A simple and reliable procedure for laparoscopic port-site closure

An 8-mm port site hernia after robotic-assisted ileocecal resection: a case report

BACKGROUND

Robotic-assisted surgery is steadily becoming more prominent. The majority of reports regarding port site hernias (PSHs) have involved laparoscopic procedures. Currently, it is common to suture the fascia at port sites that are 10 mm or larger; however, the closure of 5-mm port sites is not considered mandatory. The da Vinci® surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) utilizes a distinctive 8-mm port. We report a case of an early-onset PSH at an 8-mm port site after robotic-assisted ileocecal resection.

CASE PRESENTATION

A 74-year-old male patient with a body mass index of 19.7 kg/m2 was diagnosed with cecal cancer and underwent robotic-assisted ileocecal resection. A 3-cm midline incision was made at the umbilicus for insufflation. Under laparoscopic visualization, three ports (12 mm, 8 mm, and 8 mm) were inserted in the lower abdomen. An 8-mm port was inserted in the left subcostal region, and a 5-mm port was inserted in the left lateral abdomen. The procedure was performed without significant intraoperative complications. The fascia was closed only at the umbilicus and 12-mm port site; the fascia at the 8-mm port sites was not closed. The patient was initially discharged without complications; however, on postoperative day 11, the patient was urgently hospitalized again because of PSH incarceration. After manual reduction, the fascia was sutured closed under local anesthesia. The hernial defect was small and barely allowed the insertion of a little finger. There was no evidence of compression or significant damage to the fascia. On postoperative day 27, the patient was discharged after experiencing good recovery.

CONCLUSIONS

Robotic-assisted colectomy could contribute to the risk of PSHs because of its surgical characteristics. Although routine closure of the fascia at 8-mm port sites is not mandatory, it may be beneficial in certain cases.

Thoughts on Trocar Site Hernia Prevention. A Narrative Review

Background: Laparoscopic and robot-assisted surgery is now common place, and each trocar site is a potential incisional hernia site. A number of factors increase the risk of trocar site hernia (TSH) at any given trocar site. The aim of this paper is to explore the literature and identify the patients and the trocar sites at risk, which may allow target prevention strategies to minimise TSH. Methods: A pub med literature review was undertaken using the MeSH terms of "trocar" OR "port-site" AND "hernia." No qualifying criteria were applied to this initial search. All abstracts were reviewed by the two authors to identify papers for full text review to inform this narrative review. Results: 961 abstracts were identified by the search. A reasonable quality systematic review was published in 2012, and 44 additional more recent publications were identified as informative. A number of patient factors, pre-operative, intra-operative and post-operative factors were identified as possibly or likely increasing the risk of TSH. Their careful management alone and more likely in combination may help reduce the incidence of TSH. Conclusion: Clinically symptomatic TSH is uncommon, in relation to the many trocars inserted every day for "keyhole" surgery, although it is a not uncommon hernia to repair in general surgical practice. There are patients inherently at risk of TSH, especially at the umbilical location. It is likely, that a multi-factored approach to surgery, will have a cumulative effect at reducing the overall risk of TSH at any trocar site, including choice of trocar type and size, method of insertion, events during the operation, and decisions around the need for fascial closure and how this is performed following trocar removal.

Economizing on a 12 mm port incision site: modification of robotic bowel stapling technique in Da Vinci X/Xi left colonic resections-the modified Norfolk and Norwich robotic stapling technique

The modified Norfolk and Norwich technique allows to replace a 12 mm port incision site by an 8 mm one, therefore reducing potential postoperative complications linked to 12 mm incisions by robotically stapling through the routinely placed suprapubic Alexis port.