Port Site Hernia Research Articles

Specimen retrieval during elective laparoscopic cholecystectomy: is it safe not to use a retrieval bag?

BackgroundSince the introduction of laparoscopic surgery for gallbladder disease different types of retrieval devices have been used to extract the gallbladder from the peritoneal cavity. These devises infer additional costs and may lead to associated risks and complications. We aimed to evaluate the safety of gallbladder retrieval without the use of a retrieval device.MethodsA prospective study was conducted across two teaching hospitals in the Republic of Ireland from July 2010–2013. Patients undergoing planed elective day case laparoscopic cholecystectomy in the two institutions were included in the study. Data were collected on patient demographics, the use of a bag, any need for extension of fascial incision, any unexpected over night stay, any 30-day post operative complications and presence of port site hernia within 1 year surgery.ResultsThere were 373 planned elective day case laparoscopic cholecystectomy performed during the study period. A bag was not used to retrieve the gallbladder in 41 % (n = 152) patients. A retrieval bag was used in the majority of patients (71 %) who required over night stay due to pain. Overall wound infection rate was low (2.4 %), with 57 % of those being in patients where no retrieval bag was used. An increase incision in the fascia was required in 9.7 % of patients. The majority of these were in patients in whom a retrieval bag was used (75 %). At 1 year follow up, there were no recorded cases of port site hernia for the no retrieval bag group and two (0.9 %) cases of umbilical port site hernias in the group where retrieval bag was used.ConclusionIn cases of elective uncomplicated laparoscopic cholecystectomy for radiologically confirmed benign disease there was no benefit in using a retrieval bag. Furthermore, not using a bag was associated with less need for increasing the size of the fascial incision thereby reducing post operative pain and risk of port site hernia.

MID-TERM OUTCOME OF PERFORATED DUODENAL ULCER REPAIR USING SINGLE-PORT LAPAROSCOPIC SURGERY

Background: Single-port laparoscopic surgery (SPLS) is increasingly used in surgery and in the treatment of perforated duodenal ulcer. The aim of this study was to evaluate mid-term outcome of perforated duodenal ulcer repair using SPLS. Methods: A prospective study on 72 consecutive patients diagnosed with perforated duodenal ulcer and treated with SPLS at Hue University Hospital and Hue Central Hospital from January 2012 to Mars 2016. Results: The mean age was 48.8 ± 14.0 (17 - 79) years. Male/female ratio was 17.0. Four patients (5.6%) with history of abdominal surgery were successfully treated by pure SPLS. Patients were classified as ASA 1, ASA 2 and ASA 3 in 86.1%, 12.5%, and 1.4% of cases, respectively. Using Boey scoring system, there were 86.1% and 12.5% of cases classified as Boey 0 and Boey 1 while there were no Boey 2 and 3 cases. The average size of perforation was 4.1 ± 2.6 (1.5-22) mm. The perforation was situated on the anterior duodenal wall in 98.6% of cases and on the posterior duodenal wall in 1.4% of cases. There was one case (1.4%) in which one additional trocar was required. Conversion to open surgery was necessary in one patient (1.4%) in which the perforation was situated on the posterior duodenal wall. Average length of hospital stay was 5.7 ± 1.2 (4-12) days. Post-operative complications rate was 2.8%. There was no leakage from the repair site, no port-site hernia and no post-operative mortality. At 2-month follow-up visit, patients were classified as Visick 1 in 95.1% of cases and Visick 2 in 4.9% of cases and the duodenal ulcer was completely healed on gastroduodenoscopy in 86.7% of cases. At 12-month follow-up, patients were classified as Visick 1 in 93.5% of cases and Visick 2 in 4.3% of cases. There was one case (2.2%)diagnosed with recurrent duodenal ulcer perforation at 5 months after the repair of the first perforation. On gastroduodenoscopy, recurrent duodenal ulcer was seen in 8.9% of cases. Conclusions: SPLS is a safe method for the treatment of perforated duodenal ulcer. Conversion rate was 1.4%. Recurrent duodenal ulcer rate was 8,9% and recurrent duodenal ulcer perforation rate was 2.2% after 12-month follow-up. Key words: perforated duodenal ulcer, single port laparoscopic repair, single port laparoscopy

Impact of the Specific Extraction-Site Location on the Risk of Incisional Hernia After Laparoscopic Colorectal Resection.

