that have an impact on these complications.
 Aim of the article is to assess the role of different factors in the occurrence of port site incisional hernias according to our experience.
 Material and Methods: the 187 patients who were operated on at the General Surgery Department of the Clinical Hospital of Tetovo between January, 2017 and June, 2019 on whom the surgical intervention was performed through laparoscopic techniques were included in this study. The reason for the surgical interventions has been various surgical pathologies of the abdomen such as cholecystolithiasis, acute appendicitis, cysts of the liver, ovaries and kidneys, etc. Postoperative complications in these patients, especially port site hernia will be in the focus of our study.
 Results: Out of the total of 187 patients included in this study the occurrence of incisional hernia was recorded in six of them. In five patients the hernia was localized at the site of insertion of the supra-umbilical trocar, while in the other, the trocar was inserted below the xiphoid process. From our records it happened that in all these patients, with postoperative hernia, the insertion of the cannula was done with the cutting trocar. At the same time in all six patients with post laparoscopic hernia the surgical intervention performed was cholecystectomy or appendectomy. Thus, the removal of the gallbladder and appendix, without the use of an Endo-bag, was performed at the site of the hernia presentation. In all these patients the entrance porta infection in which the hernia has occurred, was registered in the early post operative period.
 Conclusion: Of the many factors that increase the risk of incisional hernias, at the site of cannula insertion during laparoscopic interventions, it seems that the type of trocar and the place from which the extruded organ is removed, if it is done without the use of an Endo-bag, are very important.

Open versus laparoscopic intraperitoneal on-lay mesh repair: A comparison of outcomes in small ventral hernia

PurposeThe ideal surgical treatment of small ventral hernias (defect less than 4 cm) is still debatable. In our study, we sought to compare the outcomes of open versus laparoscopic intraperitoneal on-lay mesh (IPOM) repair in small ventral hernias. MethodsPatients with a single ventral hernia defect of less than 4 cm undergoing surgical mesh repair between January 2016 and September 2018 were prospectively registered for this study. The minimum follow-up duration was 12 months. Patient demographics, operative findings and regular post-operative follow-up details including recurrence rates and complications were recorded and analysed. Results41 patients underwent laparoscopic IPOM repair and 47 patients underwent open IPOM repair. The mean age for both groups is similar with no significant difference. The mean hernia defect size for the laparoscopic group is 2.8 cm (±0.8) whereas the mean hernia defect size for the open repair group is 2.1 cm (±0.4). The mean surgery duration for open IPOM repair was significantly shorter (59 min (±17) vs 74 min (±26); p = 0.001). There was no significant difference in the incidence of seroma formation and surgical site infections post-operatively. There was also no significant difference in both groups in terms of chronic pain and recurrence at 1-year follow-up. ConclusionOpen IPOM repair for small ventral hernias may be superior to laparoscopic IPOM repair due to the shorter operative duration, single incision, and no additional risk of port-site hernias. There was no difference in chronic pain, wound infection and recurrence rate between the two groups.

The first international Delphi consensus statement on Laparoscopic Gastrointestinal surgery

BackgroundLaparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery. MethodsA committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol. ResultsA consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index.There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures.An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count. ConclusionThirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes.

Comparison of Hasson (Open) and Veress Needle (Closed) Technique of Creating Pneumoperitonium in Laparoscopic Cholecystectomy

