Case Report
Suture or not to Suture? Trocar- Site Bowel Herniation as a Rare Complication after Trocar Placement in Laparoscopic Surgery: Case Report and Review
Marek Gogacz1, Aleksandra Kamińska1, Izabela Winkler2*, Aneta Adamiak1, Tomasz Rechberger1 and Koninckx Philippe3
1Department of Gynecology, Lublin Medical University, Poland
2Department of Gynecology, St Johns’ Oncology Center in Lublin, Poland
3Department of Obstetrics and Gynecology, Catholic University Leuven, Belgium
*Corresponding author: Izabela Winkler, Department of Gynecology, St Johns’ Oncology Center in Lublin, Poland
Published: 12 Oct, 2018
Cite this article as: Gogacz M, Kamińska A, Winkler I,
Adamiak A, Rechberger T, Philippe
K. Suture or not to Suture? Trocar-
Site Bowel Herniation as a Rare
Complication after Trocar Placement
in Laparoscopic Surgery: Case Report
and Review. Clin Surg. 2018; 3: 2158.
Abstract
Laparoscopic surgery became gold standard procedure in numerous indications but despite of
minimal invasiveness it could result in added complications specific to the laparoscopic approach.
In this study, we present the case of 63 year-old patient who underwent a total laparoscopic
hysterectomy with adnexa for preinvasive cervical cancer complicated by the occurrence of small
bowel herniation at the 5-mm trocar site.
Trocar Site Hernia (TSH) is rare but potentially dangerous complication which can be asymptomatic
or requires emergency surgery. It should always be included in the different diagnosis of bowel
obstruction when the patients complain of gastrointestinal symptoms after laparoscopy. In this case,
patient required relaparotomy which confirmed the diagnosis.
Keywords: Minimally Invasive Surgery; Trocar Site Hernia; Laparoscopy
Introduction
Laparoscopic surgery is widely practiced and became the gold standard procedure in numerous
indications. It may offer more benefits than conventional surgery but despite of minimal invasiveness
it could resulted in added complications specific to the laparoscopic approach. Some of them can be
directly attributed to abdominal access with laparoscopic trocars. One of these is Trocar Site Hernia
(TSH), a rare problem that can be encountered during regular and robot-assisted laparoscopic
procedures. TSH is rare but potentially dangerous complication. It can be asymptomatic or presents
with bowel obstruction, requiring emergency surgery [1,2].
TSHs are well- known postoperative complication associated with laparoscopic surgery which
can occur in wounds of any size, ranging from 2 mm to 15 mm. The majority of reported cases are in
wound larger than 10 mm. The TSH occurred in a wound smaller than 10 mm – defined as a small
wound, are extremely rare [3,4]. Incidence of the complication has been evaluated at 0.8% to 1.2 %,
but the true incidence of herniation may be higher because many patients are asymptomatic or do
not return to the primary surgeon [2,4]. Some authors suggested that the prevalence of herniation
is 0.5% (ranging 0% to 5.2%) [4].
Hysterectomy is the most common surgical intervention on the female genital tract following
cesarean section. The first Total Laparoscopic Hysterectomy (TLH) was performer in 1989 by Harry
Reich [5].
Since then the advent of minimally invasive techniques has allowed a substantial decrease in
the rate of open abdominal hysterectomies, with shorter postoperative hospital stay, faster return to
daily activities and reduced overall costs. However, as a consequence of the frequency with which
this surgery is needed, even uncommon complications can affect large number of patient [6]. Here,
we describe a rare case of trocar site bowel herniation at the 5-mm port site which occurred after
laparoscopic total hysterectomy and bilateral salpingo-oophorectomy.
Case Presentation
A 63 year-old patient with a body mass index of 25 and history of craniotomy due to the aneurysm
of the right internal carotid artery, underwent a total laparoscopic
hysterectomy with adnexa for preinvasive cervical cancer.
After safety tests and in sufflation through a Veress needle, a
10-mm laparoscope was inserted through a 10-mm umbilical port.
One 10-mm port was inserted in the right lower abdominal quadrant
and one 5-mm port was inserted in the left abdominal quadrant. The
procedure went without any complications; the total duration of the
procedure was 100 mis and the blood loss about 70 ml.
The initial postoperative course passed normally. At the day 3
she started to present an occlusive syndrome-abdominal pain and
vomiting with clinical signs of ileus. However no obstructive features
have been demonstrated in X-ray, computed tomography and
Ultrasonography (US). The results of the laboratory test were normal.