The impact of the specific incision used for specimen extraction during laparoscopic colorectal surgery on incisional hernia rates relative to other contributing factors remains unclear. This study aimed to assess the relationship between extraction-site location and incisional hernia after laparoscopic colorectal surgery. This was a retrospective cohort study (January 2000 through December 2011). The study was conducted at a high-volume, specialized colorectal surgery department. All of the patients undergoing elective laparoscopic colorectal resection were identified from our prospectively maintained institutional database. Extraction-site and port-site incisional hernias clinically detected by physician or detected on CT scan were collected. Converted cases, defined as the use of a midline incision to perform the operation, were kept in the intent-to-treat analysis. Specific extraction-site groups were compared, and other relevant factors associated with incisional hernia rates were also evaluated with univariate and multivariate analyses. A total of 2148 patients (54.0% with abdominal and 46.0% with pelvic operations) with a mean age of 51.7 ± 18.2 years (52% women) were reviewed. Used extraction sites were infraumbilical midline (23.7%), stoma site/right or left lower quadrant (15%), periumbilical midline (22.5%), and Pfannenstiel (29.6%) and midline converted (9.2%). Overall crude extraction site incisional hernia rate during a mean follow-up of 5.9 ± 3.0 years was 7.2% (n = 155). Extraction-site incisional hernia crude rates were highest after periumbilical midline (12.6%) and a midline incision used for conversion to open surgery (12.0%). Independent factors associated with extraction-site incisional hernia were any extraction sites compared with Pfannenstiel (periumbilical midline HR = 12.7; midline converted HR = 13.1; stoma site HR = 28.4; p < 0.001 for each), increased BMI (HR = 1.23; p = 0.002), synchronous port-site hernias (HR = 3.66; p < 0.001), and postoperative superficial surgical-site infection (HR = 2.11; p < 0.001). This study was limited by its retrospective nature, incisional hernia diagnoses based on clinical examination, and heterogeneous surgical population. Preferential extraction sites to minimize incisional hernia rates should be Pfannenstiel or incisions off the midline. Midline incisions should be avoided when possible.

Percutaneous trans-abdominal external looped needle with two holes in the trocar sheath for port-site closures in difficult obese cases.

Port closure is essential after successful laparoscopic surgery to prevent incisional hernia. However, good fascial closure still represents a problem, especially in obese patients and when the port wound is oblique. We report a novel technique for port-site closures in such cases. This study involved 67 obese patients who underwent laparoscopic surgery. We used a novel technique for port-site closure that employed a looped needle passed through two holes in the port sheath. The method was used in 67 patients (45 laparoscopic cholecystectomies, 22 laparoscopic hernia repairs), with a mean BMI of 35.7 kg/m2 . No intraoperative incidents or port-site hernias were reported during follow-up (mean, 22 months). Our procedure is safe, easy, and effective for fascial port site closures, especially in cases of difficult obese patients and oblique port wounds.

Influencing factors for port-site hernias after single-incision laparoscopy.

Single-incision laparoscopic surgery (SILS) has been demonstrated to be a feasible alternative to multiport laparoscopy, but concerns over port-site incisional hernias have not been well addressed. A retrospective study was performed to determine the rate of port-site hernias as well as influencing risk factors for developing this complication. A review of all consecutive patients who underwent SILS over 4years was conducted using electronic medical records in a multi-specialty integrated healthcare system. Statistical evaluation included descriptive analysis of demographics in addition to bivariate and multivariate analyses of potential risk factors, which were age, gender, BMI, procedure, existing insertion-site hernia, wound infection, tobacco use, steroid use, and diabetes. 787 patients who underwent SILS without conversion to open were reviewed. There were 454 cholecystectomies, 189 appendectomies, 72 colectomies, 21 fundoplications, 15 transabdominal inguinal herniorrhaphies, and 36 other surgeries. Cases included 532 (67.6%) women, and among all patients mean age was 44.65 (±19.05) years and mean BMI of 28.04 (±6). Of these, 50 (6.35%) patients were documented as developing port-site incisional hernias by a health care provider or by incidental imaging. Of the risk factors analyzed, insertion-site hernia, age, and BMI were significant. Multivariate analysis indicated that both preexisting hernia and BMI were significant risk factors (p value=0.00212; p value=0.0307). Morbidly obese patients had the highest incidence of incisional hernias at 18.18% (p value=0.02). When selecting patients for SILS, surgeons should consider the presence of an umbilical hernia, increased age and obesity as risk factors for developing a port-site hernia.