Objective: The purpose of this study is to compare the outcomes between hasson (open) and veress needle (closed) technique of creating pneumoperitonium in laparoscopic cholecystectomy. Study Design: Comparative/Randomized study Place and Duration: PHFMC (ZCD 417,Toba Tek Singh). Jun 2019-May 2020 Methods: Ninety patients of both genders with ages 20-75 years were presented in this study. All patients provided written informed consent before having their full demographic information collected, which included their age, gender, and body mass index. All the patients had symptomatic gall stones disease was underwent for laparoscopic cholecystectomy. Patients were categorized into two equal groups. Group I had 45 patients and received veress needle (closed) technique and group II received hasson (open) technique for creating pneumoperitoneum. Post-operatively outcomes in terms of access time , gas leak, visceral injury, vascular injury, need for conversion, umbilical port site hematoma, umbilical port site infection, umbilical port site hernia were assessed and compared among both groups. To analyze the entire set of data, we used the SPSS 24.0 edition. Results: Mean age of the patients in group I was 36.13 ±5.77 years with mean BMI 25.06 ±6.33 kg/m2 and in group II mean age was 37.23 ±6.55 years with mean BMI 25.16 ±4.45 kg/m2 . Majority of the patients 60 (30 in each group) were female. Mean access time in group II was lower 4.78 ±11.43 minutes as compared to group I 6.11±4.12 minutes. Mean closure time in group I was 7.33 ±7.23 minute and in group II mean closure time was 6.03±3.19 minutes. Frequency of gas leak in group I was higher found in 8 (17.8%) cases as compared to group II 3 (6.7%). Visceral injury was greater in group I 3 (6.7%) as compared to group II 1 (2.2%). Vascular injury among both groups was similar 2 (4.4%) and there is no any case found for conversion. Post-operatively complications hematoma, infection and umbilical hernia were greater in group II 4 (8.9%), 2 (4.4%) and 2 (4.4%) as compared to hasson (open) group. Conclusion: Pneumoperitonium was created more quickly and efficiently in laparoscopic cholecystectomy using the hasson (open) approach in this comparative analysis than any other method. When it comes to problems and injuries, the open approach (rather than the closed technique) was determined to be less risky overall. Keywords: Laparoscopic Cholecystectomy, Hasson (open) technique, Needle Veress, Outcomes, Pneumoperitonium

Wound infection and subsequent port-site hernia following laparoscopic appendectomy: A case report and surveillance data analysis.

IntroductionNon-operative antibiotic therapy is now considered as an alternative to surgery for acute appendicitis (AA). This is in part due to the reported surgical complication rates. We report a patient who developed wound infection and port site hernia following a laparoscopic appendectomy, analyze our post-operative wound infection rates, and discuss the treatment options for AA globally.Presentation of caseWe report a 40-year-old woman who developed a wound infection and subsequent port site hernia following laparoscopic appendectomy (LA) and analyze surgical site infection (SSI) and readmission rates for patients who underwent LA at our medical center. Analysis of our surveillance data demonstrated that 15/865 (1.7%) patients developed SSIs and 7/15 (47%) of these patients had positive wound cultures. Patients who developed SSIs were more likely to be male (80% vs 20%; P = 0.03), be older (43.0 vs 34.0; P = 0.04), have higher surgical wound classification scores (66.7% vs 38.2%; P = 0.009), and have longer operative times (82 vs 62 min; P = 0.003). The overall readmission rate was 2.8%.DiscussionWe report a lower SSI rate after LA than usually reported. Surgical site infection following LA is rare and may be challenging to diagnose early. Additional complications such as port-site hernia may also be encountered in this setting.ConclusionThis data should inform both physicians and surgeons who must consider the expected complication rates associated with surgery for AA globally.

Port-site hernias in patients undergoing laparoscopic and/or robotic surgery: Can they be prevented?

As laparoscopic surgery advances into robotic surgery, there still remains the occurrence of port-site hernias. This can have severe consequences for the patient, including needing further surgery such as bowel resection. This has an impact on both patient and the National Health Service as the stay in hospital is prolonged, increasing the demand on staff and creating more expense to the National Health Service. This literature review explores the prevalence of port-site hernias and discovers the recommendations in preventive measures. Findings include the benefit of using non-bladed trocars and further studies need to be conducted into the association between smaller or larger ports and port-site hernias.

Laparoscopic intraperitoneal onlay mesh repair for ventral hernia: our experience

Background: Ventral hernia is one of the most common pathologic conditions encountered with an estimated prevalence of one-fourth of individuals being born with it, developing, or acquiring a ventral hernia in their lifetime. Ventral hernias include both primary abdominal wall hernia and incisional hernia. Numerous studies indicate that the laparoscopic approach is safe and effective, and may be superior to open repair with regard to lower rates of recurrence and wound infection, greater patient acceptance, shorter hospital stay and early return to work. Aim of the study was to analyse the outcome, complications, postoperative pain and patient compliance in laparoscopic ventral hernia repair by intraperitoneal onlay mesh (IPOM) technique, using composite mesh.Methods: This was a prospective study conducted in the department of general surgery, MVJ medical college, Bangalore from December 2020 to August 2021. There were 100 cases operated by experienced surgeons. All patients posted electively for laparoscopic repair of ventral hernia on an intention to treat basis were included in the study. The immediate complications of pain, perioperative bleeding and major visceral injury were noted in all cases. We then followed up each patient prospectively in the postoperative period at 1 month, 3 months and 6 months to assess the incidence of port-site hernia and recurrence.Results: Of the 100 patients, 63 had an umbilical hernia, 33 had incisional hernias and 4 had an epigastric hernia. The mean age of the patients was 44.7 years. Female to male ratio of 2.25:1. The average defect width was 1.3 cm for umbilical hernias and 2.4 cm for incisional hernias. The mean operating time was 38 min for umbilical hernias and 61 min for incisional hernias. The mean postoperative hospital stay was 4.7 days. The mean duration of return to normal daily activity was 6.4 days. The average duration for which postoperative pain lasted was 4.6 days. No conversion to open laparotomy was required in any of the cases. The only short complication reported was postoperative pain. No case of postoperative ileus/seroma/port site infection/mesh displacement/infection or port site hernia and recurrence was reported over one year of follow up.Conclusions: IPOM technique is safe, feasible and effective technique for treatment of ventral abdominal wall hernias.