After the surgical consultation, pharmacological stimulation of
bowel motility was implemented with good results. Due to vomiting,
an attempt was made to put the probe into the stomach, obtaining
about 500 ml of liquid content. During all this time, despite the
bloated abdomen, the peristalsis was preserved. At the day 9 because
of persistent symptoms despite pharmacological treatment it was
decided to perform US again. Diagnosis of small bowel herniation
in the left trocar site was made and patient underwent an emergency
mini-laparotomy which confirmed the diagnosis. There was no
digestive resection because the herniated bowel was viable. The fascia
was closed with absorbable sutures. The patient was discharged from
the hospital at the day 4 after second intervention and recovered
without any incident.
Laparoscopic surgery is modern surgical approach and widely
practiced. It may offer more benefits that conventional surgery but
it could result in added complications specific to the laparoscopic
approach such as port- site incisional hernia. More than 70% of small
wound trocar site hernias occurred after gynecologic laparoscopic
surgeries. Nearly 90% of them occurred at the lateral abdomen when
were left open the fascial layers [3].
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 which tend to develop more
frequently at umbilical and midline port sites due to the thinness of
the umbilical skin and weaknesses in the line a alba [7].
Trocar-site hernias are postoperative complication associated
with laparoscopic surgery, especially when the trocar site is bigger
than 10 mm in size. The incidence of port-site hernias >10 mm is well
documented in literature and the port sizes >10 mm should be closed
with sutures to prevent herniation. The trocar sites <10 mm in size are
usually not repaired. Many surgeons do not routinely repair port sites
of 5 mm because it is believed that such iatrogenic fascial defects are
not large enough to presuppose hernia [4].
The first case of bowel herniation after laparoscopic surgery was
described in 1968 by Fear [10]. Incidence of TSH has been evaluated
at 0.0% to 5.2% [2-4].
The incidence of the complication increases with trocar size.
In ports less than 10 mm in diameter, such as 5 mm and 8 mm are
difficult to estimate because it is rarely reported. Trocar site hernia on
a 8-mm port site following robotic- assisted surgery are very rare. The
occurrence of hernia in smaller trocar sites is up to 0.09%.
The classification of trocar port-site hernias was suggested/
proposed in 2004 [8].
There are 3 types of hernias:
a. The early onset trocar port hernia type (the 80% of them)
was defined as having dehiscence of fascia and peritoneum within 2
weeks, most commonly with small bowel obstruction followed by the
omentum.
b. The late onset type port- site hernia type was defined when
it occurs after 2 weeks and has dehiscence of fascial plane with sac
consisting of peritoneum; only a small part of late onset hernias
present with intestinal obstruction. The late-onset type has often been
recognized as a complication of the trocar insertion and this type of
hernia almost always develops in the late stages several months after
surgery.
c. The special types of hernia which have dehiscence of the
whole abdominal wall. Protrusion of the intestine and other tissue
such as greater omentum is recognized.
In morbidly obese patients, a thick preperitoneum predisposes
the development of the Richter hernia, despite adequate fascial
closure. Clinical character of this type is just like the early-onset type
[11]. According to the literature explorative laparotomy is often used
to repair the trocar site hernias [3]. In cases of bowel hernias, the
symptoms of bowel injury or obstruction could be presented after
couple of days. They are almost never recognized immediately after
surgery.
Patients can have a port-site hernia without bowel involvement
and without symptoms. When bowel or omentum gets involved,
patients may present symptoms like nausea, vomiting, port-site pain,
abdominal pain, fever. Depends on the site of hernia, small or large
bowel can be involved and can occur in the form of incarcerated
bowel, bowel obstruction or bowel evisceration. All of these are
considered surgical emergencies that can present a few days to weeks
after surgery.
For patients who present with gastrointestinal symptoms after
recent laparoscopic surgery, the different diagnosis should include
internal bowel hernia with or without incarceration or strangulation
[1,4]. In the past, hernias were most frequently evaluated with small
bowel oral contrast studies. Radiography and ultrasonography
along with clinical examination may enable the diagnosis although
this needs the radiologists’ awareness of this rare complication.
Radiographic features include apparent encapsulation of distended
loops of small intestine, arrangement or crowding of small bowel
loops within the hernia sac, evidence of obstruction with segmental
dilation and stasis with features of apparent fixations and reversed
peristalsis during fluoroscopic evaluation. Recently, the first-choice
imaging technique used in these patients is abdominal CT with
characteristic mesenteric vessel abnormalities with engorgement,
twisting, crowding or stretching of these vessels [9].