Laparoscopic treatment of early-stage endometrial cancer with and without uterine manipulator: Our experience and review of literature

ObjectiveThe aim of this study was to retrospectively compare in a series of 110 patients with early-stage endometrial cancer recurrence rate and surgical outcomes after total laparoscopic (LPS) hysterectomy with lymphadenectomy performed with or without uterine manipulator. Study design110 patients with clinical stage I endometrial cancer were enrolled in a retrospective study and underwent surgical staging comprised of LPS hysterectomy, bilateral salpingo-oophorectomy, and in all cases we performed systematic bilateral pelvic lymphadenectomy with uterine manipulator (Group 1, 55 patients) or without (Group 2, 55 patients). ResultsThe rate of positive cytology and LVSI did not significantly differ between Group 1 and Group 2. 1 patient of the Group 1 had a bladder injury and another patient of Group 2 had an ureteral stricture temporarily treated with a stent. 1 patient of the Group 1 had a bowel occlusion due to a port site hernia under the left 10 mm port, resolved with a bowel resection and an end-to-end anastomosis. In 1 patient of the Group 1 and 2 patients of Group 2 we observed a vaginal cuff dehiscence and in 1 case of Group 2 a pelvic lymphocyst was reported. Postoperative fever was reported in 3 patients of the Group 1 and in 5 patients of group 2 (p = 0.07). ConclusionsOur study confirms that use of uterine manipulator for laparoscopic treatment of endometrial cancer does not increase positive peritoneal citology, LVSI and recurrence rate.

Single-Incision Laparoscopic-Assisted Anorectoplasty for the Management of Persistent Cloaca.

This study aimed to evaluate the safety and efficacy of single-incision laparoscopic-assisted anorectoplasty (SILAARP) for children with persistent cloaca. Five patients with persistent cloaca underwent SILAARP and repair of the urogenital sinus between June 2014 and February 2015. The mean age of the patients at the time of operation was 0.80 ± 0.16 year (range, 0.6-1.0 year). An extralong 5-mm 30° laparoscope was inserted through the 5-mm middle port. Two 3-mm lateral ports were placed for instruments. The three ports were placed at a horizontal line through a 2-cm transumbilical incision. CO2 pressure was maintained between 8 and 12 mm Hg. The patients were evaluated for fecal continence and complications. SILAARP and repair of the urogenital sinus were successfully performed in all patients. The mean operation time ranged from 120 minutes to 130 minutes. The operative blood loss was minimal. There were no operative complications. All patients were followed up for 0.64 ± 0.29 year (range, 0.3-1.0 year). No patient developed fecal incontinence. Two of the 5 patients (40%) had two to four stools per days, but this did not cause social problems. Only 1 patient (20%) had constipation and required changes in diet. No wound infection, port-site hernia, urethrovaginal fistula, acquired anorectal atresia, or urethral injury occurred. Our results show that SILAARP is an effective and safe option for patients with persistent cloaca.

Feasibility of robot-assisted radical prostatectomy in elderly patients: Comparative analysis of the peri-surgical/oncological outcomes with younger patients.