Frequency of Visceral Injury and Post-Operative Port Site Hernia from Direct Trocar Insertion for Gaining Access to Peritoneal Cavity in Laparoscopic Cholecystectomy

Aim: To see the frequency of visceral injury and port site hernia from direct trocar entry in laparoscopic cholecystectomy. Study Design: Place and Duration of Study: Department of Surgery, District Headquarters Teaching Hospital Abbottabad from 1st December 2017 to 20th September 2019. Methodology: Two hundred and sixty patients requiring laparoscopic cholecystectomy were enrolled. Direct trocar technique was used for peritoneal first port entry using retractable trocar in all patients. Demographic characteristics of the patients, as well as intraoperative visceral injury and post operative port site hernia formation were recorded. Results: Majority of study participants were females: 229 (88 %) women while remaining men. Mean age of study population was recorded as 37±8 years. Females were older than males (p > 0.05).We have not seen a single case of visceral injury or hernia formation in our study. Conclusions: The blind technique with retractable port is safe for first port entry into peritoneum in terms of visceral injury and also hernia formation. Key words: Direct trocar, Laparoscopic cholecystectomy, Visceral injury, Port site hernia

Correlation between Robotic Gynecological Surgeries and Port Site Hernia.

Correlation between Robotic Gynecological Surgeries and Port Site Hernia.

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Introduction: Major bile duct injury in laparoscopic cholecystectomy results in morbidity and needs further management, which adds to the increased cost of treatment. However, some studies have shown that by defining critical view of safety and seeing the relationship of Rouviere's sulcus with other structures, and minimal use of diathermy in Calot's triangle, we can bring down complications further close to zero percent. We wanted to see that such a low bile duct injury rate is achievable at every center by routinely following these steps. We retrospectively reviewed the database of patients who had undergone elective laparoscopic cholecystectomy (LC) in three years and evaluated the rate of bile duct injury and other complications. Methods: We reviewed our database for patients and did a retrospective analysis on patients who were diagnosed with symptomatic cholelithiasis or chronic cholecystitis, and have undergone LC in our centre from January 2017 to December 2019. Patients less than 15 years of age, acute cholecystitis, and laparoscopic cholecystectomy combined with common bile duct exploration were excluded. We calculated the incidence of biliary injury. The secondary outcomes looked at were Veress needle or pneumoperitoneum-related complications, port site bleeding, intra-abdominal bleeding, bowel injury, liver injury, wound infection, and early port site hernia. Results: LC was performed in 642 patients. In this study, there was no bile duct injury. Two patients (0.31%) had minor bile leak which resolved without any intervention within a week. Three (0.46%) patients developed port site infection, which responded to regular dressing and oral antibiotic therapy. Conclusion: The effectiveness of these steps should make their use mandatory in every center to reduce bile duct injury.

Laparoscopic Nephrectomy in Benign Renal Diseases- A Tertiary Hospital Experience

ABSTRACT:
 
 Objectives: The purpose of our study is to share experience of performing simple laparoscopic nephrectomy in benign cases.
 Study Design: Descriptive study.
 
 Place &
 Duration of
 Study: Department of Urology, Jinnah Postgraduate Medical Center (JPMC) Karachi, between Jan 2015 to Dec 2019 with minimal one and half year follow-up.
 
 Methodology: Our inclusion criteria were benign symptomatic nonfunctioning kidneys requiring nephrectomy. Laparoscopic nephrectomy was performed under general anesthesia with oblique position with three or four port technique was used. The demographic data, operative and post- operative details were carefully noticed and recorded in SPSS software version 20.
 