Nowadays, for diagnosis and surgical management, laparoscopic
exploration of the patient who has symptoms of hernia is the
worthwhile procedure. Risk factors for developing a trocar- site hernia
include advanced age or preschool age, increased BMI, smoking
of cigarettes, uncontrolled diabetes mellitus, port-site infection,
peritoneal defect greater than the trocars size, midline insertion of
the port especially near the umbilicus, excessive manipulation of the
trocar site, site of trocar placement- lower quadrant port sites, size
of trocar, number of trocars and type of trocar tip used, extended
operative time, comorbidities associated with fascial defect- adjuvant
chemotherapy for cervical cancer or breast cancer with abdominal
metastasis, patient history of kidney failure, parietal infection, cortico
therapy, chronic bronchitis and use of drains [1,3,4].
The most important risk factor is the size of the trocar. Most of
described herniations at the port site involve ports of at least 10 mm,
only a few cases are reported at trocar sites smaller than 10 mm. A
case of bowel herniation through an 8- mm robotic port site has also
been described, even a case of bowel herniation through a 2-mm port
site in a 3-month-old infant was described in pediatric surgery [1,10].
The risk of hernia through a 12-mm trocar site (3.1%) is
approximately 13-fold greater than for 10-mm trocar site (0.23%).
It is said that extensive manipulations with repetitive movements in
different directions during operations could enlarged the defect of
the fascia and the peritoneum which becomes larger than the skin
incision.
It can be possible that 5-mm port sites hernias could happened
after drain usage because they may facilitated the herniation because
they trap or create a suction effect on the bowel when they are
removed. Therefore it is believed that when the drainage is needed,
the drain should be set through a new incision, especially when the
laparoscopic surgery has been prolonged and we can suspect that the
port sites have been enlarged during manipulations.
Closing the wall defect may be considered even for port sites
smaller than 10 mm but it cannot provide complete protection from
herniation. The possibility of bowel obstruction at the trocars site
should be known to avoid complications which can lead to bowel
resection and life-threating event [4].
There is no clear consensus that all port sites must be closed.
According to literature it appears that herniation tends to occur in
the lateral lower abdomen. To prevent port- site hernias all portsites
should be closed especially if the surgery was long and excessive
manipulation of the trocar was done. Obese patients need close
attention to closure. All ports should be removed under visualization
before deflation of CO2. A few cases of bowel hernias have been
reported after removing of drains, so tunnel drains should be placed
through the 5-mm port sites [9]. Surgeons who regularly perform
laparoscopic procedures generally do not attempt to close the fascia
of ports less than 10 mm, including the 8 mm robotic ports, because
of the technical difficulties associated with closing smaller port fascia.
Data about TSH at 8-mm port sites are not clear enough to
determine whether closure of the fascia is necessary.
Statistically, robotic 8-mm port hernia risk is minimal, but
because the medical data are limited on this issue, it is suggested
to treat 8-mm incisions in the same way as 10-mm and closed in a
similar manner [1,3].
Lambertz et al. [3] conclude that the risk of hernia development
after 5 mm trocar placement is so rare that the 5-mm port- sites can
be left without sutures because it has turned out that 96% of port site
hernias occurred after using of 10-mm trocars [2]. In this context the
preferable use of smaller trocars possible helps to reduce the risk of
port-sites hernias [2].
Conclusion
Acute herniation through lateral trocar port size is rare complication of laparoscopic surgery. However it should always be included in the different diagnosis of bowel obstruction when the patients complain of gastrointestinal symptoms after laparoscopy. It seemed that closing of the wall defect may be considered for port sites of 10 mm in diameter or more and even for wounds smaller than 10 mm.
Acknowledgement
The study was approved by the Bioethics Committee of the Medical University of Lublin. Patient gave written consent to participate in the study before the surgery.
Author Contribution
Marek Gogacz collected and interpreted of data, wrote the manuscript, conceived and designed the experiments, interpreted of data; Aleksandra Kamińska-wrote the manuscript, collected the data; Izabela Winkler- collected of data, wrote the manuscript; Aneta Adamiak collected the data, wrote the manuscript; Tomasz Rechberger collected of data, giving final approval of the version to be published, Koninckx Philippe- wrote the manuscript, giving final approval of the version to be published.
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