134 Background: Robot-assisted radical prostatectomy (RARP) has become one of standard treatments for localized prostate cancer. However, a feasibility of RARP in elderly patients has not been clear yet. We performed a comparative analysis of peri-surgical/oncological outcomes for younger and elderly patients underwent RARP. Methods: We reviewed and compared our initial 340 consecutive patients who underwent RARP from 9/2012 to 8/2015 for peri-surgical outcomes, including surgical times, blood loss, complications, pathological findings, continence recovery, and oncological outcomes stratified by age less than 70 and over 70 years. Results: In our cohort, 202 men were age less than 70 and 138 men were ≥70. Preoperative parameters (age, PSA, Gleason score) were similar in both younger and elder groups. Operative time (median: 167 vs. 171 minutes) and estimated blood loss were similar in both groups. One of elder patients (0.7%) needed transfusion. Peri/post-operative complications in both groups appeared to be minimal with no cases of intra-operative open conversion. One of younger patients needed a surgical settlement for port site herniation. Surgical positive margin rates in organ-confined (pT2) disease were also similar (5.6%, younger vs. 9.0%,elder). Continence at 3 months was 82% in elder patients as opposed to 87% in younger patients. Median follow-up period in in elder patients and younger patients were 15.2 and 15.3 months, respectively. Biochemical recurrence free survival rates in elder patients and younger patients were 89.9% and 93.6%, respectively (p=0.1026). Conclusions: In our study, RARP in elderly patients was relatively safe and yielded good oncologic results. RARP is feasible even in elderly patients.

No Need of Fascia Closure to Reduce Trocar Site Hernia Rate in Laparoscopic Surgery: A Prospective Study of 200 Non-Obese Patients.

BackgroundLaparoscopy is widely practiced and offers realistic benefits over conventional surgery. Port closure is important after a laparoscopic procedure to prevent port site incisional hernia. Larger port size and increasing numbers of ports needed to perform more complex laparoscopic procedures are likely to increase the incidence of port site hernias (PSHs). PSHs 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. More than 90% of PSHs occur through 10 mm and large ports can occur through 5 mm ports also. The aim was to study the outcomes and complications in laparoscopic surgery without fascial sheath closure of port site. We compared the results with another group in which fascial closure was done by a standard method.MethodsThis was a prospective study carried out in the Department of Surgery, MMIMSR, Mullana, Ambala, from August 2013 to 2015 in a single unit by a single surgeon. A total of 200 patients were selected randomly for the different laparoscopic procedures. Patients were divided into group A (only skin closure was done without fascia closure) and group B (fascial closure of the port in addition to skin closure). In both groups, we used blunt trocar for the 10 mm port. Skin of the 5 mm port was closed simply. The results in two groups were compared in terms of complications like PSH, bleeding, and wound infection.ResultsThe outcomes in two groups were compared with and without fascia closure of 10 mm trocar port site. Patients operated for lap cholecystectomy were 170 (85%), 10 (5%) for lap appendicectomy, and 20 (10%) for lap hernia. The study compared the results in two groups mainly for PSH formation. The P value was insignificant and Fischer’s exact test result came as 1.00. There were no significant differences between the two groups in terms of PSH, bleeding and infection in non-obese cases.ConclusionIn both groups, blunt trocar was introduced into the abdomen. We concluded that this is safe, without visceral injury, and no bleeding was seen in both the groups. We had not encountered any case with PSH formation in follow-up of 6 - 8 months. There was no infection over the port site.

Incarcerated umbilical port site hernia

With increase in the number of laparoscopic procedures being performed, the incidence of port site complications has also increased proportionately. Infection and port site hernia are the commonest of the complications. Port site hernias are more prone to complications in view of the irregularity and narrowness of the defect. A case of an incarcerated umbilical port site hernia is presented to highlight the complexity of the problem and the surgical challenge that it poses.

Two-port Laparoscopic Cholecystectomy: An Initial Experience of 25 Cases with a New Technique

Background: In Nepal, it is quite common to find patients with large stone burden and thick gallbladder wall which often leads to incision extension. We have used this extended incision to our advantage. The present technique of two-port Laparoscopic cholecystectomy not only helps overcoming the specimen extraction difficulties but also contributes to better cosmesis. Patients and methods: Total of 25 patients were underwent the surgery in 2008 to 2010. Results: The mean operating time was 50 minutes. None had significant procedural blood loss, iatrogenic injury, perforation of gallbladder, bile spillage, significant gas leak or subcutaneous emphysema at either port site. All patients were comfortable in the postoperative period and were routinely discharged on 2nd postoperative day except for 2 patients who has surgical site infection and fever respectively. Although 3 cases were converted to standard four-port technique, none required conversion to open cholecystectomy. Out of 25 patients, 7 cases have completed 3 months follow up and did not show any complication like port site hernia.