 Results: Total 40 patients were included in the study. Twenty four were females and 16 were males. Age ranges from 20 to 62 years with mean age of 44.64 + 11.04 years. Left sided were 24 patients (60%) while the right sided in 16(40%). Flank pain was the most common presenting complaint seen in 92.50% patients. Renal stone disease representing the most common indication for nephrectomy (40%) followed by ureteric stone (22.5%), chronic pyelonephritis (17.5%) and PUJO (15%). Our mean operative time was 200.29+47.98. Six patients (15%) were converted to open surgery because of intraoperative complications in 10% of patients including hilar vascular injury and gut injury and failure to progression in two (5%). Among the post- operative complications, early included low grade fever (10%) and wound infection (7.5%) while late included port site hernia (5%) and abscess at renal bed (2.5%). Chronic pyelonephritis was the most common histopathological report representing 45% of total cases. Our success rate was 85%.
 
 Conclusion: The role of laparoscopic nephrectomy in benign non-functioning kidneys is a better alternate to open nephrectomy in terms of pain, post-operative recovery and cosmetic results. The operative time and conversion rate can minimize after passing through adequate learning time and experience

Laparoscopic –Assisted Orchidopaxy in Non-Palpable Testes in Adult Population

ABSTRACT:
 
 Objectives: To present our experience of managing impalpable undescended testes in post-pubertal patients with intention of testicular preservation using laparoscopic assisted orchidopaxy. 
 
 Study Design: Descriptive Case series.
 
 Place &
 Duration of
 Study: Department of Urology, Jinnah Postgraduate Medical Center (JPMC) Karachi, between Jan 2015 to Dec 2020 with minimal 6 months follow-up.
 
 Methodology: We included all patients with clinically impalpable testes with aged 12 and above. All patients had ultrasound abdomen performed as initial screening test followed by laparoscopic assessment and definite procedure. Patients with normal or hypo-plastic testes were underwent single staged orchidopaxy, while patients with testicular atrophy were planned for orchiectomy. Intraoperative testicular biopsy and Semen analysis were not routinely performed in our study.
 
 Results: Total 36 patients with 41 impalpable testes underwent laparoscopic localization and management. Mean age of patients was 20.75+ 5.98 years. 50% of testes were on the right side, 36.1% on left sided while 3.88% were bilateral. 5 (12.1%) patients had clinical inguinal hernia.. Diagnostic yield of ultrasound was (75.6%) and 100 % in laparoscopy. 33 testis were true intra-abdominal while 4 were inguinal and 4 were vanishing testes Normal looking testes were observed in 24 testes (64.86%) followed by hypoplastic in 11(29.72%) while 2 testes (5.40%) were atrophic. Two intra-operative complications included urinary bladder injury and vas deferens injury in one patient each. Postoperatively testicular ischemic necrosis in one (2.4%) and wound infection in 2 (4.8%) patients were noted. Late follow up revealed one port site hernia (2.4%) and one testicular atrophy (2.4%). Success rate of orchidopaxy in our study was 94.6%.
 
 Conclusions: Laparoscopic has been proved as excellent diagnostic and therapeutic tool for the management of intra- abdominal undescended testes in adolescent and post-pubertal patients.
 
 
 Key words: Impalpable testes, Laparoscopic-assisted orchidopaxy, Adolescent, Adult

Laparoscopic Port-Site Hernia: An Underrecognized Iatrogenic Complication of Laparoscopic Surgery.

Port-site hernia is an iatrogenic complication with a documented incidence between 0.65% and 2.8%. However, the true incidence could be higher because of delayed onset, asymptomatic nature, and loss to follow-up. Port-site hernia could be further complicated by incarceration or strangulation leading to small bowel obstruction requiring emergent surgical intervention, thus imposing significant financial and emotional burden to patients. This article aims to provide a summary of the available literature concerning port-site hernia and explore preventive strategies for future clinical practice. This review was formulated through electronic literature searches in Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. The reference lists of the included studies were hand searched to identify other relevant articles to capture all available literature in this narrative review. Following screening for eligibility based on relevance to the topic under consideration, 28 studies were identified. This included 5 original articles, 1 case series, and 22 review articles, including 4 systematic reviews. Included studies were critically appraised in formulating this review. Port-site hernia is an underrecognized yet preventable complication with careful consideration of predisposing technical and host factors, thorough attention to surgical technique, or use of a fascial closure device. With the widespread and increasing use of laparoscopic methods to treat surgical pathologies, knowledge of this complication is imperative to encourage prevention strategies and facilitate early recognition and management should it occur.

