Trocar-site incisional hernia after laparoscopic colorectal surgery: a significant problem? Incidence and risk factors from a single-center cohort

Clinical observation of extraction-site incisional hernia after laparoscopic colorectal surgery

BACKGROUND

Laparoscopic colorectal cancer surgery increases the risk of incisional hernia (IH) at the tumor extraction site.

AIM

To investigate the incidence of IH at extraction sites following laparoscopic colorectal cancer surgery and identify the risk factors for IH incidence.

METHODS

This study retrospectively analyzed the data of 1614 patients who underwent laparoscopic radical colorectal cancer surgery with tumor extraction through the abdominal wall at our center between January 2017 and December 2022. Differences in the incidence of postoperative IH at different extraction sites and the risk factors for IH incidence were investigated.

RESULTS

Among the 1614 patients who underwent laparoscopic radical colorectal cancer surgery, 303 (18.8%), 923 (57.2%), 171 (10.6%), and 217 (13.4%) tumors were extracted through supraumbilical midline, infraumbilical midline, umbilical, and off-midline incisions. Of these, 52 patients developed IH in the abdominal wall, with an incidence of 3.2%. The incidence of postoperative IH was significantly higher in the off-midline incision group (8.8%) than in the middle incision groups [the supraumbilical midline (2.6%), infraumbilical midline (2.2%), and umbilical incision (2.9%) groups] (χ2 = 24.985; P < 0.05). Univariate analysis showed that IH occurrence was associated with age, obesity, sex, chronic cough, incision infection, and combined diabetes, anemia, and hypoproteinemia (P < 0.05). Similarly, multivariate analysis showed that off-midline incision, age, sex (female), obesity, incision infection, combined chronic cough, and hypoproteinemia were independent risk factors for IH at the site of laparoscopic colorectal cancer surgery (P < 0.05).

CONCLUSION

The incidence of postoperative IH differs between extraction sites for laparoscopic colorectal cancer surgery. The infraumbilical midline incision is associated with a lower hernia rate and is thus a suitable tumor extraction site.

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.

Risk factors for umbilical incisional hernia after laparoscopic colorectal surgery

BACKGROUND

Laparoscopic colorectal surgery (LCRS) requires a small laparotomy at the umbilicus. The wound is small and inconspicuous, but if the patient develops an umbilical incisional hernia (UIH), the wound is visible and the patient suffers from symptoms of discomfort. However, the incidence of UIH after LCRS and its risk factors are not well understood. The purpose of this study was to investigate the risk factors for UIH after LCRS for colorectal cancer.

METHODS

This was a single-centre retrospective study of 135 patients with colorectal cancer, conducted at our hospital from April 2013 to March 2019. The diagnosis of UIH was based on computed tomography and physical examination findings. Preoperative patient data such as enlargement of the umbilical orifice (EUO), subcutaneous fat thickness (SFT) and intraperitoneal thickness (IPT) were collected and analysed using univariate and multivariate analyses for the presence of risk factors for UIH.

RESULTS

A total of 135 patients who underwent LCRS were analysed. The incidence of UIH was 20.7%. Univariate analysis revealed significantly high body mass index (BMI) ≥ 25 (P = 0.032), EUO (P < 0.001), SFT ≥18 mm (P = 0.011), and IPT ≥61 mm (P < 0.01) in the UIH group. Multivariate analysis revealed significant differences in EUO (P < 0.001), SFT ≥18 mm (P = 0.046) and IPT ≥61 mm (P = 0.022).

CONCLUSION

EUO was the most important risk factor for UIH, followed by IPT and SFT. These findings are predictive indicators of the development of UIH after LCRS and can be assessed objectively and easily with preoperative computed tomography.