Study of laparoscopic cholecystectomy in rural hospital

Background: Laparoscopic cholecystectomy is the preferred mode of treatment for gall stone diseases. This study is the audit of 125 laparoscopic cholecystectomy done in our institute between year 2013 to year 2014. In laparoscopic cholecystectomy common bile duct injuries were more common than open surgery. Objective of this study is to find out intra and postoperative complications in laparoscopic cholecystectomy and to find the reasons for conversion to open cholecystectomy. Methods: This is the retrospective study of standard four port laparoscopic cholecystectomy done during year 2013 to year 2014 in our institute. The result and complications of laparoscopic surgery were documented in audit form for each laparoscopic cholecystectomy and at the end the results are analyzed. Results: There were no common bile duct injury in our study of 125 cases and we had 5.6% conversion to open cholecystectomy due to various reasons discussed in the paper. There were no cases of postoperative abdominal abscess, port site hernia, common bile duct stricture or mortality in our study. One patient with cystic duct leak was managed successfully with post-operative endoscopic spincterotomy and stenting of common bile duct. Conclusions: Laparoscopic cholecystectomy as treatment of choice is associated with high success rate at our institute with added benefits of minimal invasive surgery. Our results are comparable to international standards. Critical view of safety is an essential prerequisite for prevention of bile duct injuries.

ZEAL: “Z” ending abdominal laparoscopy - a simple and effective technique for port insertion

Up to 50% of complications at a laparoscopic procedure occur at port insertion. Thus, safe and strategic port placement remains the key to obtaining acceptable results at laparoscopy. While several methods have been discussed in the literature, none have been seen as a benchmark. In this paper, we describe a simple method of laparoscopic port introduction that follows a path resembling the English letter’ Z’. We have found this technique to be advantageous in many ways. Apart from being safe and effective, it is easy to learn and ergonomically advantageous with the potential to minimize the incidence of port-site herniation. We have used it successfully on 7500 occasions over the past seven years without any short/long-term complications. Hence, it could be recommended for routine use. Such a method is yet to be reported.

Retrieval of the gastric specimen following laparoscopic sleeve gastrectomy. Experience on 275 cases

Severe obesity leads to a high incidence of complications and a decrease in life expectancy, especially among younger adults. Laparoscopic sleeve gastrectomy (LSG) first intended as the first step of biliopancreatic diversion with duodenal switch is gaining a per-se procedure role because of its effectiveness on weight loss and comorbidity resolution. Different techniques have been described for specimen extraction in LSG. In this article we report the technique adopted in 275 LSGs performed in our department.In the first 120 LSGs performed from 2007, the specimen was extracted through a mini laparotomy. In the following 155 cases the technique has been simplified: the grasped specimen has been withdrawn through the 15 mm trocar site.We registered in the fist group six cases of wound infection (5%), ten cases of hematoma (8.3%) and four cases of port site hernia (3.3%). In the second group only one case of hematoma (0.6%, p = 0.01) but no cases of wound infection (p = 0.01) or port site hernia, (p = 0.03) although we registered a specimen perforation during retrieval in 16 patients, were reported.The technique described in the 155 cases of the control group has shown to be more effective than the technique we used in the case group, allowing significantly lower operative time (112.9 ± 1.0 vs 74.9 ± 9.1 p < 0.001) and complications, and providing unchanged costs.

Trocar Site Hernia after Use of an 8-mm Bladeless Trocar in Robotic Colorectal Surgery

Port site hernias are a rare complication after laparoscopic and robotic surgery. The current case is an 8-㎜ port site hernia which occurred after robot-assisted colorectal surgery. A 70-year-old female with a BMI (body mass index) of 25.7 was diagnosed as rectosigmoid colon cancer. She underwent a robot-assisted low anterior resection with double-stapled anastomosis for AJCC (American Joint Committee on Cancer) stage IIIB. After the main procedure, fascial defects in the supra-pubic and the supra-umbilical site were closed with a routine procedure (12 ㎜). Thirty two months after surgery, she developed an incisional hernia in the left mid abdomen (8-㎜ port). Recognition of the potential for a port site hernia using an 8-mm bladeless trocar port as well as a 12-㎜ port is essential in robotic surgery. Patients with risk factors for a port site hernia may require complete port site closure.