Single incision laparoscopic appendectomy: A prospective study

Background: Appendicitis is one of the common pathologies encountered in surgical practice. Except in minority of the cases, the treatment is usually surgical. Till recent past, open appendectomy has been the procedure of choice for appendicitis. With increasing expertise in laparoscopic surgeries more and more surgeons are utilizing the laparoscopic approach for appendectomy. Laparoscopic surgeries have distinct advantages such as less surgical trauma, improved and quick postoperative recovery, and esthetic results. Single-incision laparoscopic surgery (SILS) is rapidly gaining acceptability in young population because of its cosmetic advantages. Moreover, these surgeries also avoid the risk of port-site hernias and the possibility of wound infection. Aims and Objective: The purpose of this study is to present our initial experience with this surgery using a single incision laparoscopic appendectomy (LA) using conventional instruments. Materials and Methods: This was a prospective cohort study conducted in the department of surgery of a tertiary care medical college situated in an urban area. The duration of the study was 2 years. All adult patients diagnosed to be having uncomplicated appendicitis and undergoing appendectomy by SILS were included in this study on the basis of a predefined inclusion and exclusion criteria. Pre-operative data collected included age, sex, weight, duration of complaint, concomitant medical conditions (like ischemic heart disease, chronic obstructive airway disease, diabetes mellitus, pancreatitis, and liver cirrhosis) and previous upper or lower abdominal surgery. All patients were treated by SILS except 1 patient in whom the procedure was converted to open surgery. Mean surgical time, Intraoperative procedure details and postoperative complications were studied in all the cases. p < 0.05 was taken as statistically significant. Statistical analysis was done using SSPS 21.0 software. Results: Out of 30 patients in this study 26 patients were female and 4 patients were male. The male to female ratio was found to be 1:6.15. Mean age of studied cases was found to be 26.2 years. Operative time required for the first 15 cases in an average was 120.00 min however it was reduced for the next 15 cases was 73.73 min. Overall time required in an average was 96.86 min. Out of 30 cases, The procedure was completed with Single Incision LA in 23 Patients, i.e., 76.6 %. In the initial cases, we started with two 5 mm and one 10mm port. To reduce crowding we replaced the 5 mm port to 3 mm port. The 10 mm port was also replaced by 5 mm in the past few cases in 1 patient the procedure was converted to open surgery. The analysis of postoperative complications showed that five patients had Post-Operative wound Infection. One patient had post-operative peritonitis. Conclusion: SILS is a feasible and safe surgical method for appendectomy and is being increasingly preferred particularly by young patients due to its excellent cosmetic results.

Direct Trocar Insertion: an Efficient Access Technique for Laparoscopic Cholecystectomy

Aim: To evaluate the feasibility and safety of direct trocar insertion for gaining access to peritoneal cavity in laparoscopic cholecystectomy. Methods: An Observational study was conducted at Surgical unit II Ghulam Mohammad Mahar Medical College Hospital Sukkur from January 2016 to December 2020. Two thousand one hundred twenty (n=2120) patients were included in the study. All the patients who underwent laparoscopic cholecystectomy were included in the study. Informed and written consent was obtained from every patient to participate as study subject. Data was analyzed on SPSS version 16. Mean +/- standard deviation was calculated for age, first port access time and time to establish pneumoperitoneum. Results: Under general anesthesia with patient in supine posture, abdominal access gained by first making small incision of 10mm in skin and subcutaneous fat at sub umbilical region with No. 11 scalpel and then by direct trocar insertion followed by creation of pneumoperitoneum. Cholecystectomy performed. Study variables included first port access time, no. of attempts for DTI, extraperitoneal CO2 insufflation, port site bleeding, visceral injury, port site infection and port site hernia and were recorded on predesigned proforma. Variables like extraperitoneal CO2 insufflation, port site bleeding and visceral injury were expressed as percentage. Conclusion: We conclude that direct trocar insertion is the safe, quick and effective method for creation of pneumoperitoneum and should be employed routinely in all laparoscopic procedures. Keywords: Laparoscpy, Cholecystectomy, Trocars

A safe, reliable, and efficient robot-assisted port site closure for robot-assisted gastrectomy