Multidetector computed tomography evaluation of post cholecystectomy complications: A tertiary care center experience.

To evaluate the role of multidetector computed tomography (CT) and CT angiography (CTA) in post cholecystectomy complications. A retrospective analysis of data from December 2012 to August 2014 was performed. Eight hundred sixty consecutive patients with history of cholecystectomy (laparoscopic or open) were evaluated. After exclusion of 645 patients with normal imaging, analysis for post cholecystectomy complications was performed in 215 patients. A contrast enhanced CT/CTA was performed. Mean interval to imaging was 10 months (range 3 days to 15 months). A complication rate of 25% was noted in patients undergoing imaging following cholecystectomy. Gallbladder bed or perihepatic collections were seen in 11.9% cases (n = 103). Intrahepatic biliary radicle dilatation (IHBRD) was seen in 7% patients (n = 60). Isolated right or left ductal dilatation was seen in 9 patients; rest of the patients had bilateral IHBRD. Cholangitic abscesses and mild acute pancreatitis were seen in 11 (1.2%) and 12 (1.3%) patients respectively. These comprised biliary complications. Venous thrombosis involving the portal vein was the most frequently encountered vascular complication (n = 12). Right hepatic artery pseudoaneurysm was seen in two patients. Less common complications were abdominal wall hematoma (n = 2), incisional hernia (n = 6), port site hernia (n = 2), large bowel injury (n = 1), biliocutaneous fistula (n = 1) and enterocutaneous fistula (n = 1). CT allows classification of post cholecystectomy complications and guides further management. CTA provides an efficient road map for management of vascular complications.

Multi-institutional Experience in Laparoendoscopic Single-site Surgery (LESS): For Major Extirpative and Reconstructive Procedures in Pediatric Urology

To review peri-procedural outcomes from a large, multi-institutional series of pediatric urology patients treated with laparaendoscopic single-site surgery (LESS) for major extirpative and reconstructive procedures. Consecutive LESS cases between January 2011 and May 2014 from three free-standing pediatric referral centers were reviewed. Data include age, sex, operative time, blood loss, length of stay, and complications according to the modified Clavien-Dindo classification. Hasson technique was used for peritoneal entry, GelPOINT advanced access platform was inserted, and standard 5mm laparoscopic instruments were used. Fifty-nine patients (median age 5 years, 4 months-17 years) met inclusion criteria: 29 nephrectomies, 9 nephroureterectomies, 3 bilateral nephrectomies, 5 heminephrectomies, 5 renal cyst decortications, 3 bilateral gonadectomies, 2 Malone antegrade continence enema, 2 calyceal diverticulectomy, and 1 ovarian detorsion with cystectomy. Median operative times for each case type were comparable to published experiences with traditional laparoscopy. Overall mean and median length of stay was 36.2 hours and 1 day, respectively. There were two complications: port site hernia requiring surgical repair (Clavien IIIb) and a superficial port site infection that resolved with antibiotics (Clavien II). Cosmetic outcomes were subjectively well received by patients and their parents. Operative time was significantly shorter between the first half of the experience and the second half (102 vs 70 minutes, P < .05). LESS approach can be broadly applied across many major extirpative and reconstructive procedures within pediatric urology. Our series advances our field's utilization of this technique and its safety.

Incisional and port-site hernias following robotic colorectal surgery.

The association between extraction site location, robotic trocar size, and the incidence of incisional hernias in robotic colorectal surgery remain unclear. Laparoscopic literature reports variable rates of incisional hernias versus open surgery, and variable rates of trocar site hernias. However, conclusions from these studies are confusing due to heterogeneity in closure techniques and may not be generalized to robotic cases. This study evaluates the effect of extraction site location on incisional hernia rates, as well as trocar hernia rates in robotic colorectal surgery. A retrospective review of multiport and single incision robotic colorectal surgeries from a single institution was performed. Patients underwent subtotal, segmental, or proctocolectomies, and were compared based on the extraction site through either a muscle-splitting (MS) or midline (ML) incision. Hernias were identified by imaging and/or physical exam. Demographics and risk factors for hernias were assessed. Groups were compared using a multivariate logistic regression analysis. The study included 259 colorectal surgery patients comprising 146 with MS and 113 with ML extraction sites. Postoperative computed tomograms were performed on 155 patients (59.8%) with a mean follow-up of 16.5months. The overall incisional hernia rate was 5.8%. A significantly higher hernia rate was found among the ML group compared to the MS group (12.4 vs. 0.68%, p<0.0001). Of the known risk factors assessed, only increased BMI was associated with incisional hernias (OR 1.18). No trocar site hernias were found. Midline extraction sites are associated with a significantly increased rate of incisional hernias compared to muscle-splitting extraction sites. There is little evidence to recommend fascia closure of 8-mm trocar sites.