IntroductionThe overall incidence of port site hernias in laparoscopy and robot-assisted surgeries ranges from 0% to 5.2%. Sufficient port site closure is essential to reduce and prevent the occurrence of port site hernia. However, complete fascial closure of 8-mm robot-port site appears to be difficult. In this study, we propose a safe and reliable robot-assisted port-site closure for robot-assisted gastrectomy. Materials and methodsThe robotic arm was tilted 60–70° cranially or caudally to create a small gap between the port and the skin margin that was cut open for port insertion. While viewing through the robotic camera and grasping the polydioxanone (PDS) thread, the Lapa-Her-Closure was inserted into the peritoneal cavity through the gap. The Lapa-Her-Closure was removed after the PDS thread was grasped with robotic forceps. Subsequently, the Lapa-Her-Closure was inserted into the abdominal cavity by tilting the arm cranially or caudally, in contrast to the previous step. The PDS thread was inserted into the loop wire using robotic forceps. After tightening the loop wire and grasping the PDS thread, the Lapa-Her-Closure was removed, and the PDS thread was ligated to complete the abdominal wall closure, with total closure of the fascia and peritoneum. Results and conclusionsWe utilized this port site closure technique in 12 patients who underwent robot-assisted gastrectomy for gastric cancer. The procedure was accomplished safely and efficiently in all cases without any technical problems. In conclusion, our port site closure is safe, reliable, and efficient procedure that can be performed using basic surgical techniques.

Trends in Robotic Port Closure and Hernia Risk by Surgical Specialty

<h3>Study Objective</h3> Determine if the rate of robotic fascial port closure differs by surgical specialty and assess the relationship between fascial closure and port-site hernias after a robotic-assisted surgery. <h3>Design</h3> Retrospective chart review of patients undergoing robotic surgery by gynecologists, urologists and general surgeons in which a 10 mm assistant port was used. <h3>Setting</h3> Urban Teaching Hospital with dual-console robotic teaching program. <h3>Patients or Participants</h3> Patients on the Gynecology, Urology, and General Surgery services at the University of Colorado between in 2019 who underwent a robot-assisted surgical procedure with or without fascial closure. <h3>Interventions</h3> Fascial closure or non-closure of the 10 mm laparoscopic port sites. <h3>Measurements and Main Results</h3> A total of 361 patients underwent robotic-assisted laparoscopy for gynecologic, urologic and general surgery procedures during the study period. Gynecologists were most likely to suture close the 10 mm fascial ports with 99% closure rate. General Surgeons closed the fascial port 87% of the time. Urologists were significantly less likely to close the 10 mm fascial port site with a 26% closure rate (P<0.001). The overall hernia rate was low for all cases at 0.6%. The fascial hernia rate was 0% for Gynecological procedures, 0.8% for Urological procedures, and 0% for General Surgery procedures. There was no difference in the hernia rates between the surgical specialties (P=0.89). There also no difference between the hernia rates whether the fascial port was closed or not (0% vs 1.1%, P=0.64). <h3>Conclusion</h3> There are differences between surgical specialties in the decision to close a 10 mm laparoscopic port with Gynecologists and General Surgeons suturing the fascia closed more commonly than Urologists. Despite this difference in practice, the hernia risk is very low in robotic surgery.

344 Managing Clinical Rarities: A Unique Case of Non-Inflamed Appendix in A Port Site Hernia

Abstract Introduction Port site hernias containing the appendix are sporadically described in the literature, with most cases presenting with acute appendicitis. Cases of a normal appendix being found in such hernias are extremely rare and rarely published. Here we describe a patient with a port site hernia containing a non-inflamed appendix. The lack of similar recorded cases makes this a unique case to highlight and discuss. Case Description 81-year-old lady, with adenocarcinoma of the upper rectum, underwent a laparoscopic high anterior resection in late 2018. With 12 mm ports placed in Umbilicus and RIF. 5mm ports placed in RUQ and LUQ. The 12 mm ports were closed with deep suture closure and the skin was closed using clips. Computerised tomography (CT) imaging at one year showed local cancer recurrence and a small abdominal wall hernia in the right iliac fossa. During subsequent resection surgery, a RIF port site hernia was identified intraoperatively. The hernia sac consisted of an uninflamed appendix. The hernia was reduced and an appendicectomy was performed with the hernia being closed with interrupted suture closure. Histology of the appendix confirmed no evidence of inflammation. Discussion When a clinical rarity is encountered there is often minimal literature to guide management and decisions must be made based on surgical principles and clinical reasoning. Although here an appendicectomy was performed, resection of a normal appendix remains a contentious point in the surgical field. This case demonstrates a potential management option to guide surgeons who encounter this clinical rarity in their future practice.