Occult Radiographically Evident Port-Site Hernia After Robot-Assisted Urologic Surgery: Incidence and Risk Factors

Laparoscopic trocar-site hernias (TSH) are rare, with a reported incidence of 1% or less. The incidence of occult radiographically evident hernias has not been described after robot-assisted urologic surgery. We evaluated the incidence and risk factors of this problem. A single-institution retrospective review of robot-assisted urologic surgery was performed from April 2009 to December 2012. Patients with preoperative and postoperative CT were included for analysis. Imaging was reviewed by two radiologists and one urologist. One hundred four cases were identified, including 60 partial nephrectomy, 38 prostatectomy, and 6 cystectomy. Mean age was 58 years and mean body mass index (BMI) was 29 kg/m(2). The cohort was 77% male. Ten total hernias were identified by CT in 8 patients, 2 of which were clinically evident hernias. Excluding these two hernias, occult port-site hernias were identified radiographically in seven patients. Per-patient incidence of occult TSH was 6.7% (7/104), and per-port incidence was 1.4% (8/564). All hernias were midline and 30% contained bowel. Eight of the 10 occurred at 12 mm sites (p = 0.0065) and 3 of the 10 occurred at extended incisions. Age, gender, BMI, smoking status, diabetes mellitus, immunosuppressive drug therapy, ASA score, procedure, blood loss, prior abdominal surgery, and history of hernia were not significant risk factors. Specimen size >40 g (p = 0.024) and wound infection (p = 0.0052) were significant risk factors. While the incidence of clinically evident port-site hernia remains low in robot-assisted urologic surgery, the incidence of CT-detected occult hernia was 6.7% in this series. These occurred most often in sites extended for specimen extraction and at larger port sites. This suggests more attention should be paid to fascial closure at these sites.

Closure of the Cystic Duct Comparison Ultrasonic Harmonic Scalpel versus Clip Application in Laparoscopic Cholecystectomy

Background: Laparoscopic cholecystectomy (LC) is usually performed using titanium clips (TC) for occlusion of the cystic duct and cystic artery. The use of Harmonic scalpel (HS) in LC has been reported. Aim: This study aimed to compare effect of HS and clips application for closure of the cystic duct and artery in patients undergoing LC. Patients and Methods: Totally 50 patients were operated using LC technique from April 2010 to April 2012. Patients were retrospectively, divided into 2 groups according to the instruments used for division of the cystic artery and duct as well as for dissection of the liver bed. On the one hand, group 1 consisted of 30 patients who were all treated with the ultrasonic harmonic scalpel as the sole instrument used in the whole procedure. On the other hand, group 2 comprised 20 patients in whom dissection and coagulation were performed using monopolar coagulation, and occlusion of the artery and duct with clips. The operative time, postoperative hospital stay, morbidity, and mortality for each group were analyzed and compared with each other. Results: The 2 groups were comparable for age, sex, indication for cholecystectomy, and combined procedures. Patients were randomly treated either with the ultrasonic HS or with clips. Postoperative hospital stay of all patients in the group 1 and group2 was 2 days. Superficial wound infection seen in one patient (2%) in group 2 which was treated by oral antibiotics. During the follow-up period, one port-site hernia was detected in one patient (2%) in group 2. One case (2%) of peritoneal fluid collection seen in (group 1) and treated with percutaneous drainage was found. Conclusions: The use of harmonic scalpel was accepted as a reasonable alternative for closure of cystic ducts < 4 mm in diameter. This Study has shown that the HS is an effective and safe tool for the closure of both the cystic duct and artery in patients who undergo LC.